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Mississippi Envision
Electronic Remittance Advice
Please complete the following Mississippi Medicaid EDI ERA Provider Agreement and Enrollment Form. Complete all areas of the form, unless otherwise indicated. You may contact the EDI Support Unit at 1-800-884-3222, Monday-Friday 8AM-5PM CST if you have any questions about the EDI ERA Provider Agreement and Enrollment Form or wish to inquire upon the status of a form that has already been submitted. If you wish to receive dual delivery (paper and electronic) of the Remittance Advices for at least 31 days or 3 payments, whichever is greater; please send a written request to the address, "Mississippi Medicaid Program,
Provider Enrollment, P.O. Box 23078, Jackson, Mississippi 39225". For further instructions please click here.
Provider Information
Provider Name*:
Provider Identifiers Information
Provider Federal Tax Identification Number (TIN)*:
or Employer Identification Number (EIN)  
National Provider Identifier (NPI)*:
Trading Partner ID:
Provider Contact Information
Provider Contact Name:
Title :
Telephone Number : Telephone Number Extension :
Email Address :
Fax Number :
Electronic Remittance Advice Information
Account Number Linkage to Provider Identifier: Provider Tax Identification Number (EIN/TIN)
(Must Match EFT Preference) National Provider Identification Number (NPI)
Method of Retrieval *:
Clearinghouse Information
If you have indicated that you plan to use the services of a Software Vendor to submit your transactions electronically to Conduent EDI Gateway, please provide the following information regarding your agent. Your Software Vendor is required to enroll and receive their unique Trading Partner ID to test with Conduent EDI Gateway. Please indicate your Software Vendor's Conduent EDI Gateway trading partner ID. Please contact your Software Vendor for this required information.
Clearinghouse Name :
Software Vendor Information
If you have indicated that you plan to use the services of a Software Vendor to submit your transactions electronically to Conduent EDI Gateway, please provide the following information regarding your agent. Your Software Vendor is required to enroll and receive their unique Trading Partner ID to test with Conduent EDI Gateway. Please indicate your Software Vendor's Conduent EDI Gateway trading partner ID. Please contact your Software Vendor for this required information.
Vendor Name :
Submission Information
Reason for Submission*: New Enrollment
  Change Enrollment
  Cancel Enrollment
Terms of Agreement
The Provider agrees to abide by the requirements for Administrative Simplification as defined in the provisions of the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) based on the compliance date of the final rules or a date mutually agreed upon between the Provider and the DOM or its designated Fiscal Agent.

The Provider agrees to abide by the requirements for EDI submissions and submitters as published in the appropriate DOM Electronic Transactions Submission Manual.

The Provider agrees to send and receive data in a manner that protects the integrity and confidentiality of the transmitted information according to the relevant provisions of state and federal laws and regulations.

The Provider agrees that if a Billing Agency or Clearinghouse is used for the submission of electronic transactions, the Billing Agency or Clearinghouse identified in Section III must have a Trading Partner Service Agreement on file with the DOM or its designated Fiscal Agent.

If using a Billing Agency or Clearinghouse, the Provider agrees to report information accurately and completely to the Billing Agency or Clearinghouse as required in the Appropriate DOM Electronic Transactions Submission Manual and agrees to be completely responsible for the electronic transactions generated from the information submitted to the DOM or its Fiscal Agent by the Billing Agency or Clearinghouse.

If using a Billing Agency or Clearinghouse, the Provider agrees to not use any Billing Agency or Clearinghouse except the one listed in Section III of this agreement until this EDI Agreement has been terminated in writing to the DOM or its designated Fiscal Agent.

If using an EDI software vendor for submission of electronic transactions, the Provider agrees to insure that all data meets the requirements for EDI submissions and submitters as published in the appropriate DOM Electronic Transactions Submission Manual.

If any information supplied in this EDI Agreement changes at any time during the Provider's enrollment in the Mississippi Medicaid program, the Provider agrees to notify the DOM or its designated Fiscal Agent immediately in writing. Failure to do so may invalidate this EDI Agreement.

Whenever necessary, this EDI Agreement may be amended by mutual consent of the DOM and the Provider to meet federal or other operational requirements. The Provider agrees that the EDI Submitter ID is confidential and is not transferable or assignable. This EDI Agreement is not transferable or assignable and may be terminated on thirty (30) days written notice by either party.

This EDI Agreement is automatically terminated in the event the Provider's license is revoked by the Appropriate Board, the Provider is disqualified through a federal administrative action, or as set forth in Miss. Code Ann. Section 43-13-121(l) (1972, as amended).

Authorized Signature
Printed Name of Person Submitting Enrollment : Submission Date :
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