South Carolina Medicaid Trading Partner Agreement (Page 7 of 8) in pdf

South Carolina Medicaid

Trading Partner Agreement

Electronic Claims and Related Transactions

(b)). Further "payment may be made in accordance with a reassignment from the

provider to a government agency or reassignment by a court order." (42 CFR

447.10 (e)).

B. That if the Provider decides to utilize a business agent to submit claims, Provider

must authorize the business agent by written contract to submit Medicaid claims

in his behalf.

C. To furnish a copy of the aforementioned contract to DHHS or its designee upon

request.

D. To assure that claims are submitted in the format specified by DHHS and to

submit test claims for approval by DHHS prior to submitting claims for payment.

E. To assure that a transmittal letter is submitted as specified by DHHS along with

each cartridge/tape/diskette.

F. To correct any and all discrepant claims submitted.

G. To maintain and ensure ready association of electronic claims with source

documents, including but not limited to: (1) a signed statement from the patient

consenting to the release of information necessary to process claims;

(2)

justification for rendering services; (3) identification of practitioner rendering

services; (4) records corroborating that the services furnished were the same

services contained in the claim; and (5) documentation proving that a claim was

submitted electronically, by whom it was submitted and when it was submitted.

H. To retain all records for a period of seventy-two (72) months after the close of the

federal fiscal year in which the services were rendered.

I. That DHHS, the United States Department of Health and Human Services,

General Accounting Office, the State Auditor, the Attorney General, or their

designees, have the right to audit and confirm information submitted and to access

and/or photograph source documents and medical records during regular business

hours.

J. That any incorrect payments ascertained as a result of such an audit will be

adjusted according to applicable provisions of Title XIX of the Social Security

Act as amended, the S.C. State Plan for Medical Assistance, other applicable State

and Federal laws and regulations, and DHHS Medicaid guidelines.

K. That I understand that the submission of an electronic media claim is a claim for

Medicaid payment and that "payment of this claim will be from Federal and State

funds, and that any falsification, or concealment of a material fact may be

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 7