Electronic Data Interchange Trading Partner Agreement Form. This is a Montana form and can be use in Workers Compensation.
Tags: Electronic Data Interchange Trading Partner Agreement, Montana Workers Compensation,
EDI Trading Partner Agreement Workers' Compensation Claims Assistance Bureau/ Data Management Unit ELECTRONIC DATA INTERCHANGE (EDI) TRADING PARTNER AGREEMENT Objective: To initiate, implement and maintain First Reports of Injury (FROI) and Subsequent Reports (SROI) through electronic filing. We, the undersigned, as representatives of our respective organizations, corporations or governmental entity, do hereby agree to the following: 1. The Montana Department of Labor and Industry, Employment Relations Division ("the Division") is the regulatory agency for workers' compensation and occupational disease laws in Montana. __________________ is an insurer providing workers' compensation insurance in Montana or the third party administrator for an insurer. The Division, the receiver, and ____________________, the sender, agree that the sender will report workers' compensation information to the receiver via the national standards for Electronic Data Interchange (EDI) developed by the International Association of Industrial Accident Boards and Commission's (IAIABC) EDI Project. You are a mandatory/voluntary Trading Partner. This agreement will commence upon the approval of the Division's Claims Assistance Bureau, Data Management Unit Supervisor, as demonstrated by his/her signature on this document. The Trading Partners agree to use the IAIABC Claims Release 1 Flat File format. The Trading Partners will perform a test of the reporting system to determine whether the transmission mechanism is acceptable. Trading Partners must meet all technical requirements as outlined in the State of Montana, EDI Implementation Guide. The term of the test is sixty days from the commencement of this agreement unless the Division approves an extension. Once the testing requirements are met and production status granted the sender is no longer required to file paper forms. 2. 3. 4. 5. American LegalNet, Inc. www.FormsWorkFlow.com 6. 7. Once production status is granted, the sender is required to achieve and maintain a 95% acceptance rate. The format of data elements and definitions will conform to the IAIABC data dictionary, including future amendments, unless otherwise agreed between the Trading Partners. The Division will provide the sender with a minimum of thirty days notice prior to implementing amendments. Technical requirements, data elements, and codes specific to Montana are found in the State of Montana EDI Implementation Guide. Any error in transmission will be timely identified by the Division, and sent to the sender via the acknowledgment record. The sender will correct the identified errors and resubmit the record within 14 days of receiving the acknowledgment record. The sender will pay any and all EDI transmission costs. This agreement may not be modified or terminated except by the written agreement of the Trading Partners, with either party giving at least thirty days written notice to the other party. 8. 9. 10. 11. IN WITNESS WHEREOF, the parties hereto have executed this Agreement as dated below: ______________________________________________ Trading Partner ______________________________________________ Name and Title ______________________________________________ Address ______________________________________________ City, State Zip Code ______________________________________________ Phone ______________________________________________ Fax ______________________________________________ e-mail David Elenbaas, Supervisor, Data Management Montana Department of Labor and Industry Employment Relations Division 1805 Prospect Helena, MT 59601 Ph: (406) 444-6527 Fax:(406) 444-4140 Email: firstname.lastname@example.org ______________________________________________ Signature ______________________________________________ Date ______________________________________________ Signature ______________________________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com