MEDI-CAL (MC051) ERA ENROLLMENT INSTRUCTIONS

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MEDI-CAL (MC051) ERA ENROLLMENT INSTRUCTIONS WHICH FORM(S) SHOULD I DO? Electrnic Healthcare Claim Payment/Advice Receiver Agreement (ANSI ASC X12N 835-Transactin) WHERE SHOULD I SEND THE FORMS?

1 MEDI-CAL (MC051) ERA ENROLLMENT INSTRUCTIONS WHICH FORM(S) SHOULD I DO? Electrnic Healthcare Claim Payment/Advice Receiver Agreement (ANSI ASC X12N 835-Transactin) WHERE SHOULD I SEND THE FORMS? Mail the riginal frms t: Medi-Cal Fiscal Intermediary ATTN: HIPAA Help Desk PO Bx Sacrament, CA PLEASE NOTE: Faxed cpies are NOT accepted, riginals must be sent t Medi-Cal. WHO CAN SIGN THE FORM(S)? Medi-Cal enrllment requires the prvider s signature r president, CEO, r wner f a grup in BLUE INK! Signature must be ORIGINAL Signature must be in BLUE INK Signature must be by prvider r wner n file at Medi-Cal as authrized t sign Medi-Cal will nt accept signatures in black ink r signatures frm ffice managers r billers DO NOT use white ut Office Ally P.O. Bx Vancuver, WA Phne Fax:

2 ELECTRONIC HEALTH CARE CLAIM PAYMENT/ADVICE RECEIVER AGREEMENT (ANSI ASC X12N 835-Transactin) TYPE OF AUTHORIZATION: NEW CHANGE CANCEL IDENTIFICATION OF PARTIES This agreement is between the State f Califrnia, Department f Health Care Services (DHCS), hereinafter referred t as the Department, and the undersigned Prvider. PROVIDER INFORMATION The Electrnic Health Care Claim Payment/Advice Receiver Agreement (ANSI ASC X12N 835-Transactin) must be cmpleted and submitted by an active Medi-Cal Prvider. Rendering Prviders will need t use the Grup Prvider Number. Nn-prviders can receive an 835-Transactin (per prvider instructin); hwever, the authrizing Prvider must submit the agreement. A letter f acknwledgement will be ed t the prvider when pssible; therwise, the letter will be mailed t the prvider s service address. Imprtant Nte: The fllwing prvider infrmatin must match the current infrmatin n file with DHCS Prvider Enrllment, r the applicatin will nt be apprved. T verify if the prvider infrmatin is current, cntact the Medi-Cal Fiscal Intermediary r the Department f Health Care Services, Prvider Enrllment Divisin. If yur file is nt updated, submit a supplemental applicatin frm t DHCS Prvider Enrllment Divisin. PROVIDER NAME (full legal) DBA (if applicable) PROVIDER NUMBER Last 4 digits f Tax Identificatin Number r Scial Security Number PROVIDER SERVICE ADDRESS (number, street) CITY STATE ZIP CODE CONTACT PERSON CONTACT PERSON ADDRESS (number, street) CITY STATE ZIP CODE CONTACT PHONE NUMBER CONTACT ADDRESS Nte: Full legal name(s), assumed (DBA) name(s), and prvider number(s) are required. The prvider identified abve will be hereinafter referred t as the Prvider. Privacy Statement (Civil Cde Sectin 1798 et seq.) The infrmatin requested n this frm is required by the Department f Health Care Services fr purpses f identificatin and dcument prcessing. Furnishing the infrmatin requested n this frm is mandatry. Failure t prvide the mandatry infrmatin may result in yur request being delayed r nt be prcessed. RECEIVER INFORMATION A Prvider can designate up t tw entities t receive an 835-Transactin. The tw Receivers can be either the Prvider r an utside party (such as a billing service, clearinghuse, r anther prvider), r up t tw utside parties. A prvider must have a business assciate agreement with DHCS 6246 (Rev. 12/07) 1 f 5

3 utside parties wh are designated t receive the 835-Transactin. This business assciate agreement must be in cmpliance with 45 Cde f Federal Regulatins Sectin (e). A Prvider designated as a Receiver will need an active Prvider Number (Rendering Prvider Numbers may nt be used), and a Medi-Cal Pint f Service (POS) Netwrk/Internet Agreement Frm n file r submitted with this agreement frm. If a Cmputer Media Claims (CMC) Submitter Identificatin Number is used, a Medi-Cal Pint f Service (POS) Netwrk/Internet Agreement Frm is nt necessary. All nn-prviders authrized by the Prvider t receive an 835-Transactin must have a DHCS-issued Cmputer Media Claims (CMC) Submitter Identificatin Number n file. If the nn-prvider des nt have a CMC Submitter ID Number, they shuld cntact the CMC Help Desk, (916) t request a CMC Applicatin/Agreement Frm. The CMC Applicatin is als available at The authrizing Prvider must cmplete this sectin. Receiver #1 RECEIVER NAME (full legal) Office Ally, LLC RECEIVER ADDRESS (number, street) 1300 SE Cardinal Curt, Suite 190 CONTACT PERSON Custmer Service DBA (if applicable) RECEIVER PHONE NUMBER Optin 1 CITY STATE ZIP CODE Vancuver WA RECEIVER ID: (PROVIDER # r CMC SUBMITTER ID#) JQR Receiver #2 (ptinal) RECEIVER NAME (full legal) DBA (if applicable) RECEIVER PHONE NUMBER RECEIVER ADDRESS (number, street) CITY STATE ZIP CODE CONTACT PERSON RECEIVER ID: (PROVIDER # r CMC SUBMITTER ID#) BACKGROUND INFORMATION The Prvider/Receiver agrees t prvide the Department with the abve requested infrmatin in rder t verify qualificatins t act as a Receiver f the 835-Transactin. DEFINITIONS The terms used in this agreement shall retain rdinary meaning except thse terms defined in Title 22, Califrnia Cde f Regulatins, Sectin , which may, frm time t time, be amended. CHANGE IN RECEIVING ELECTRONIC 835-Transactin The Prvider/Receiver and the Department agree that any changes in Prvider/Receiver status, which might affect eligibility t receive 835-Transactins pursuant t Federal and State law, shall be prmptly cmmunicated t each party. Reference the Medi-Cal Prvider Manuals 835- Transactin sectin fr current prcedures n the recrd update prcess. CONFIDENTIALITY OF RECORD The Prvider/Receiver agrees t maintain adequate administrative, technical, and physical safeguards t prtect the cnfidentiality f prtected health infrmatin in accrdance with State and Federal statutes and/r regulatins, in particular 45 Cde f Federal Regulatins Parts 160 and 164. Any breach f security r unlawful disclsure f prtected health infrmatin shall be DHCS 6246 (Rev. 12/07) 2 f 5

4 reprted t the Department within 24 hurs f the Prvider/Receiver learning f such breach r disclsure and may be grunds fr terminatin f this Agreement. SCOPE OF SERVICE The Medi-Cal Fiscal Intermediary agrees t supply t Prvider/Receiver 835-Transactin Remittance Advice Detail (RAD) data fr adjudicated Medi-Cal claims fr Prviders wh have authrized the Department t send such infrmatin. The Medi-Cal Fiscal Intermediary will: (a) Lad weekly adjudicated Health Care Payment/Advice data (835-Transactin) t the Medi- Cal Internet Web site ( by the Medi-Cal warrant date. (b) Retain weekly adjudicated Health Care Payment/Advice data (835-Transactin) n the Medi-Cal Internet Web site fr six weeks. Fr RAD data beynd six weeks, reference the Medi-Cal Prvider Manuals fr instructins t rder a hard cpy RAD. Hard cpy RADs are required fr Claims Inquiry Frms/Appeals. (c) The Prvider will receive an ntificatin when the Electrnic Health Care Claim Payment/Advice Receiver Agreement applicatin is apprved. PROVIDER OBLIGATIONS The Prvider will: (a) Cmplete and submit t the Medi-Cal Fiscal Intermediary an Electrnic Health Care Claim Payment/Advice Receiver Agreement frm fr any additinal receivers f 835-Transactin data. A Prvider can designate up t tw entities t receive an 835-Transactin. The tw Receivers can be bth the prvider and an utside party (such as a billing service, clearinghuse, r anther prvider), r tw utside parties. All nn-prviders that have been authrized by a prvider t receive an 835-Transactin must have a Cmputer Media Claims (CMC) Submitter Identificatin Number n file and must have a business assciate agreement in effect between the nn-prvider and the prvider, which cmplies with 45 Cde f Federal Regulatins, Sectin (e). (b) Ensure that a current and cmplete Medi-Cal Pint f Service (POS) Netwrk/Internet Agreement frm and Electrnic Health Care Claim Payment/Advice Receiver Agreement frm are n file with the Medi-Cal Fiscal Intermediary. (c) Nt prvide the data supplied under this Agreement t any third party except the applicable agents fr whm the Prvider has authrized t prvide billing cllectin and/r recnciliatin services and which have a business assciate agreement in effect with the prvider, in cmpliance with 45 Cde f Federal Regulatins, sectin (e). The Prvider acknwledges that 835-Transactin data is cnfidential infrmatin wned by the State, the Medi-Cal Fiscal Intermediary, and/r applicable prviders. This prvisin shall survive the expiratin f this Agreement. (d) Regardless f whether the Prvider emplys a third party Receiver t access the 835-Transactin, the Prvider agrees t retain persnal respnsibility fr the receipt f all Health Care Payment/Advice (835-Transactin) infrmatin. (e) The Prvider/Receiver agrees t use their DHCS-issued CMC Submitter Identificatin Number and Prvider Identificatin Number (PIN) when accessing the Medi-Cal Internet Web site. The CMC Submitter ID Number will identify the Receiver and shall serve as acceptance t the terms and cnditins f the Department s Telecmmunicatins Prvider and Biller Applicatin/Agreement (DHCS Frm 6153). The Prvider further acknwledges the necessity f maintaining the privacy f the DHCS-issued CMC Submitter ID Number and agrees t bear full legal respnsibility fr use r misuse f the CMC Submitter ID Number and PIN if privacy is nt maintained. DHCS 6246 (Rev. 12/07) 3 f 5

5 (f) Upn review f all 835-Transactin data, if the Prvider/Receiver finds the data unreadable r incrrect, they are instructed t cntact the Medi-Cal Fiscal Intermediary fr reslutin. Failure t reprt any such data inaccuracies shall cnstitute acceptance theref. (g) The Prvider agrees t be respnsible fr the review and verificatin f the accuracy f claims payment infrmatin prmptly upn the receipt f any payment. The Prvider agrees t seek crrectin f any claim errrs thrugh the apprpriate prcesses as designated by the Department r its Fiscal Intermediary including, but nt limited t, the prcess set ut in Title 22, Califrnia Cde f Regulatins, Sectin 51015, as, frm time t time, amended. EFFECTIVE DATE This agreement shall becme effective upn apprval f the Department s authrizing agent. TERMINATION The Department r Prvider may terminate this agreement with r withut cause by giving 30 days prir written ntice f intent t terminate, and the Prvider has n right t appeal such terminatin by the Department. The Prvider/Receiver has n right t appeal terminatin fr cause pursuant t this subpart prir t the effective date f such terminatin. The Prvider/Receiver may appeal any grievance resulting frm the terminatin in accrdance with the prcedure established by Title 22, Califrnia Cde f Regulatins, Sectin 51015, as frm time t time, amended. PROVIDER/RECEIVER TO HOLD STATE OF CALIFORNIA HARMLESS The Prvider/Receiver agrees t hld the State f Califrnia harmless fr any and all failures t perfrm by the Receiver services, sftware, r ther features f 835-Transactins, which d nt ccur with paper (hard cpy) Remittance Advice Details. The Prvider/Receiver explicitly agrees that the Prvider/Receiver assumes any and all risks that accmpany receiving 835- Transactins, and that the Prvider/Receiver is nt relying upn the evaluatin, if any, the State has made f the electrnic receiver s system r sftware the Prvider/Receiver is using. Prvider/Receiver acknwledges that neither the Department nr its agent is respnsible fr errrs r prblems, including prblems f incmpatibility, caused by hardware r sftware nt prvided by the Department. Furthermre, the Prvider/Receiver acknwledges that if the electrnic Receiver system, sftware f Receiver cntracted with, is r has been listed as available in Medi-Cal bulletins, that such listing was nt an endrsement by the State f Califrnia nr des it imply that the service, system, r sftware has met r is cntinuing t meet a standard f perfrmance. LIMITATION OF LIABILITY The Department shall nt be liable t Prvider r any authrized Receiver fr any claim f, r damage r injury suffered by Prvider r any authrized Receiver caused by the Department s delay in furnishing the data supplied hereunder. Mrever, neither party shall be liable fr any damage amunts representing indirect, cnsequential (such as lss f business r lss f prfits), r punitive damages. Each party shall be excused frm perfrmance under this Agreement fr any perid and t the extent that it is prevented frm perfrming; in whle r in part, as a result f delays caused by the ther party, the State, r an act f Gd, war, civil disturbance, curt rder, labr dispute, r ther cause beynd its reasnable cntrl. DHCS 6246 (Rev. 12/07) 4 f 5

6 AGREEMENT BETWEEN PROVIDER AND ADDITIONAL THIRD PARTY RECEIVER (IF OTHER THAN THE PROVIDER OF SERVICE) The Prvider stipulates that any agreements with a Receiver t receive Medi-Cal 835-Transactins shall be in cnfrmance with State and/r Federal law gverning electrnic transactins and shall cntain prvisins including, but nt limited t, the fllwing: (a) The Prvider shall specifically designate the Receiver as the agent f the Prvider fr the purpse f receiving 835-Transactins fr the Prvider. As the Prvider s agent, the Receiver agrees t cmply with all Medi-Cal requirements n recrd making and retentin as established by statute and regulatin including, but nt limited t, Welfare and Institutins Cde, Sectin and and Title 22, Califrnia Cde f Regulatins, Sectin, The Receiver als agrees t cmply with state and federal laws n privacy f individually identifiable health infrmatin, including 45 Cde f Federal Regulatins Parts 160 and 164. (b) The parties shall agree that the Department will make available 835-Transactins t additinal Receivers nly as lng as the agreement between the Prvider and the Receiver including the business assciate prvisins required by 45 Cde f Federal Regulatins Sectin (e), remains in existence and in effect. The Prvider is required t ntify the Department in writing immediately upn any change in r terminatin f their agreement. In additin t the electrnic 835-Transactin, des the Prvider want t cntinue t receive the hardcpy RAD (Remittance Advice Detail Summary)? YES NO T be cmpleted by Prvider - CHECK APPROPRIATE BOX I hereby authrize the Califrnia Medicaid Prgram/Title XIX t lad my 835-Transactins t the Medi-Cal Internet Web site I hereby authrize the Califrnia Medicaid Prgram/Title XIX t update the previus 835-Receiver Agreement with the infrmatin n this frm. I hereby cancel my 835-Transactin authrizatin. FULL PRINTED NAME PROVIDER SIGNATURE INFORMATION TITLE PROVIDER SIGNATURE (ORIGINAL SIGNATURE REQUIRED; DO NOT USE BLACK INK) DATE Please return t Medi-Cal Fiscal Intermediary, HIPAA Help Desk, P.O. Bx 13029, Sacrament, CA This authrizatin remains in full frce and effect until the Califrnia Medicaid Prgram/Title XIX receives written ntificatin frm the Prvider f its terminatin, r until the Califrnia Medicaid Prgram/Title XIX r appinting authrity deems it necessary t terminate the agreement. DHCS 6246 (Rev. 12/07) 5 f 5

Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account

PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare ERA Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider Name