Wps Gha Portal Edi Enrollment Form printable pdf download

WPS GHA Portal EDI Enrollment Form

This Agreement notifies Wisconsin Physicians Service Insurance Corporation of the provider’s

consent to participate in Electronic Data Interchange (EDI). EDI may include claims and claims

attachments, remittances, eligibility/benefits, claim status, and any other electronic information for

Centers for Medicare & Medicaid Services (CMS) federal program data (including but not limited to Title

XVIII of the Social Security Act (Medicare), and/or Section 1011 of the Medicare Modernization Act)

covered under Health Insurance Portability and Accountability Act (HIPAA) Transactions and Code

Sets or Section 1011 of the Medicare Modernization Act (MMA) legislation.

A. The provider agrees:

1. That it will establish and maintain procedures and controls so that information concerning Medicare and/or

Section 1011 beneficiaries, or any information obtained from CMS or its contractors, shall not be used by

agents, officers, or employees of a business associate except as provided by the contractor (in accordance

with §1106(a) of the Social Security Act (the Act));

2. That it will use sufficient security procedures (including compliance with all provisions of the HIPAA security

regulations) to ensure that all electronic transmissions are authorized and protect all beneficiary-specific

data from improper access;

3. That it will notify the contractor or CMS within two business days if any transmitted data are received in an

unintelligible or garbled form

4. The provider agrees to the following provisions for submitting and retrieving/receiving Medicare and/or

Section 1011 information electronically to/from CMS or CMS contractors:

a) That it will be responsible for all Medicare and/or Section 1011 transactions submitted to CMS by the

provider, its employees, or its business associates;

b) That it will not disclose any information concerning a Medicare and/or Section 1011 beneficiary to any

other person or organization, except CMS and/or its contractors, without the express written permission

of the Medicare/Section 1011 beneficiary or his/her parent or legal guardian, or where required for the

care and treatment of a beneficiary who is unable to provide written consent, or to bill insurance primary

or supplementary to Medicare and/or Section 1011, or as required by State or Federal law;

c) That it will submit claims only on behalf of those Medicare and/or Section 1011 beneficiaries who have

given their written permission to do so, and to certify that required beneficiary signatures, or legally

authorized signatures on behalf of beneficiaries, are on file;

d) That it will submit/request electronic transactions on only those beneficiaries with whom the provider has

a professional relationship;

e) That the CMS-assigned unique identifier number (submitter identifier) constitutes the provider’s legal

electronic signature and when used for claims submission, it constitutes an assurance by the provider

that services were performed as billed;

f) That it will ensure that every electronic claim can be readily associated and identified with an original

source document. Each source document must reflect the following information (except if not required for

Section 1011):

•

Beneficiary’s name;

•

Beneficiary’s health insurance claim number;

•

Date(s) of service;

•

Diagnosis/nature of illness; and

Privacy Act Statement: Information you furnish on this form may be disclosed by WPS to another person or

government agency only with respect to the Medicare Program and to comply with Federal laws requiring or

permitting the disclosure of information or the exchange of information between the Department of Health and

Human Services and other agencies.

04/26/2016

Wps Gha Portal Edi Enrollment Form

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