Free INDIANA STATE DEPARTMENT OF HEALTH - Indiana

TRADING PARTNER AGREEMENT ELECTRONIC DATA INTERCHANGE (EDI)
State Form 51402 (R/1-08) / Part of State Publication 286

Indiana State Department of Health

This document constitutes an agreement to the following provisions for exchanging Electronic Data Interchange (EDI) between the Trading Partner listed under the Signatures heading in this agreement and the Indiana State Department of Health (ISDH). A. Definitions. 1. "HIPAA" means the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder. 2. "PHI" means protected health information as defined by HIPAA, but limited to the PHI that is exchanged between the parties to this agreement. 3. "Confidential Information" means information concerning ISDH health plan participants or any information obtained by Trading Partner from ISDH. 4. "Providers" are healthcare providers who are clients and Business Associates of Trading Partner, as defined under the Administrative Simplification provisions of HIPAA. B. The Trading Partner agrees: 1. That it will conform to the requirements of HIPAA as concerns PHI and that it will take no action which adversely affects ISDH's HIPAA compliance. 2. That it will promptly notify ISDH of any and all unlawful or unauthorized disclosures of Confidential Information or PHI that come to its attention and that it will cooperate with ISDH in the event any litigation arises concerning the unauthorized use, transfer, or disclosure of either confidential information or PHI. 3. That it will use sufficient security procedures to ensure that all HIPAA transmissions with ISDH are authorized and to protect all participant-specific PHI from improper access. 4. That all files it transmits to ISDH will comply with the national Electronic Data Interchange (EDI) Transaction Set Implementation Guide effective on the date of transmission. 5. That it will establish and maintain procedures and controls so that Confidential Information shall not be used by agents, officers, or employees of the trading partner other than for its intended purpose. 6. That the information stated in any EDI Trading Partner Profile(s) submitted with this Agreement, or subsequently, is correct and complete. 7. That it will allow ISDH 30 days after receipt of written notice from the provider if there is any change in the trading partner representative or location where electronic transactions are sent. 8. That it is bound by written agreement with the provider to comply with state and federal law, if the Trading Partner is an intermediary for the billing provider.

ISDH ­ EDI Provider Relations Trading Partner Agreement EDI Trading Partner Agreement

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C. Indiana State Department of Health agrees: 1. That it will conform to the requirements of HIPAA as concerns PHI and that it will take no action which adversely affects the trading partner's HIPAA compliance. 2. That it will use sufficient security procedures to ensure that all HIPAA transmissions are authorized and to protect all participant-specific PHI from improper access. 3. That all files it transmits to Trading Partner will comply with the national Electronic Data Interchange (EDI) Transaction Set Implementation Guide effective on the date of transmission. D. Both parties agree: 1. That data transmitted between them will not be considered as received and no responsibility assigned until accessible at the receiving party's computer. 2. That upon receiving any HIPAA transaction from the other, to prepare and transmit a timely response or an acknowledgment of transaction receipt. If acceptance of a transaction is required, a document is not considered received until an acceptance acknowledgement is returned. 3. That it will notify the other party within a reasonable time frame if any transmitted data are received in an unintelligible or garbled form. 4. That it will provide and maintain the equipment, software, services, and testing necessary to transmit data with the other party. 5. That it will conduct business and perform under this agreement as required by this agreement and as required by any applicable rules or regulations. 6. That this agreement will remain in effect until terminated by either party with at least 30 days prior written notice. The notice will specify the effective date of termination, but will not affect the obligations or rights of either party prior to the effective date of termination. This agreement is automatically terminated in the event the Trading Partner or provider is disqualified through a federal administrative action or state action. 7. That any document transmitted according to this agreement will be considered an original and signed when received electronically. Neither party will contest the validity or enforceability of signed documents under any applicable law concerning whether certain agreements must be signed in writing to be binding. Neither party will contest the admissibility of copies of signed documents under the business records exception to the hearsay rule, the best evidence rule, nor the basis that the signed documents were not originated in documentary form. 8. That neither party will be liable to the other for any special, incidental, exemplary, or consequential damages resulting from any delay, omission, or error in the electronic transmission or receipt of any document, even if either party has been advised such damages are possible. 9. That both parties will attempt to resolve any issues relating to this agreement.

ISDH ­ EDI Provider Relations Trading Partner Agreement EDI Trading Partner Agreement

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E. Signature: I am authorized to sign this document on behalf of the indicated party and I have read and agree to the foregoing provisions and acknowledge same by signing below.

Trading Partner: _________________________

Authorized Signature: ____________________________

Title of Authorized Signatory: ____________________________

Date: ______________

Address: _______________________________________

City: _________________ State: _______ ZIP +4: __________

Phone: ___________________________

Remittance Address: Indiana State Department of Health Office of HIPAA Compliance EDI Division 3K 2 North Meridian Street Indianapolis, IN 46204-3010 317-233-9803

ISDH ­ EDI Provider Relations Trading Partner Agreement EDI Trading Partner Agreement

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