Providers

Electronic Data Interchange (EDI) Information

Trading Partner Enrollment — Trading Partner Profile Completion Instructions

MANAGED CARE TRADING PARTNER PROFILE
COMPLETION INSTRUCTIONS

Use of this form is mandatory. The DHCF Electronic Data Interchange (EDI) Department will not accept other versions (i.e., retyped or otherwise reformatted) of this form.

INSTRUCTIONS: Return the completed form using one of the following:

PURPOSE OF MANAGED CARE TRADING PARTNER PROFILE FORM
The DHCF requires managed care organizations to complete a trading partner profile form containing specific transaction and contact information as the first step in the DHCF EDI enrollment process. The DHCF EDI Department must receive and process the profile form before trading partners may begin testing with the DHCF.

GENERAL INSTRUCTIONS FOR COMPLETING THE MANAGED CARE TRADING PARTNER PROFILE FORM
The DHCF only requires that one profile form be completed for each managed care organization, even if the managed care organization possesses multiple provider numbers. Accurate and timely completion of the profile form will prevent delays in testing and approval for production processing. The DHCF EDI department will return incomplete forms to originating party.

SPECIFIC FIELD INSTRUCTIONS FOR COMPLETING THE TRADING PARTNER PROFILE FORM

SECTION I — TRADING PARTNER INFORMATION
For each of the following fields enter the information for the managed care organization responsible for the direct exchange of electronic transactions with the DHCF.

Name — Organization
Address Line 1 — Organization
Address Line 2 — Organization
City, State, Zip Code — Organization

For each of the following fields enter the information for the primary contact within the managed care organization responsible for business related issues, concerns, and questions related to the exchange of electronic transactions with the DHCF. The contact does not need to be an individual person and may be a department or unit within the organization.

Name — Primary Contact Name
Address Line 1 — Primary Contact
Address Line 2 — Primary Contact
City, State, Zip Code — Primary Contact
Telephone Number — Primary Contact
Fax — Primary Contact
E-mail Address — Primary Contact

For each of the following fields enter the information for the technical contact within the managed care organization responsible for network issues, concerns, and questions related to the exchange of electronic transactions with the DHCF. The contact does not need to be an individual person and may be a department or unit within the organization.

Name — Technical Contact
Address Line 1 — Technical Contact
Address Line 2 — Technical Contact
City, State, Zip Code — Technical Contact
Telephone Number — Technical Contact
Fax — Technical Contact
E-mail Address — Technical Contact

SECTION II — TRADING PARTNER TRANSACTION SETS
For each of the applicable programs, indicate the transaction sets that you will exchange by checking the applicable box.

SECTION III — INDIVIDUAL COMPLETING FORM
For each of the following fields enter the information for the individual responsible for completing the trading partner profile form. Forms that are not signed and dated will be returned.

Name — Individual Completing Form
Telephone Number — Individual Completing Form
FAX Number — Individual Completing Form
E-mail Address — Individual Completing Form
Signature — Individual Completing Form
Date Signed

SECTION IV — OFFICE USE ONLY
Do not write in this section.