South Carolina Medicaid Trading Partner Agreement printable pdf download

South Carolina Medicaid Trading Partner Agreement

South Carolina Medicaid

Trading Partner Agreement

Electronic Claims and Related Transactions

I. General

This Agreement, effective upon execution by both parties (the “Effective Date”),

is between the South Carolina Department of Health and Human Services

(SCDHHS) and the Electronic Data Interchange (EDI) Partner identified in

paragraph A. below:

A. Provider/ EDI Partner Information:

1. Name: ________________________________________________

2. Provider Number(s) - If Applicable:

_______________________________________

3. Address: ______________________________________________

______________________________________________________

4. Contact Name: _________________________________________

5. Contact Telephone Number: ______________________________

6. Contact E-Mail Address: _________________________________

7. Contact Fax Number: ____________________________________

II. Purpose

A. This Agreement outlines the requirements for the electronic transfer of

protected health information (PHI) between the EDI Partner named in

paragraph I. A. (above) and SCDHHS.

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 Medicaid beneficiaries of the SCDHHS.

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)

Return all pages of TPA to: SC Medicaid TPA, P.O. Box 17, Columbia, S.C. 29202.

Call 1-888-289-0709 for assistance with questions.

REV.7 October 2003

South Carolina Medicaid Trading Partner Agreement