03/19/1997 Agreement •
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BRANCH OFFICE CLERK OF THE CIRCUIT COURT BRANCH OFFICE
3117 OVERSEAS HIGHWAY MONROE COUNTY 88820 OVERSEAS HICHWA*
MARATHON,FLORIDA 33050 500 WHITEHEAD STREET PLANTATION KEY,FLORIDA 33070
TEL.(305)289- 027 KEY WEST,FLORIDA 33040 TEL.(305)852-7145
FAX(305)289-1745 TEL(305)292-3550 FAX(305)852-7146
FAX(305)295-3660
MEMORANDUM
TO: Reggie Faros
Director of Public Safety
Attention: Stacy DeVane
FROM: Ruth Ann Jantzen
Deputy Clerk
DATE: April 11, 1997
At the March 19, 1997 County Commission Meeting,the Board granted approval
and authorized execution of an Electronic Data Interchange (EDI) Enrollment Form for
electronic submission of Medicare claims to Health Care Financing Administration
(HCFA) or to Health Care Financing Administration's Contractors.
Enclosed please find a duplicate original of the above Contract, executed on
behalf of Monroe County. Please be sure that one fully executed copy is returned to this
office as soon as possible.
If you have any questions regarding the above,please do not hesitate to contact
this office.
cc: County Attorney
Finance
County Administrator, w/o document
File
PLEASE RETURN ALL
PAGES. IF ALL PAGES
ARE NOT RECEIVED YOUR
ENROLLMENT FORM WILL
BE REJECTED.
TIM Enrollment Form
The provider agrees to the following provisions for submitting Medicare claims electronically to HCFA or to'
HCFA's contractors.
A. The Provider Agrees:
I. That it will be responsible for all Medicare claims submitted to HCFA by itself,its
employees,or its agents.
2. That it will not disclose any information concerning a Medicare beneficiary to any other
person or organization,except HCFA and/or its contractors,without the express written
permission of the Medicare beneficiary or his/her parent or legal guardian,or where
required for the care and treatment of a beneficiary who is unable to provide written
consent,or to bill insurance primary or supplementary to Medicare,or as required by State or Federal law.
3. That it will submit claims only on behalf of those Medicare beneficiaries who have given
their written authorization to do so,and to certify that required beneficiary signatures,or
legally authorized signatures on behalf of beneficiaries,are on file.
4. That it will ensure that every electronic entry can be readily associated and identified
with an original source document. Each source document must reflect the following
information.
• Beneficiary's name,
• Beneficiary's health insurance claim number,
• Date(s)of service,
• Diagnosis/nature of illness,and
• Procedure/service performed.
5. That the Secretary of Health and Human Services or his/her designee and/or the
contractor has the right to audit and confirm information submitted by the provider and
shall have access to all original source documents and medical records related to the
provider's submissions, including the beneficiary's authorization and signature. All
Incorrect payments that are discovered as a result of such an audit shall be adjusted
according to the applicable provisions of the Social Security Act, Federal Regulations,
and HCFA guidelines.
6. That it will ensure that all claims for Medicare primary payment have been developed for
other insurance involvement and that Medicare is the primary payer.
7. That it will submit claims that are accurate,complete,and truthful.
8. That it will retain all original source documentation and medical records pertaining to
any such particular Medicare claim for a period of at least 6 years, 3 months after the bill
is paid.
9. That it will affix the HCFA-assigned unique identifier number oftheprovider on each
claim electronically transmitted to the contractor.
•
I . That the HCFA-assigned unique identifier number constitutes the provider's legal
electronic signature and constitutes an assurance by the provider that services were
performed as billed.
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11. That it will use sufficient security procedures to ensure that all transmissions of
documents are authorized and protect all beneficiary-specific data from improper access.
12. That it will acknowledge that all claims will be paid from Federal funds,that the
submission of such claims is a claim for payment under the Medicare program,anjthat
anyone who misrepresents or falsifies or causes to be misrepresented or falsified any
record or other information relating to that claim that is required pursuant to this
Agreement may, upon conviction,be subject to a fine and/or imprisonment under
applicable Federal law.
13. That it will establish and maintain procedures and controls so that information
concerning Medicare beneficiaries,or any information obtained from HCFA or its
contractor,shall not be used by agents,officers,or employees of the billing service
except as provided by the contractor (in accordance with §1106(a)of the Act).
14. That it will research and correct claim discrepancies.
IS. That it will notify the contractor or the HCFA within 2 business days if any transmitted
data are received in an unintelligible or garbled form.
B. The Health Care Financing Administration will:
1. Transmit to the provider an acknowledgment of claim receipt.
2. Affix the intermediary/carrier number,as its electronic signature,on each remittance
advice sent to the provider.
3. Ensure that payments to providers are timely in accordance with HCFA's policies.
4. Ensure that no contractor may require the provider to purchase any or all electronic
services from the contractor or from any subsidiary of the contractor or from any
company for which the contractor has an interest. The contractor will make alternative
means available to any electronic biller to obtain such services.
5. Ensure that all Medicare electronic bitters have equal access to any services that
HCFA requires Medicare contractors to make available to providers or their billing
services regardless of the electronic billing technique or service they choose. Equal
access will be granted to any services the contractor sells directly, indirectly,or by
arrangement.
6. Notify the provider within 2 business days if any transmitted data are received in an
unintelligible or garbled form.
NOTICE-
Federal law shall govern both the interpretation of this document and the appropriate jurisdiction and venue for
appealing any final decision made by HCFA under this document.
This document shall become effective when signed by the provider. The responsibilities and obligations contained
in this document will remain in effect as long as Medicare claims are submitted to HCFA or the contractor. Either
party may terminate this arrangement by giving the other party(30)days written notice of its intent to terminate. In
the event that the notice is mailed,the written notice of termination shall be deemed to have been given upon the
date of mailing,as established by the postmark or other appropriate evidence of transmittal.
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•
C. Signahvr•
1 am authorized to sign this document on behalf of the indicated party and 1 have read and agreed to the foregoing
provisions and acknowledge same by signing below:
Provider's Name ^^
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WOnma (aAn UMdrG snCV /"6 Clcf .1i. Seri/II'dn5
Title / /
990 63 cci Sfrea+/( 3LAC-ke /75
Address
r7
City/State/Zip
By
Title
IS D vL «KOLRNSEERKAApPpOVED SUFFICIEN
Date 310101 D Y S NNE • B
p N
DATE R `�
PLEASE P IDE FOLLOWING MEDICARE INFORMATION
- Billing Service
ysici /Suppli r A ou sp.Administrator Signature
Name of Company
Sender Number: '-- Clearing House
Contact Person: Ere 1y L. $to I/ Name of Company
Telephone Number: 305 2 ? -6003
Type of Claim: Medicare Part A
(ledicare Pa�
Medicare B Physician/Supplier/PA Group Provider Number: Aogrt/
Madicara A 4 digit Provider Number: I
PA Groupe should complete the reveres aide for Medicare B only
Page 3 of 4
For PA Groups Only: PA Group#
To expedite the processing of your agreement,please provide the name,signature,provider number,and date of all
physicians billing under this PA Group.
Physician's
Provider
Name(Signature!) Name(Printed) Number w/suffix Date
Page 4 of 4
NEW ELECTRONIC SENDER INSTALLATION / CHANGE OF VENDOR FORM
To avoid delay in processing, please complete every section that applies. If you need assistance with this form,
please contact your vendor.
"I SECTION Al. TYPE APPLICATION: SECTION A2. TYPE LOCATION:
(Please Check One! (Please Check One)
'14 New Installation (sender number application) Provider/Supplier/Facility
(Complete entire form)
Li Change of Vendor (Changing software support 0 Billing Service/Clearing House/Service Bureau
company) (Complete sections A-C only)
SECTION B. SENDER LOCATION INFORMATION: (to be completed by provider location)
Location Name: mOncoia coon a'i tCkAn5/ Corn»7,;s5 C)n€IS
Tax ID or Health Industry Number (HINT: 5^7- &0007(/9 I
Mailing Address: WO (03cd Street Ocean Sfn (‘iv /75
City/State/Zip: /TIC✓q-i-incif) F7 3305o A
Contact Name #1: L.rn. /V („ 5ya/l Position/Title: Atfl& !gnte-g t/, n L
Contact Name #2: / Position/Title:
Telephone Telephone
#1 1 365 ) l9- 6003 #2 (
FAX # ( 3os ) P ' - ((0/3
If location currently files automated claims, indicate sender#:
Comment(s):
SECTION C: VENDOR INFORMATION (to be completed by software support vendor)
Company Name: Woo-} eomf)liciTtr 3(2CII Crts
Mailing Address: 70 -Sax. 3Y9
City/State/Zip: LJeSi Un;0>7 , IA CuI75 -031f9
Contact Name: Position/Title:
Telephone
Number: ( 3/ 9 I Clad - 5L35? FAX# 13)? ) N -5)Y7
Comment(s):
INTERNAL USE ONLY : DO NOT WRITE INSIDE THIS BLOCK
Production Sender Code: Remote No: Par Status:
Source: Week Processed:
Estimated Medicare B claims volume monthly: Vendor Number:
Revised: April 1996
Page 1 of 4
SECTION D. TYPE FORMAT (to be completed by software support vendor)
(complete information within applicable format 1, 2 or 3)
1. NATIONAL STANDARD FORMAT (NSF)
(a.) Lines of Business (check all that apply):
❑ Medicare B ❑ Medicare A ❑ Blue Shield ❑ Health Options
(b.) Communication Type (check one of the following):
LI Asynchronous (continue to Section El or,
❑ Bisynchronous (complete information below)
Select one for each of the three characteristics listed below:
LI Blocked or ❑ Compressed or ❑ Transparent or
Un-blocked ❑ Non-Compressed ❑ Non-Transparent
Type Protocol (check one): ❑ 2780 ❑ 3780
2. AMERICAN NATIONAL STANDARDS INSTITUTE (ANSI) 837 CLAIMS FORMAT:
(Medicare A and B only at this time)
(a.) Lines of Business (check all that apply): ❑ Medicare B ❑ Medicare A
(b.) Communications Type (check one of the following):
:1 Asynchronous
U. Bisynchronous
(c.) Envelope:
Sender Qualifier & ID (Tax/Mailbox ID) (ISA 06):
Receiver Qualifier & ID (ISA 08): (use 592-015-694)
Application Sender Code (GS 02):
Application Receiver Code-Part A (GS 03): (use MEDA00090EMC)
Application Receiver Code-Part B (GS 03): (use MEDBCLM00590)
Implementation Version (3051, etc.):
HCFA Version (REF 01) (3A, 3B, etc.):
Revised: April 1996
(Page 2 of 4)
•
3. COMMON FORMAT (Proprietary format for Blue Cross Blue Shield of Florida)
(Not available for Medicare Part A or HI
(a.) Lines of Business (check all that apply):
❑ Blue Shield ❑ Blue Cross ❑ Health Options
(b.) Communication Type (check one of the following):
❑ Asynchronous (continue to Section El or.
❑ Bisynchronous (complete information below)
Select one for each of the three characteristics listed below:
❑ Blocked or ❑ Compressed or ❑ Transparent or
❑ Unblocked ❑ Non-Compressed ❑ Non-Transparent
Type Protocol (check one): ❑ 2780 ❑ 3780
SECTION E. MAILBOX REQUEST (to be completed by software support vendor)
(this is a means of communication that is determined by the software support vendor)
To obtain a MAILBOX, check here ❑
(Important: If checked, Tax ID or HIN must be indicated on page 1)
SECTION F. PROVIDER/SUPPLIER/PA GROUP/FACILITY NUMBERS
INDIVIDUAL PROVIDERS (not in group): List all individual provider numbers assigned by Blue Cross Blue Shield
of Florida, Inc. that will be submitting claims via this sender location. PLEASE INDICATE SUFFIXIES) IF
APPLICABLE.
Provider
Number
``// Suffix Provider Name
(please print or type) (`
AOgg -^ /'/nnine Cnun r�cc df 0Clart Comm3S:ondf.5
Revised: April 1996
Page 3 of 4
•
GROUP OF PROVIDERS: List the PA Group number assigned by Blue Cross Blue Shield of Florida, Inc. that will
be submitting claims via this sender location, followed by the provider(s) individual number(s). PLEASE INDICATE
APPLICABLE SUFFIXIES).
PA GROUP
Number Suffix Provider Namg (please print or type)
PROVIDERS WITHIN GROUP (Please indicate appropriate suffixles) assigned to the above group)
Number Suffix Provider Name (please print or type)
NOTE: If additional PA Group numbers or physicians will be submitting claims via this sender location at any time in
the future, you must notify the Medicare EDI Department by submitting a signed EDI Enrollment Form indicating
your sender number.
RETURN COMPLETED FORMS TO:
Mailing Address: Physical Address: le. g. Federal Express, etc.)
Blue Cross Blue Shield of Florida Blue Cross Blue Shield of Florida
Medicare EDI (a. k. a. PES) Medicare EDI (a. k. a. PES)
P. a Box 44071 - 6 Tower 532 Riverside Ave. - 6 Tower
Jacksonville, FL 32231-4071 Jacksonville, FL 32202
Attention: Kathy Hart
QUESTIONS/CONCERNS:
If you have any questions or concerns after reviewing the "Completion Requirements" please feel free to contact
the Medicare EDI Department (9041791-8608 or Provider Electronic Services (PES) Marketing (904)791-8767.
Revised: April 1996
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