Free ForwardHealth Trading Partner Profile, F-13043 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13043A (07/08)

STATE OF WISCONSIN

FORWARDHEALTH

TRADING PARTNER PROFILE 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 receipt of Electronic Data Interchange (EDI) transactions from the DHS. This is a mandatory form. The EDI Department will not accept alternate versions of this form (i.e., retyped or otherwise reformatted). Trading partners may submit their completed Trading Partner Profile, F-13043, 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 Profile may also be submitted online through the Trading Partner area of the ForwardHealth Portal at www.forwardhealth.wi.gov/. PURPOSE OF TRADING PARTNER PROFILE The DHS requires trading partners to complete a Trading Partner Profile containing specific transaction and contact information as the first step in the EDI enrollment process. The EDI Department must receive and process the form before trading partners may begin testing with the DHS. The Trading Partner Profile 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 Accurate and timely completion of the Trading Partner Profile will prevent delays in testing and approval for production processing. The EDI Department will return incomplete forms to the originating party. Providers Billing providers who exchange electronic transactions directly with ForwardHealth and possess multiple provider numbers may choose one of the following options: · To consolidate the exchange of EDI transactions for all or some of the provider numbers, only one Trading Partner Profile form should be submitted. A single Trading Partner Identification Number will be assigned for each consolidated set of provider numbers, enabling the trading partner to submit EDI transactions for the consolidated set of providers under a single Trading Partner ID. To consolidate the receipt of 835 Health Care Claim Payment/Advice (835) transactions for all or some of the provider numbers, a Trading Partner 835 Designation form, F-13393, must be submitted for each consolidated set of providers listing the provider number(s). Designate the appropriate trading partner that should receive the 835 transaction. Refer to the Trading Partner 835 Designation Completion Instructions, F-13393A, for further information. To exchange EDI transactions separately for each of the provider numbers, a separate Trading Partner Profile must be submitted. Separate Trading Partner IDs will be assigned.

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Clearinghouses, Billing Services, or Software Companies Exchanging Electronic Transactions with ForwardHealth Third-party trading partners that exchange electronic transactions on behalf of certified providers should only return one Trading Partner Profile, even if the trading partner represents multiple providers.

TRADING PARTNER PROFILE COMPLETION INSTRUCTIONS F-13043A (07/08)

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SECTION I -- TRADING PARTNER IDENTIFICATION NUMBER INFORMATION Type of Submission Select one of the following: · · Initial Submission -- If this is an initial request to become a ForwardHealth Trading Partner, select this box. Update Submission -- If this is a request to update Trading Partner information for an existing ForwardHealth Trading Partner, select this box.

Trading Partner Identification Number If "Update Submission" is selected, enter the nine-digit ForwardHealth interChange Trading Partner ID. If "Initial Submission" is selected, a Trading Partner ID is generated at the end of the process (do not lose this number). SECTION II -- TRADING PARTNER INFORMATION Enter the following information about the trading partner: · · · · · · Name -- Trading Partner. Address Line 1 -- Trading Partner. Address Line 2 -- Trading Partner. City, State, ZIP+4 Code -- Trading Partner. Name -- Electronic Data Interchange (EDI) Contact. (The EDI Contact does not need to be an individual person; it may be a department or unit.) Telephone Number -- EDI Contact.

SECTION III -- TRADING PARTNER TRANSACTION SETS Indicate the transaction sets that the provider will exchange. At least one selection is required. SECTION IV -- AUTHORIZED REPRESENTATIVE Enter the name and telephone number of the provider's authorized representative. The individual signing this form must be a representative authorized by the trading partner to conduct EDI-related business. Forms that are not signed and dated by the authorized representative will be returned. Note: After this form is accepted and processed by the DHS, the trading partner will receive a Trading Partner ID and personal identification number (PIN) to create a Portal user account to exchange EDI transactions. The mailings containing the Trading Partner ID and PIN will be addressed to the authorized representative identified in this section.