Free ForwardHealth Trading Partner 835 Designation Completion Instructions, F-13393A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13393A (08/08)

STATE OF WISCONSIN

FORWARDHEALTH

TRADING PARTNER 835 DESIGNATION COMPLETION INSTRUCTIONS
The Department of Health Services (DHS) requires certain information to enable the DHS to authorize trading partners to exchange electronic transactions with ForwardHealth. Personally identifiable information about DHS providers is used for purposes directly related to the administration of ForwardHealth, such as processing provider claims for reimbursement. Failure to supply the information requested by this form will prevent the DHS from sending the provider's electronic X12 835 Health Care Claim Payment/Advice (835) transactions to a third-party Electronic Data Interchange (EDI) trading partner. This is a mandatory form. The EDI Department will not accept alternate versions of this form (i.e., retyped or otherwise reformatted). The completed Trading Partner 835 Designation form, F-13393, may be submitted by fax at (608) 221-0885 or by mail to the following address: ForwardHealth EDI Department 6406 Bridge Rd Madison WI 53784-0009 The Trading Partner 835 Designation form may also be submitted through the Provider area of the ForwardHealth Portal at www.forwardhealth.wi.gov/. PURPOSE OF TRADING PARTNER 835 DESIGNATION The DHS requires providers to complete a Trading Partner 835 Designation form containing specific provider and trading partner information to authorize the DHS to send the provider's 835 transaction to a third-party trading partner. The EDI Department must receive and process the form before the provider's 835 transaction will be sent to the authorized third-party trading partner. The Trading Partner 835 Designation form applies to any or all of the following ForwardHealth programs : · · · · · BadgerCare Plus. SeniorCare. Wisconsin Chronic Disease Program. Wisconsin Medicaid. Wisconsin Well Woman Program.

GENERAL INSTRUCTIONS The DHS only requires that one Trading Partner 835 Designation form be completed for each trading partner being authorized to receive the 835 transactions on the provider's behalf. Providers that possess multiple provider numbers should only return one form if only one trading partner is being designated for all provider numbers. Separate Trading Partner 835 Designation forms must be submitted if the provider has multiple provider numbers and is designating more than one trading partner or is designating different trading partners for transactions submitted on behalf of a provider for more than one ForwardHealth program. Accurate and timely completion of the form will prevent delays in sending the 835 transactions to the authorized trading partner. The EDI Department will return incomplete designation forms to the originating party. Providers that possess provider numbers for multiple ForwardHealth programs are required to supply each provider number for the 835 to be designated to the appropriate trading partner. SECTION I -- PROVIDER ADDRESS INFORMATION Enter the name and address information for the provider where correspondence should be sent. If the DHS is unable to process the form due to incomplete or invalid information, it will be returned to this address with a letter of explanation. If the DHS is able to process the form, a notification letter will be sent to the provider's "mail to" name and address on record. SECTION II -- PROVIDER NUMBER INFORMATION List the provider number(s) for each ForwardHealth program for the provider authorizing the trading partner identified in Section III of this form. Providers may list up to 10 provider numbers. The provider number listed must correspond with the provider name on file with ForwardHealth interChange. List additional provider number information on a separate form, if needed. SECTION III -- TRADING PARTNER INFORMATION Enter the name of the third-party trading partner that is being authorized to receive the 835 transaction. Provide the trading partner identification number assigned by the DHS to the trading partner. SECTION IV -- AUTHORIZED REPRESENTATIVE Enter the name and telephone number of the provider's authorized representative certifying that the trading partner identified in Section III is authorized to receive the 835 transactions on the provider's behalf. Forms that are not signed and dated by the authorized representative will be returned to the address entered in Section I.