Regional Generic Provider Agreement - Ohio Department of Job and ...
Regional Generic Provider Agreement - Ohio Department of Job and ...
Regional Generic Provider Agreement - Ohio Department of Job and ...
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Appendix C<br />
Covered Families <strong>and</strong> Children (CFC) population<br />
Page 17<br />
Electronic Data Interchange<br />
The MCP shall comply with all applicable provisions <strong>of</strong> HIPAA including<br />
electronic data interchange (EDI) st<strong>and</strong>ards for code sets <strong>and</strong> the following<br />
electronic transactions:<br />
Health care claims;<br />
Health care claim status request <strong>and</strong> response;<br />
Health care payment <strong>and</strong> remittance status;<br />
St<strong>and</strong>ard code sets; <strong>and</strong><br />
National <strong>Provider</strong> Identifier (NPI).<br />
Each EDI transaction processed by the MCP shall be implemented in<br />
conformance with the appropriate version <strong>of</strong> the transaction implementation<br />
guide, as specified by applicable federal rule or regulation.<br />
The MCP must have the capacity to accept the following transactions from the<br />
<strong>Ohio</strong> <strong>Department</strong> <strong>of</strong> <strong>Job</strong> <strong>and</strong> Family services consistent with EDI processing<br />
specifications in the transaction implementation guides <strong>and</strong> in conformance with<br />
the 820 <strong>and</strong> 834 Transaction Companion Guides issued by ODJFS:<br />
ASC X12 820 - Payroll Deducted <strong>and</strong> Other Group Premium Payment for<br />
Insurance Products; <strong>and</strong><br />
ASC X12 834 - Benefit Enrollment <strong>and</strong> Maintenance.<br />
The MCP shall comply with the HIPAA m<strong>and</strong>ated EDI transaction st<strong>and</strong>ards <strong>and</strong><br />
code sets no later than the required compliance dates as set forth in the federal<br />
regulations.<br />
Documentation <strong>of</strong> Compliance with M<strong>and</strong>ated EDI St<strong>and</strong>ards<br />
The capacity <strong>of</strong> the MCP <strong>and</strong>/or applicable trading partners <strong>and</strong> business<br />
associates to electronically conduct claims processing <strong>and</strong> related transactions in<br />
compliance with st<strong>and</strong>ards <strong>and</strong> effective dates m<strong>and</strong>ated by HIPAA must be<br />
demonstrated, to the satisfaction <strong>of</strong> ODJFS, as outlined below.<br />
Verification <strong>of</strong> Compliance with HIPAA (Health Insurance Portability <strong>and</strong><br />
Accountability Act <strong>of</strong> 1995)<br />
MCPs shall comply with the transaction st<strong>and</strong>ards <strong>and</strong> code sets for sending<br />
<strong>and</strong> receiving applicable transactions as specified in 45 CFR Part 162 – Health<br />
Insurance Reform: St<strong>and</strong>ards for Electronic Transactions (HIPAA regulations)<br />
In addition the MCP must enter into the appropriate trading partner agreement <strong>and</strong><br />
implemented st<strong>and</strong>ard code sets. If the MCP has obtained third-party certification