835 Electronic Remittance Agreement Instructions New Jersey Medicaid HIPAA EDI 835 - ELECTRONIC REMITTANCE – Instructions Following are instructions for completing the New Jersey Medicaid HIPAA EDI Agreement for the 835 Electronic Remittance. Providers are to complete this form designating the entity you wish to have your 835 Electronic Remittance data sent to. Please understand Molina Medicaid Solutions will ONLY allow one submitter to receive your 835 Health Care Claim Payment Advise. This form is ONLY to be used to request the 835 HIPAA EDI format. By completing this form, you have the option of receiving your 835 Health Care Claim Payment Advise or having another entity receive it for you. For the MEDICAID, ENCOUNTER or CHARITY CARE check boxes located at the top of the form, indicate the Provider Type for which you would like to receive electronic remittance in the 835 HIPAA format. Check one box only. A separate New Jersey Medicaid HIPAA EDI Agreement is required for each provider number you will be electronically receiving claims for unless the provider is a group practice and the group is responsible for the billing of the individual providers associated with the provider group. DOCTYPE: EMCAGREE Who should complete this section? ONLY AUTHORIZED MOLINA MEDICAID SOLUTIONS PERSONNEL. This is for internal use only. SECTION A: MEDIA PREFERENCE Who should complete this section? Any PROVIDER wishing to receive 835 HIPAA Formatted claims or designating a specific entity to receive your 835 HIPAA Claims Payment Remittance. 01) 835 Media Preference: Indicate by putting a check mark in the appropriate box describing the preferred media for receipt of 835 Health Care Claim Payment/Advise information. A check mark indicating your choice of: Check one box only. Internet - Indicates the 835 information will be picked-up through a secure area of the New Jersey Medicaid Web site. Remittance Information will remain on the website for six weeks. INTERNET is the preferred method of receiving Remittance Information. CD-ROM - Indicates the 835 information will provided on compact disc and mailed. Before checking this box, there is a minimum number of claim submissions (1,000) per month in order to request a CD. Cartridge - Indicates the 835 information will be provided on tape cartridge and mailed. Before checking this box, there is a minimum number of claim submissions (1,000) per month in order to request a cartridge. In addition, the cartridges are the property of Molina Medicaid Solutions Corporation. The cartridges may not be reused for any reason. The cartridges must also be returned in 30 days. Failure to comply with these standards will be at the discretion of Molina Medicaid Solutions personnel to eliminate the use. SECTION B: PROVIDER INFORMATION 02) Provider Name: Enter the name of the Provider or Provider's Group name as registered with New Jersey Medicaid. PLEASE PRINT. Page 2-24 Table of Contents August 2004 Electronic Data Interchange June 2010 Version American LegalNet, Inc. www.FormsWorkFlow.com 835 Electronic Remittance Agreement Instructions 03) Submitter Name: Enter the Submitter’s Name who you authorize to receive the 835 Health Care Claim Payment information. This could be your computer company or some other entity. It could be in the case of a provider who maintains their own computer department, the Provider’s name. If you are using the Provider’s name, please use the group name as registered with Provider Enrollment. 04) Date: Enter the date you wish to begin the 835 Health Care Claim Payment information. In a lot of cases it will be a new software product so it may be a date in the future. It is best to install new software after the weekly submission is sent and approved. We recommend a Monday date. 05) Provider’s Signature: This field is for the signature of the New Jersey Medicaid Provider. In the case of a group practice, the person that has signature authority for the group as a whole. THIS PERSON SHOULD HAVE LIABILITY AUTHORITY. 06) Date: Enter the date the form is being completed. 07) Medicaid Provider ID: Enter the number of the Provider or Provider's Group that was assigned by Molina Medicaid Solutions. 08) NPI: Enter the Provider or Provider's Group NPI (National Provider Identification) number. 09) Provider Name: Enter the name of the Provider or Provider's Group name as registered with New Jersey Medicaid. PLEASE PRINT. 10) Provider Address: Enter the physical street address of the Provider or Provider's Group. PO Box addresses will not be accepted. 11) Provider City, State, Zip Code: Enter the city, state and zip code of the physical address the 835 Health Care Claim Payment/Advise information is to be delivered to. If you have chosen INTERNET, a physical street address is still required. SECTION C: 835 RECEIVER INFORMATION 12) Submitter Name: Enter the incorporated name of the billing service/software vendor or computer firm who will be receiving your 835 Health Care Claim Payment/Advise. 13) Submitter ID: Enter the Electronic Submitter ID previously assigned by Molina Medicaid Solutions if one exists. Doing so will notify Molina Medicaid Solutions that the Provider Number entered at the top of this EDI Agreement is to be linked only to the 835 Health Care Claim Payment/Advise. If one has not been assigned or you do not wish the Provider Number entered above to be linked to the previously assigned Electronic Submitter ID leave this blank. 14) Submitter Address: Enter the physical street address of the entity receiving the 835 Health Care Claim Payment/Advise. PO Box addresses will not be accepted. If you have chosen INTERNET as the preferred method of receipt of Remittance information, Molina Medicaid Solutions will still require a physical street address. Molina Medicaid Solutions will ship all 835 information created on CD-ROM or tape cartridge media via Federal Express second day and therefore we must have the physical street address for delivery. Page 2-25 Table of Contents August 2004 Electronic Data Interchange June 2010 Version American LegalNet, Inc. www.FormsWorkFlow.com 835 Electronic Remittance Agreement Instructions 15) Submitter City, State, Zip Code: Enter the city, state and zip code of the entity receiving the 835 Health Care Claim Payment/Advise. 16) EDI Contact Person: Enter the name of the person to be contacted by Molina Medicaid Solutions regarding the 835 Health Care Claim Payment/Advise. 17) Phone/Ext: Enter the area code, telephone number, and extension of the EDI Contact Person regarding the 835 Health Care Claim Payment/Advise. 18) E-Mail: Enter the e-mail address of the EDI Contact Person if one exists. Return the completed EDI Agreement to Molina Medicaid Solutions at the following address: Via U.S. Mail Provider Enrollment Molina Medicaid Solutions P.O. Box 4804 Trenton, New Jersey 08650 - 4804 Other Carriers Provider Enrollment Molina Medicaid Solutions 3705 Quakerbridge Road, Suite 101 Trenton, New Jersey 08619 Page 2-26 Table of Contents August 2004 Electronic Data Interchange June 2010 Version American LegalNet, Inc. www.FormsWorkFlow.com For Internal Use Only EMCAGREE Submitter Id Update Initials Submitter & Provider Name Date QA Initials/Date Provider Group Number 835 Electronic Remittance Agreement 835 - ELECTRONIC REMITTANCE MEDICAID ENCOUNTER CHARITY CARE SECTION A: MEDIA PREFERENCE 01) 835 Media Preference (check only one): Internet CD-ROM Cartridge SECTION B: PROVIDER INFORMATION 02) hereby authorize (Provider Name print) 03) to receive my (Submitter Name print) electronic remittance information as of 04) Date: . I understand this electronic information contains Patient Health Information (PHI) and have taken the necessary steps with the parties named on this document to maintain the confidentiality of all PHI data. 05) 06) Date: 07) (Provider’s Signature) Medicaid Provider ID (GROUP ID): 09) Provider Name: 10) Provider Address: 11) Provider City, St, Zip Code: 08) NPI (GROUP ID): SECTION C: 835 RECEIVER INFORMATION 12) Submitter Name: 14) Submitter Address: 15) Submitter City, St, Zip Code: 16) EDI Contact Person: 18) 13) Submitter ID: E-Mail: 17) Phone/Ext: ( ) *** PLEASE MAINTAIN A COPY OF THIS DOCUMENT FOR YOUR RECORDS. *** Return this completed REMITTANCE EDI Agreement to Molina Medicaid Solutions at the following address: Via U.S. Mail Provider Enrollment Molina Medicaid Solutions P.O. Box 4804 Trenton, New Jersey 08650 - 4804 Other Carriers Provider Enrollment Molina Medicaid Solutions 3705 Quakerbridge Road, Suite 101 Trenton, New Jersey 08619 For detailed instructions on completing this agreement, please refer to the 835 Electronic Remittance Agreement Instructions. 4010A1-PART-C Table of Contents August 2004 Electronic Data Interchange June 2010 Version American LegalNet, Inc. www.FormsWorkFlow.com