South Carolina Medicaid Trading Partner Agreement (Page 6 of 8) in pdf

South Carolina Medicaid Trading Partner Agreement Page 6

South Carolina Medicaid

Trading Partner Agreement

Electronic Claims and Related Transactions

Appendix A

MEDICAID PROVIDER

ELECTRONIC MEDIA BILLING AGREEMENT

The South Carolina Department of Health and Human Services (DHHS) and

Provider Name: ____________________________ Provider Medicaid # ____________

recognize the mutual advantage of submitting claims electronically. This agreement sets

forth the necessary procedures for submitting claims electronically.

-Address Of Medicaid Provider: _____________________________________________

-Phone Number of Medicaid Provider: ________________________________________

-Name and title of individual practitioner, administrator, proprietor, corporate officer or

individual within the Medicaid Provider's organization who has authority to enter into a

contract and sign this agreement: (Signature of authorized representative required on last

page)

-Name: ___________________________

Title:______________________________

Provider will submit claims through an electronic claims company or vendor.

Vendor Name: _______________________ Vendor Phone # _____________________

The Provider agrees:

A. To submit claims only through a business agent as defined in 42 CFR 447.10(f)

which states:

Payment may be made to a business agent, such as a billing service or an

accounting firm, that furnishes statements and receives payments in the name of

the provider, if the agent's compensation for the service is (1) Related to the cost

of processing the billing; (2) Not related on a percentage or other basis to the

amount that is billed or collected; and (3) Not dependent upon the collection of

the payment."

The Provider understands that, in accordance with 42 CFR

447.10(h) "Payment for any service furnished to a recipient by a provider may

not be made to or through a factor, either directly or by power of attorney."

"Factor means an individual or an organization, such as a collection agency or

service bureau, that advances money to a provider for accounts receivable that the

provider has assigned, sold or transferred to the individual organization for an

added fee or a deduction of a portion of the accounts receivable." (42 CFR 447.10

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 6