Form Fa-35 Electronic Transaction Agreement For Service Centers

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Hewlett Packard Enterprise  Nevada Medicaid and Nevada Check Up
Electronic Transaction Agreement for Service Centers
This is to certify that ___________________________________________________________ (“Service Center”)
(Service Center, Clearinghouse or direct Service Center’s business name)
of ___________________________________________________________________________________________
(Zip Code)
on this _________ day of __________________, 20____, agrees to follow conditions for the submission of
electronic transactions to Hewlett Packard Enterprise (HPE) for processing transactions for Nevada
Medicaid and Nevada Check Up (“Medicaid”):
Authorized Uses
Data is only to be used for Medicaid business done on behalf of Medicaid providers, including preparing
accurate claims or determining eligibility for specific services.
Service Centers may only forward requests on behalf of and on the explicit request of health care provider
subscribers to support a direct patient treatment relationship and verification of eligibility to support
treatment, payment or health care operations as defined by the Health Insurance Portability and
Accountability Act of 1996 (HIPAA).
The Service Center agrees to abide by the policies of HPE and the Nevada Division of Health Care
Financing and Policy (DHCFP).
The Service Center is recognized as an electronic transaction preparation service only and is not to be
construed as an agent of HPE or the DHCFP.
A provider’s enrollment in Medicaid is not affected by this agreement.
The Service Center will not submit an eligibility inquiry except as an authorized agent of the health care
provider and pursuant to a Business Associate contract as required by 45 CFR 164.314(a) and 164.504(e)
with the health care provider.
The Service Center will notify the HPE EDI Department of the names of providers either added to or
discontinued from service within five (5) business days.
The Service Center is fully accountable for all transactions submitted and will cooperate with HPE and
DHCFP or their agents in the event there is a security concern with respect to any transaction submitted.
The Service Center will not make any disclosure of information that is not specifically authorized.
Service Center will be able to associate each inquiry with the provider or billing service making the inquiry.
For each inquiry submitted, the Service Center will be able to identify the provider making the request for
beneficiary information and be able to assure that the eligibility responses are routed only to the provider
that originated each request.
If the Service Center submits a transaction that has been prepared by a provider/supplier utilizing
clearinghouse services, the Service Center will be responsible for ensuring that the provider/supplier
(pv 01/15/2013)


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