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

South Carolina Medicaid Trading Partner Agreement Page 8

South Carolina Medicaid

Trading Partner Agreement

Electronic Claims and Related Transactions

prosecuted under Federal and State Laws." (42 CFR 455.18(a)(2)).

L. That either party may terminate this agreement at any time upon written

notification of the other party.

M. That certain claims may not be submitted electronically and that DHHS has the

sole authority to determine which claims may or may not be submitted

electronically.

N. That under certain circumstances, DHHS may require prepayment review of

claims and that I (we) will be notified in writing of the DHHS's intent to conduct

prepayment review during which time electronic claims will not be accepted.

O. That this agreement in no way exempts me from being subject to all other

Medicaid regulations in effect at the time I submit a claim.

P. That I shall safeguard and shall require, in my written contract with my business

agent, that my business agent shall safeguard the use and disclosure of

information concerning Medicaid recipients in accordance with all applicable

Federal and State laws and regulations. Provider understands that, in accordance

with 42 CFR 431.305(b), "this information must include at least (1) name and

address; (2) medical services provided; (3) social and economic conditions or

circumstances; (4) agency evaluation of personal information; and (5) medical

data, including diagnosis and past history of disease or disability."

Q. That I am responsible for all services rendered, charges billed, and reimbursement

received.

I have read, understand and agree with the conditions set forth in this agreement.

_____________________________________

_____________________________

Signature (must be authorized representative

Date of Signature

designated on page 6)

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 8