South Carolina Medicaid Trading Partner Agreement (Page 2 of 8) in pdf

South Carolina Medicaid Trading Partner Agreement Page 2

South Carolina Medicaid

Trading Partner Agreement

Electronic Claims and Related Transactions

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

D. The EDI Partner is prohibited from transferring PHI received from

SCDHHS for any purpose not expressly permitted by and related to

paragraphs II A, B, and C above.

III. Provisions of the Agreement

A. The EDI Partner agrees to follow the SCDHHS billing guidelines as

provided to providers for the submission of Health Care Claim

transactions.

B. All Medicaid providers must enter into an “Electronic Media Billing

Agreement” with SCDHHS (see Appendix A).

C. All transactions must be formatted in accordance with the HIPAA

Implementation Guides available at

SCDHHS Medicaid Companion Guides, which specify certain situational

data

elements

necessary

for

SCDHHS,

are

available

HIPAA transactions to be exchanged

between EDI Partner and SCDHHS are identified in the SC Medicaid

Technical Communications User’s Manual.

D. The EDI Partner must complete testing for each of the transactions it will

implement and shall not be allowed to exchange data with SCDHHS in

production mode until testing is satisfactorily passed as determined by

SCDHHS.

Successful testing means the ability to successfully pass

HIPAA compliance checking and to process PHI transmitted by EDI

Partner to SCDHHS. SCDHHS 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 SCDHHS. Such certification must be at least level 4 as defined

by WEDI.

E. The EDI Partner warrants and represents that it 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 the SCDHHS.

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 Page 2

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