MEDICAID LOUISIANA (MCDLA) PRE-ENROLLMENT INSTRUCTIONS

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Byron Bailey
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1 MEDICAID LOUISIANA (MCDLA) PRE-ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Prvider s Electin t Emply Electrnic Data Interchange f Claims fr Prcessing in the Luisiana Medical Assistance Prgram (EDI Cntract fr Business/Entity) and Pwer f Attrney NOTE: Original signature is required and the frm must be ntarized 2018 Annual Certificatin frm. WHERE SHOULD I SEND THE FORM(S)? Mail the frm t: Mlina EDI Department PO Bx Batn Ruge, LA WHAT IS THE TURNAROUND TIME? Standard prcessing time is 3 weeks. HOW DO I CHECK STATUS? Yu will receive a letter frm Medicaid LA infrming yu f yur apprval. Yu may als call Medicaid LA at (225) and ask if yu have been linked t Office Ally s Submitter ID Once yu receive cnfirmatin that yu ve been linked t Office Ally, yu must supprt@fficeally.cm with the belw infrmatin prir t submitting claims electrnically. Subject: Medicaid Luisiana (MCDLA) - EDI Apprval Bdy f Please lg my EDI apprval fr Medicaid Luisiana. Prvider Name NPI Tax ID Office Ally P.O. Bx Vancuver, WA Phne: Fax:

2 PROVIDER'S ELECTION TO EMPLOY ELECTRONIC DATA INTERCHANGE OF CLAIMS FOR PROCESSING IN THE LOUISIANA MEDICAL ASSISTANCE PROGRAM (EDI CONTRACT FOR BUSINESS/ENTITY) INSTRUCTIONS Prir t submitting electrnic claims t Luisiana Medicaid, a seven-digit Submitter number (450XXXX) must be btained frm the Mlina Medicaid Slutins Prvider Enrllment Unit. The Submitter number must be linked t all prvider numbers fr whm claims will be submitted. The fllwing frm(s) is (are) t be cmpleted if the Entity/Business enrlling at this time plans t submit claims electrnically t Luisiana Medicaid. Prvider s Electin t Emply Electrnic Data Interchange f Claims fr Prcessing in the Luisiana Medical Assistance Prgram (EDI Cntract fr Business/Entity) Luisiana Medicaid Prvider Number enter the Luisiana Medicaid prvider number fr which claims will be electrnically submitted t Mlina Medicaid Slutins. (Leave blank if applying fr new Prvider Number.) Natinal Prvider Identifier (NPI) enter the NPI f the prvider fr which claims will be electrnically submitted. Nte: Atypical prviders leave this blank. DBA Name f Enrlling Business/Entity enter the name f the entity / business enrlling r the business prvider name assciated with the prvider number and NPI listed abve. Billing Agent/Submitter Name/Business Name enter the business name f the billing / submitting agent. Name f Cntact Persn enter the name f the persn designated as the pint f cntact fr questins regarding this request. Cntact Phne Number enter the phne number f Cntact Persn. Submitter Number if linking t a submitter wh already has a Luisiana Submitter number, then yu are required t enter the Luisiana Medicaid submitter number yu want t link t. (Leave blank if applying fr a new submitter number.) Printed Name f Authrized Representative print the name f the persn authrized t enter int a binding Title/Psitin enter the title/psitin f the persn authrized t enter int a binding agreement with Luisiana Medicaid. Signature f Authrized Representative enter the signature f the persn authrized t enter int a binding Date f Signature enter the date the authrized representative signed the frm. Entity/Business Medicaid Electrnic Media Limited Pwer f Attrney (EDI Pwer f Attrney) Luisiana Medicaid Prvider Number enter the Luisiana Medicaid prvider number fr which claims will be electrnically submitted t Mlina Medicaid Slutins. (Leave blank if applying fr a new Prvider Number.) Natinal Prvider Identifier (NPI) enter the NPI f the prvider fr which claims will be electrnically submitted. Nte: Atypical prviders leave this blank. DBA Name f Enrlling Business/Entity enter the name f the entity / business enrlling r the business prvider name assciated with the prvider number and NPI listed abve. Service Address f Business/Entity enter the service address f the prvider name entered. Submitter Number if linking t a submitter wh already has a Luisiana Submitter number, then yu are required t enter the Luisiana Medicaid submitter number yu want t link t. (Leave blank if applying fr a new submitter number.) Billing Agent/Submitter Business Name enter the business name f the Billing Agent/Submitter. Billing Agent/Submitter Cntact Persn enter the name f the persn designated as the pint f cntact fr the Billing Agent/Submitter business. Billing Agent/Submitter Phne Number enter the phne number f the Billing Agent/Submitter cntact persn. Enter the Parish (r Cunty) Name where the Ntary Public is lcated Enter City, State and Date f Ntarizatin Signature f Authrized Representative enter the signature f the persn authrized t enter int a binding Printed Name f Authrized Representative print the name f the persn authrized t enter int a binding Ntary Public Signature the Ntary Public shuld sign the frm and affix his/her seal. If the prvider will be using a Third Party Biller r Clearinghuse, a Limited Pwer f Attrney MUST be cmpleted and ntarized. Please cmplete the enclsed Limited Pwer f Attrney in its entirety t be mailed with yur cmpleted EDI Cntract. Entity/Business EDI Instructins Page 1

3 PROVIDER'S ELECTION TO EMPLOY ELECTRONIC DATA INTERCHANGE OF CLAIMS FOR PROCESSING IN THE LOUISIANA MEDICAL ASSISTANCE PROGRAM (EDI CONTRACT FOR BUSINESS/ENTITY) Luisiana Medicaid Prvider Number (7 digits) Submitter Number (7 digits) (leave blank if applying fr new number) Natinal Prvider Identifier (NPI) (10 digits) DBA Name f Enrlling Business/Entity: Billing Agent/Submitter Name/Name f Business that will be submitting claims (prvider name r third party biller s name): Name f Cntact Persn: Cntact Phne Number: The Medicaid File can hld a maximum f three Submitter Numbers per Medicaid Prvider Number at any ne time. Current plicy is t clse ld Submitter Numbers as new nes are pened unless therwise requested by the prvider. It is als vital t identify which Submitter Number will be designated t dwnlad the Electrnic Remittance Advices (ERA). In rder fr Lusiana Medicaid t gather this infrmatin, cmplete the fllwing, if applicable: When a new Submitter Number is issued, it will be set up t retrieve ERAs. If a previusly assigned Submitter Number is t be used t retrieve ERAs as well, then place it in the spaces prvided belw. By checking this bx yu are giving authrizatin t have 835s prduced and made available fr dwnlad by either this new submitter number r the previusly assigned submitter number. List ther Submitter Number(s) that are currently n file which will NOT be used fr 835 ERA, but which need t remain pen in the spaces belw: I am currently enrlled r am requesting enrllment in Luisiana Medicaid and wish t submit my wn claims electrnically t Luisiana Medicaid. I am currently enrlled r am requesting enrllment in Luisiana Medicaid and wish t use a Third Party (Clearinghuse, Billing Agent, Submitter, etc.) t submit my claims electrnically t Luisiana Medicaid. (Pwer f Attrney frm is required.) PROVIDER ACKNOWLEDEGEMENT 1. The prviders attest that all infrmatin supplied with this Agreement is true, accurate and cmplete. 2. On the date f signature belw, the undersigned elects and agrees t submit Luisiana medical assistance claims by means f the electrnic media claims prcessing methd in accrdance with Paragraphs 1 thrugh 17 belw. This is dne in cnsideratin fr the Luisiana Department f Health (LDH), Bureau f Health Services Financing's (BHSF) prcessing f prvider claims, as well as ther valuable cnsideratins. 3. All published specificatins set frth shall be met as t every entry sught t be prcessed. The effective date fr EDI submissin will be set by Prvider Enrllment nce the cntract has prcessed. Entity/Business EDI Frm Page 1

4 Prvider Name: 4. The Prvider, r his agent, shall be respnsible fr ttal cmpliance with said specificatins including 42CFR which gverns the payment ptins fr Third Party Billers. The Prvider's data prcessing agent fr submissin f medical assistance claims is stated abve and any changes in the Prvider's data prcessing agent shall be preceded by 30 days written ntice t LDH. 5. The Prvider shall prvide upn request f LDH r any authrized agent f LDH any supprtive dcumentatin t ensure that all technical requirements are being met, i.e. prgram listings, data submissins, flw charts, file descriptins, accunting prcedures, etc. 6. The undersigned Prvider shall cntinue t be ultimately respnsible fr the accuracy and truthfulness f all medical assistance claims submitted fr payment. Nevertheless, the Prvider, if electing a data prcessing agent t submit medical assistance claims directly, must give a legal pwer f attrney t that agent in rder t submit electrnic claims and the Annual Certificatin frm. A cpy f the certificatin statement is attached and is hereby incrprated by reference int this paragraph. 7. It is expressly understd that LDH r its Fiscal Intermediary (Mlina Medicaid Slutins) may reject an entire submissin at any time fr failure t cmply with the fficial specificatins fr submitting claims n electrnic media r fr any ther reasn. 8. The Prvider agrees that this electin des nt in any way mdify the requirements t the Plicies and Prcedures applicable t their prvider type, except as the claims submissin prcedures which will be transmitted in electrnic frmat rather than hardcpy. 9. LDH and the Prvider mutually agree that this Agreement may be amended by mutual cnsent f the cntracting parties. Such amendments must, hwever, be in writing and must be signed by the authrized representatives f cntracting parties. This Agreement shall nt be verbally amended. 10. The Prvider agrees t submit t LDH, Fiscal Intermediary r any ther authrized agent, upn request, sufficient dcumentatin t substantiate the scpe and nature f services prvided fr thse claims submitted and fr which reimbursement is claimed. 11. The Prvider acknwledges and accepts respnsibility fr the prvisins f Public Law pertaining t fraud. 12. The Prvider and LDH agree that each party t this Agreement shall have the right t unilateral terminatin f this Agreement upn delivery f written ntice f terminatin upn the ther party. The effective date f such terminatin shall be 30 days frm the receipt f the ntice f terminatin. 13. Further, fr a perid f five years, during the curse f a Federal/state audit r investigatin, shuld dcumentatin f the existence, nature and scpe f the services pertaining t a medical assistance claim be requested, the Prvider shall prvide the dcumentatin as requested and prduce such fr examinatin and cpying at n cst. 14. The Prvider agrees that this electin shall be enfrced in accrdance with the laws f the State f Luisiana and that this electin des nt in any way mdify LDH's limited bligatins as set in a certain Prvider Agreement between LDH and the Prvider. 15. I attest that all claims submitted under the cnditins f this Agreement are certified t be true, accurate and cmplete. 16. I understand that all claims submitted under the cnditins f this Agreement will be paid and satisfied frm Federal and state funds, and that any falsificatin r cncealment f a material fact, may be prsecuted under Federal and State laws. 17. Applicable t thse receiving 835s: I authrize the Medicaid Fiscal Intermediary t send all HIPAA required data in the 835 transactin which includes claims infrmatin; payment infrmatin; and bank accunt infrmatin, prvided by me and currently n file if enrlled in Electrnic Funds Transfer, t the submitter identified abve. This authrizatin will remain in effect until discntinued by written request r changed by a future request. Printed Name f Authrized Representative Title/Psitin Signature f Authrized Representative Date f Signature Entity/Business EDI Frm Page 2

5 ENTITY / BUSINESS MEDICAID ELECTRONIC MEDIA LIMITED POWER OF ATTORNEY (EDI POWER OF ATTORNEY) This frm is required by all prviders wh will have electrnic claims submitted by a third party. Luisiana Medicaid Prvider Number (7 digits) Submitter Number (7 digits) (leave blank if applying fr new number) Natinal Prvider Identifier (NPI) (10 digits) DBA Name f Enrlling Business/Entity (Prvider Name): Service Address f Business/Entity: Billing Agent /Submitter Business Name: Billing Agent /Submitter Cntact Persn: Billing Agent /Submitter Phne Number: BE IT KNOWN that n this day, BEFORE ME, A Ntary Public duly cmmissined and qualified in and fr the Parish f, State f Luisiana, therein residing: PERSONALLY CAME AND APPEARED the abve named prvider, represented herein by the prvider r its duly authrized representative wh is f majrity and a resident f and dmiciled in the State shwn under Prvider Address abve wh declared unt me, Ntary, that he des by these presents, name, cnstitute and appint the abve named Billing / Submitter Agent, a persn r entity with full legal capacity, t be his true and lawful agent and attrney-in-fact, t execute fr him, and in his name, place and stand, the Luisiana Medical Assistance Prgram s applicable claims, by prvider type, fr electrnic submissin f claims prcessing, the said appearer further authrizing the said agent t receive all infrmatin regarding payments made t the appearer fr such claims, and appearer finally declaring that he r it by these presents des agree t indemnify and hld harmless the said agent frm any and all liability resulting frm claims submitted by the said agent fr the said appearer. THUS DONE AND PASSED BEFORE ME, Ntary, in the City f, State f n the day f, 20. Signature f Authrized Representative Ntary Public Signature Printed Name f Authrized Representative Ntary Seal r Ntary Identificatin Number (required) Entity/Business Pwer f Attrney Frm Page 1

6 Prvider Number (7-Digits) EDI ANNUAL CERTIFICAT ION OF ELECTRONIC FILES Certificatin Perid: January 1 t December 31, 2018 Submitter Number 2018 Natinal Prvider Identifier (10 Digits) Submitter Name: Primary Cntact Name: Address: Secndary Cntact Name: Address: Submissins by Prvider Rendering Services Using their wn Submitter ID: I certify that all services rendered during the abve identified Certificatin Perid were necessary, medically indicated and were rendered by me r under my persnal supervisin. I have reviewed the claims infrmatin submitted and certify that it is true, accurate and cmplete. I agree t keep such recrds which will disclse fully the extent f services prvided t individuals under the state s Title XIX plan and t furnish infrmatin regarding any payments claimed fr prviding such services as the state agency, Medicaid Fraud Cntrl Unit r the Secretary f the United States Department f Health and Human Services (DHHS) may request fr five years frm date f service r therwise required by law r regulatin. I agree t accept payment frm the Bureau f Health Services Financing as payment in full fr services and nt seek additinal payment frm the recipient fr any unpaid prtin f a bill except t Spend-dwn Medically Needy recipients as indicated n Frm 110-MNP. I agree t adhere t the published regulatins f the Secretary f DHHS and the regulatins, plicies, criteria and prcedures f BHSF Medical Assistance Prgram including thse rules regarding recupment. I understand that payment and satisfactin f these claims will be frm federal and state funds, and that any false claims, statements, dcuments, r cncealment f material fact, may be prsecuted under applicable federal and state laws. Attach a list f all Prviders Names, Medicaid ID#s and NPI Numbers assciated with this Submitter Number NOTICE: This is t certify that the freging infrmatin is true, accurate and cmplete. Submissins by Third Party Biller (Billing Agents/Clearinghuses) Using their Submitter ID: I certify that the claim infrmatin submitted t Luisiana Medicaid is an exact duplicate f detailed claim line infrmatin received frm the prvider and has nt been materially altered r revised except fr translatin t the current 837 transactin frmat r insertin f minr data. I certify that the infrmatin submitted in electrnic frmat is true, accurate and cmplete as received frm the prvider. Additinally, I understand that payment f these claims will be Federal and State funds, and that any falsificatin, r cncealment f a material fact may be prsecuted under Federal and State laws. I als certify that prvider(s) with whm I have a direct relatinship have furnished me with an EDI Annual Certificatin f Medicaid Claims Submitted Electrnically Frm n which the prvider has attested t the truth, accuracy and cmpleteness f the claim infrmatin. If I d nt have a direct relatinship with submitting prviders (fr instance, if the relatinship is with a vendr), Luisiana Medicaid understands that I will nt have an EDI Annual Certificatin Frm frm the individual(s) r entity(ies) with whm I d nt maintain a cntractual relatinship. I agree t maintain all frms I am required t cllect fr a perid f five (5) years. Identify all claim types that will be submitted during this Certificatin Perid: CLAIM TYPE 837P 1500 Claim Frm 837D Dental Claim Frm 837I UB4 Claim Frm Other DATE SUBMITTER SIGNATURE (ORIGINAL) NOTE: Updated certificatin frms MUST be submitted annually. Failure t maintain a cmpleted Certificatin Frm n file will result in the clsure f the submitter number withut ntice t submitter. All files submitted with clsed submitter numbers will be drpped frm the system withut being prcessed. This Certificatin Frm can nly be mailed t either address lcated belw. The frm can t be faxed r scanned and ed. Submit t: Mlina EDI Department, PO Bx 91025, Batn Ruge, LA Phne #: 225/ Or: 8591 United Plaza Blvd., Bldg. V, Suite 300, Batn Ruge, LA 70809

MEDICAID LOUISIANA (MCDLA) PRE-ENROLLMENT INSTRUCTIONS

MEDICAID LOUISIANA (MCDLA) PRE-ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Provider s Election to Employ Electronic Data Interchange of Claims for Processing in the Louisiana Medical Assistance Program