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PARTNERS BEHAVIORAL HEALTH (13141) PRE-ENROLLMENT INSTRUCTIONS WHICH FORM(S) (Office Ally)

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• Trading Partner Agreement
• Mail the Trading Partner Agreement to:
Partners Behavioral Health
Attn: IT Department
901 South New Hope Road
Gastonia, NC 28054
• Standard processing time is 7-10 business days
• Approximately 7-10 business days after Partners BH receives your form, they will notify you and assign a
Provider ID.
• Once you receive confirmation that you have been linked to Office Ally, you MUST email
Support@officeally.com
with the below information PRIOR to submitting claims electronically.
Email Subject: PARTNERS BEHAVIORAL HEALTH (13141) – EDI Approval
Body of Email:
Please log my EDI approval for PARTNERS BEHAVIORAL HEALTH.
o Provider Name
o NPI
o Tax ID
• If you DO NOT receive a notification from Partners BH in regards to enrollment, call (704) 842-6413 or email
sking@partnersBHM.org
and ask if your Trading Partner Agreement has been processed and what your
assigned Provider ID is.
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
PARTNERS BEHAVIORAL HEALTH (13141)
PRE-ENROLLMENT INSTRUCTIONS
WHICH FORM(S) SHOULD I DO?
WHERE SHOULD I SEND THE FORM(S)?
WHAT IS THE TURNAROUND TIME?
HOW DO I CHECK STATUS?
CORPORATE OFFICE:
901 South New Hope Rd.
Gastonia, NC 28054
ELKIN REGIONAL OFFICE:
200 Elkin Business Park Dr.
Elkin, NC 28621
HICKORY REGIONAL OFFICE:
1985 Tate Blvd. SE, Suite 529
Hickory, NC 28602
PHONE: 1-877-864-1454 • ACCESS TO CARE: 1-888-235-HOPE (4673) • WEBSITE: www.PartnersBHM.org
TRADING PARTNER AGREEMENT COVER LETTER
A Trading Partner Agreement (TPA) is a document that is required to be completed for any entity that is
transmitting or receiving HIPAA compliant X12 Electronic Transactions with Partners Behavioral Health
Management. An entity could be a Provider, Clearinghouse, or Billing Agency. The Trading Partner Agreement
must contain original signatures and mailed along with this completed cover letter to the following address:
Partners Behavioral Health Management
901 South New Hope Road
Gastonia, NC 28054
Attn: IT Department
The following information is requested to process your TPA:
Trading Partner Name: _____________________________________________
Current Log On ID (if applicable): _____________________________________
(If you are a Partners’ System user, what is your current log on ID?)
Provider Number(s): ________________________________________________
(If more than one, attach a sheet with provider name and number)
Software Name: ____________________________________________________
Vendor Name: _____________________________________________________
Vendor Contact Person: ______________________________________________
Vendor Contact Phone Number: ________________________________________
For any questions regarding the completion of this cover letter and the attached TPA, please contact the
Partners IT Department Helpdesk at (704)842-6431.
Proprietary
Office Ally
360-975-7000 Option 1
I. General
This agreement effective on _____________, (the “Effective Date”) is between Partners Behavioral
Health Management with offices located at 901 S. New Hope Rd. Gastonia, NC 28054 and the Electronic
Data Interchange (EDI) Partner identified in paragraph ‘A’ below:
A. Company Name: ________________________________________________
1. Address:
________________________________________________________
________________________________________________________
2. Contact Name:
________________________________________________________
________________________________________________________
3. Contact Telephone Number:
________________________________________________________
________________________________________________________
4. Contact Fax Number:
________________________________________________________
________________________________________________________
5. Contact E-mail Address:
________________________________________________________
________________________________________________________
II. Purpose
A. This agreement outlines the requirements for the transfer of electronic health care information
between the EDI Partner named in paragraph I, A, (above) and Partners Behavioral Health
Management.
B. The EDI Partner is in the business of submitting said electronic transactions on behalf of itself or
provider(s).
C. The exchange of information is for the purpose of allowing providers to conduct electronic
transactions through the EDI Partner for health care services provided to beneficiaries of the
Partners Behavioral Health Management. This agreement provides for the exchange of information
between these parties necessary for the processing of such transactions. These transactions must
be in accordance with the American National Standards Institute (ANSI) accredited standards and in
compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, CFR 45
Parts 160 and 162, Standards for Electronic Transactions, published in the Federal Register August
17, 2000.
D. The EDI Partner is prohibited from transferring electronic health care information received from
Partners Behavioral Health Management for any purpose not expressly permitted by or related to
paragraphs II, A,B, and C above.
III. Provisions of the Agreement
A. The EDI Partner agrees to follow the DMA and DMH/DD/SAS billing guidelines as provided to
providers for the submission of Health Care Claim Transactions.
B. All transactions must be formatted in accordance with the HIPAA Implementation Guides available
at http://www.wpc-edi.com/hipaa
. Partners Behavioral Health Management will provide
companion guides for the transactions, which specify certain situational data elements. HIPAA
transactions to be exchanged between EDI Partner and Partners Behavioral Health Management are
identified in Appendix A, Transaction Sets.
C. The EDI Partner must complete testing for each of the transactions it will implement and shall not
be allowed to exchange date with Partners Behavioral Health Management in production mode until
testing is satisfactorily passed as determined by Partners Behavioral Health Management.
Successful testing means the ability to successfully pass HIPAA compliance checking and to process
electronic healthcare information transmitted by EDI Partner to Partners Behavioral Health
Management. Partners Behavioral Health Management will accept certification from any third-
party testing and certification entity that has been identified by the Workgroup for Electronic Data
Interchange, Strategic National Implementation Process (WEDi/SNIP) in lieu of an EDI Partner being
tested by Partners Behavioral Health Management.
D. The EDI Partner warrants and represents that is has a legally binding contract between itself and all
providers for whom it is submitting data or that the EDI Partner is itself a provider authorized to
submit claims and receive health care information for beneficiaries who have coverage for services
by Partners Behavioral Health Management. The EDI Partner shall indemnify and hold Partners
Behavioral Health Management harmless from any claim, actions, or costs that result from a breach
or threatened breach of this warranty and representation.
E. Partners Behavioral Health Management and the EDI Partner will protect the health care
information contained in the exchange of information by means of both physical and electronic
security measures.
1. Each entity will control access to its physical locations so that only authorized personnel
have access to the information.
2. Each entity will utilize passwords in accordance with established procedures so that only
authorized personnel have knowledge of those passwords. Upon departure of personnel
from employment, the EDI Partner will promptly or immediately notify Partners Behavioral
Health Management so that a new password can be established.
3. Each party to this agreement will report to the other any violation of security and/or the
release of protected information that is not in accordance with this Agreement.
F. The following technical rules will be used for the transfer of electronic health information between
the Parties:
1. The recommended delimiters for the inbound X12 transaction sets will be:
a. * Asterisk for data element separation
b. ^ Caret for sub-element separation
c. Tilde for segment terminator
2. The delimiters set by Partners Behavioral Health Management for the outbound X12
transaction sets will be:
a. * Asterisk for data element separation
b. ^ Caret for sub-element separation
c. Tilde for segment terminator
3. The Internet Protocol (IP) address for File Transfer Protocol (FTP) transfer can be found in
Appendix B.
4. The production sign-on procedures once connected to Partners Behavioral Health
Management will be followed according to instructions issued by the Partners Behavioral
Health Management Testing Coordinator after completion of successful testing or proof of
third-party certification.
5. Contact Information for testing and troubleshooting is contained in Appendix B.
G. The transfer of electronic health information between the Parties shall occur as follows:
1. The EDI Partner will connect to the Partners Behavioral Health Management system and FTP
files into its assigned directory.
2. Partners Behavioral Health Management will query directories on a recurring, daily, periodic
basis and process the transactions as appropriate.
3. In response to the EDI Partner delivered message, Partners Behavioral Health Management
will deliver to the assigned directory the appropriate response based on established
processing schedules as outlined in Appendix A.
IV. Modification and Termination
A. Except as otherwise provided herein, this Agreement may be modified or amended only by
agreement of the parties, in writing, and executed with the same formality as this Agreement. The
failure of either party to insist upon strict performance of any provision of this Agreement shall not
constitute a waiver of any subsequent default of the same or similar nature.
B. The parties agree to modify this Agreement to comply with changes to applicable federal and state
regulations.
C. Modifications to transaction set formats used to exchange Electronic Health Information between
the EDI Partner and Partners Behavioral Health Management will only necessitate an update to
Appendix A, and not the entire Agreement.
D. Either party may terminate this Agreement without cause by providing the other party with 30 days
written notice. The Agreement may be terminated immediately upon written notice if:
1. A party fails to adhere to the proscribed and agreed upon formats.
2. If it is determined that either Party is not using the exchanged information for the purposes
provided for under this Agreement.
3. Upon termination of Partners Behavioral Health Management contract, in whole or part, by
NCDMA/NCDMHDDSAS.
E. Binding Effect and Entire Agreement
1. This agreement contains the entire understanding of the parties, and there are no
representations, warranties, covenants, or undertakings other than those expressed and set
forth herein. Except as otherwise stated herein, all the provisions of this Agreement shall be
binding upon the respective successors in interest to the parties.
2. Termination or expiration of this Agreement for any reason shall not release either Party
from any liabilities or obligations set forth in this Agreement.
F. Governing Law: this agreement shall be construed in accordance with and governed by the laws of
the state of North Carolina regardless of the forum where is may come up for construction.
V. Confidentiality
A. Each party agrees that during the term of this agreement and for a period of 3 years thereafter, such
party shall use the same means it uses to protect its own confidential proprietary information, but in
any event not less than reasonable means, to prevent the disclosure and to protect the
confidentiality of both when:
1. Written information received from the other party which is marked or identified as
confidential.
2. Oral or visual information identified as confidential at the time of disclosure, which is
summarized in writing and provided to the other party in such written form promptly after
such oral or visual disclosure (“Confidential Information”).
B. The foregoing shall not prevent either Party from disclosing Confidential Information that belongs to
such party or is:
1. Already known by the recipient Party without an obligation of confidentiality other than
under this Letter Agreement.
2. Publicly known or becomes publicly known through no unauthorized act of the recipient
Party.
3. Rightfully received from a third Party.
4. Independently developed by the recipient party without use of the other party’s
Confidential Information.
5. Disclosed without similar restrictions to a third party by the Party owning Confidential
Information.
6. Approved by the other Party for disclosure.
7. Required to be disclosed pursuant to a requirement of a governmental agency or law so
long as the disclosing Party provides the other Party with notice of such requirement prior
to any such disclosure. Each Party represents that it has the right to disclose information
that it has made and will make available to the other hereunder.
VI. Liability
Partners Behavioral Health Management liability to the EDI Partner for any damages arising out of or related to
this Agreement, regardless of the form of action that imposes liability, whether in contract, equity, negligence,
intended conduct, tort or otherwise, will be limited to and will not exceed, in the aggregate for all claims,
actions, and causes of action of every kind and nature, the sum of 10 thousand dollars ($10,000). In no event
will the measure of damages payable by Partners Behavioral Health Management include, nor will Partners
Behavioral Health Management be liable for any amounts for loss of income, profit, or savings or indirect,
incidental, consequential, exemplary, punitive or special damages of any party, including third parties, even if
such party has been advised of the possibility of such damages in advance, and all such damages are expressly
disclaimed. No claim, demand, or cause of action that arose out of an event or events that occurred more than
2 years prior to the filing suit alleging a claim or cause of action may be asserted by either party against the
other. The provisions of the paragraph VI will survive the expiration or termination of this Agreement for any
reason.
VII. Definitions
(a) Business Associate. “Business Associate” shall mean the EDI
(b) Covered Entity. “Covered Entity” shall mean Partners Behavioral Health
Management and/or the EDI
(c) Privacy Rule. “Privacy Rule” shall mean the Standards for Privacy of Individually
Identifiable Health Information at 45 CFR part 160 and 164, subparts A and E.
(d) Protected Information. “Protected Information” shall have the same meaning as
the term “protected health information” in 45 CFR 164.501, limited to the
information created or received by Business Associate from or on behalf of Covered
Entity.
(e) Required to be disclosed. “Required to be disclosed” shall have the same meaning
as the term “required by law” in 45 CFR 164.501.
VIII. Term
The term of this Agreement shall commence on the Effective Date and continue in effect until
terminated by either party upon 30 days prior written notice to the other party.
EDI Partner Signature DATE
Partners Behavioral Health Management Signature DATE
Appendix A, Transaction Sets
As initiated below by both parties, the following transaction sets are made part of the Trading Partner
Agreement for health care transactions. All transactions are to be implemented in accordance with the HIPAA
implementation guides. Partners Behavioral Health Management will provide companion documents for each
of the transactions that the EDI Partner will exchange. As additional transaction sets are implemented each
party will complete a new Appendix A indicating the transaction sets that are to be part of this agreement.
Health Care Transaction Sets:
______Professional Claim: ASC X12N 837 005010X222A1 – Health Care Claim: Professional
______Institutional Claim: ASC X12N 837 005010X223A2 – Health Care Claim: Institutional
______Health Care Payment and Remittance Advice: ASC X12N 835 005010X221A1 – Health Care
Payment/Advice – to be provided in accordance with the published provider checkwrite schedule.
Only paid and denied claims will be reported on the 835.
EDI Partner Signature DATE
Partners Behavioral Health Management Signature DATE
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Appendix B, Partners Behavioral Health Management
Communications and Contact Information
Method of Communication shall be through a secure FTP Communication.
Providers will submit their test 837 file by uploading it to Partners secure FTP site. Providers will need to contact
Shawn King at (704) 842-6413 to obtain a user name and password and the FTP address. Once the format
testing is complete, providers will be given their login credentials for their permanent FTP site inside of Alpha
MCS.
Partners Behavioral Health Management Information for EDI questions and Trouble Shooting:
Partners Behavioral Health Management Helpdesk - (704)842-6431 or (704)842-6416 or e-mail
helpdesk@partnersbhm.org. Shawn King - (704) 842-6413 or e-mail at sking@partnersbhm.org
Partners Behavioral Health Management Information for EDI Testing Assistance:
Partners Behavioral Health Management Helpdesk - (704)842-6431 or (704)842-6416 or e-mail
helpdesk@partnersbhm.org. Shawn King - (704) 842-6413 or e-mail at sking@partnersbhm.org
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Completed 8 April 2021

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