Oregon Medicaid: DHS

Enrollment Instructions

Thank you for your interest in Electronic Data Interchange (EDI).

Required Documents for those applying for new Submitter IDs

The following documents are required enrollment documents that must be completed, signed and returned to the DHS office prior to initiation of electronic claims submission or inquiry.

1. EDI Registration Form - https://apps.state.or.us/Forms/Served/oe2082.pdf
2. Application for Authorization Form - https://apps.state.or.us/Forms/Served/oe2081.pdf
3. Trading Partner Agreement - https://apps.state.or.us/Forms/Served/oe2080.pdf

Required Documents for those with existing Submitter Ids but need to make changes to their account:

Use this form to change mailing address, email address, contact information, authorized users and EDI vendors.
1. Exhibit C to update your EDI registration - https://apps.state.or.us/Forms/Served/oe2083.pdf

To obtain the forms above, please download them from:
http://www.oregon.gov/OHA/edi/reg_testing.shtml

If you have any questions regarding any of the documents in this package, please phone the DHS EDI Technology Support Center at 1-800-527-5772.

Required Information

We recommend that you have the following information ready before filling out your forms:

New EDI Submitters

Follow these instructions to fill out forms for a new EDI Submitter ID.

EDI Registration

Section 1

• Please select “A new registration”
• Enter today’s date as the Effective Date
• Enter your Business, Provider or Practice name
• Enter your mailing address, phone number and fax number

Section 2

• Enter your Medicaid Provider number and your NPI
• Enter your Taxonomy codes

NOTE: If you have more than one provider you must complete a separate Registration form for each.

Section 3, 4, 5 & 6

• Complete these sections with the designated contact persons for these items in your office.
• For Submitter Type: Choose “Billing provider” and “Self” if you are a provider using SolAce. (You are the EDI Submitter)

Note: If the provider is using a Billing Service fill in the Billing Service’s information in Section 5 & 6 and choose the “Billing Service” option for Submitter type.

Section 7

• Choose whether the transactions you will be billing are for FFS or Prepaid health plan
• Choose either 837P or 837I
• If you would like to receive your EOBs electronically, choose 835
• For response reports, choose 999

Section 8

• Please sign and date this section

Application for Authorization

Header

• Please select “New Application”
• Enter today’s date as the effective date

Section A.

• Enter your business name or provider name as the “trading partner”
• Please select all the boxes
• Complete the box at the bottom of Section A with your information (You are the trading partner)

Section B.

• Complete the box at the bottom of Section B with your information. (You are the EDI Submitter)
• New applicants may leave the submitter number blank.

Note: If a provider is using a Billing Service that uses SolAce, the Billing Service’s information must be filled in here. The Billing Service’s submitter number must be provided in this section.

Section C.

• Complete section C with your information (You are the Trading Partner and the EDI Submitter)
• New applicants may leave the submitter number blank.

Trading Partner Agreement

Section 1

• Please enter your Business, Practice, or Provider name
• Complete the last section of this form.

Updating an Existing EDI Submitter ID

Those with existing Submitter IDs that need to make changes to their account should fill out the following forms.

Exhibit C to update your EDI registration

Use this form to change mailing address, email address, contact information, authorized users, the addition or deletion of authorized transactions or any other changes that may affect the accuracy of, or authority for, an EDI transaction. (Change forms must include the signature of your authorized primary or secondary signer.)

Section 1

• Please enter your trading partner information

Section 2

• Enter your Provider/Plan number
• Enter your NPI and Taxonomy codes
  (A separate Exhibit C must be completed for each provider number.)

Section 3

• Please enter your Trading partner authorized signer information (cannot be a billing service or clearinghouse).
• If the primary signer listed here is different from the one listed on your current TPA, you must complete a new TPA , Exhibit A and Exhibit B before we can update your EDI registration.

Section 4

• Please enter your Claims contact information (this should be someone from your office)

Section 5

• Please enter your information for the EDI submitter information
• If this is different from what is on your current Exhibit A (DMAP 2081) and Exhibit B (DMAP 2082), you will also need to complete and submit a new Exhibit A and B.
  Note: If you are using a Billing Service, your Billing Service will be the EDI Submitter.
• For Submitter Type, if you are using SolAce, choose “Self”. If you are using a Billing Service, choose “Billing Service”

Section 6

• If you are using SolAce, you are the EDI Submitter so please enter your information in this section.
• If you are using a Billing Service then your Billing Service will be the EDI Submitter.

Section 7

• Select whether the claims you bill are FFS or PHP
• Choose the transaction types that you want to either add or delete to your account.
  • Choose 837P or 837I
  • 835 for Electronic EOBs
  • 999 for Response reports

Section 8

• Please sign and date this section.

Submitting your forms

It is recommended that you keep a copy of all the forms you will be submitting for your records. Mail the enrollment forms reflecting original signatures to:

Department of Human Services
Office of Medical Assistance Programs
Provider Enrollment Unit, E44
500 Summer St. NE
Salem, OR 97301-1079
503-945-6898 (fax): 1-888-690-9888 (phone)

It is very important that you complete and return the entire enrollment packet as described above. Incomplete packets will not be processed and will be returned to the submitter.

Waiting for a response

Once the complete provider enrollment packet has been received, the documents will be processed. Processing will take approximately two weeks from the date of receipt. (Remember that mailing time can take as much as five days.)

After processing, a confirmation will be faxed to you as notification to begin filing claims electronically. If neither confirmation nor a returned packet is received after two weeks, contact the DHS EDI Technology Support Center at 1-800-527-5772.

Testing

Once you have received your Submitter ID and password from DHS, please call the AXIOM Systems Support Team and set an appointment for a Mailbox setup and Test Transmission.

Please have 25 test claims ready for testing. Test files should consist of a variety of claims that represent the type of claims you will be submitting once production status is achieved. Test claims will not be processed for payment but will be validated against production files; therefore, they must contain valid patient procedure, diagnosis, and provider information.