Free ForwardHealth Managed Care Trading Partner Profile Completion Instructions, F-13076A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13076A (07/08)

STATE OF WISCONSIN

FORWARDHEALTH

MANAGED CARE 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). Managed care trading partners may submit their completed Managed Care Trading Partner Profile, F-13076, by fax at (608) 221-0885 or by mail to the following address: ForwardHealth EDI Department 6406 Bridge Rd Madison WI 53784-0009 The Managed Care Trading Partner Profile may also be submitted through the Trading Partner area of the ForwardHealth Portal at www.forwardhealth.wi.gov/. PURPOSE OF MANAGED CARE TRADING PARTNER PROFILE The DHS requires managed care organizations (MCOs) to complete a Managed Care 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. GENERAL INSTRUCTIONS The DHS requires that one Managed Care Trading Partner Profile be completed for base managed care Provider Number. Accurate and timely completion of the form will prevent delays in testing and approval for production processing. Failure to supply the information requested by the form will prevent receiving the transactions from the DHS. The EDI Department will return incomplete forms to the originating party. SECTION I -- MANAGED CARE 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 managed care trading partner, select this box. Update Submission -- If this is a request to update Trading Partner information for an existing ForwardHealth managed care trading partner, select this box.

Trading Partner Identification Number If "Update Submission" is selected, enter the Trading Partner Identification Number. A Trading Partner ID is not required for initial submissions. SECTION II -- MANAGED CARE TRADING PARTNER INFORMATION Enter the following information about the Managed Care Trading Partner: · · · · · · Name -- Managed Care Trading Partner. Address Line 1 -- Managed Care Trading Partner. Address Line 2 -- Managed Care Trading Partner. City, State, ZIP+4 Code -- Managed Care 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 -- MANAGED CARE TRADING PARTNER TRANSACTION SETS Indicate the transaction sets that the managed care trading partner will receive. 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 MCO to conduct EDI-related business. Forms that are not signed and dated by the authorized representative will be returned.