STATE OF NEW YORK
DEPARTMENT OF HEALTH
eMedNY
NCPDP Batch Pharmacy Dial-Up User Manual
TABLE OF
CONTENTS
Section
3.0 eMedNY User Manual Notation
5.0 Hardware and
Software Requirements
6.1 ETIN Application for new submitters
8.0 ECSS File Formats
Supported
9.0 Obtaining an eMedNY User Access Key
11.0 Electronic File
Submission (upload)
12.0 Electronic File
Retrieval (download)
13.0 Informational
Documents Retrieval (download) 13.0.1
14.0 Environment
Configuration
15.0 Disconnecting from eMedNY
Certification
Statement For Provider Utilizing Electronic Billing
Provider
Electronic Transmission Identification Number (ETIN) Application
AGREEMENT for
eMedNY System ACCESS
Provider/Vendor
eMedNY Access Request Form
Every effort will be made to ensure the information contained in this document is as accurate as possible. However, information in the document is subject to change without notice and does not represent a commitment on the part of New York State or Computer Sciences Corporation (CSC).
Enhanced version(s) of this document will be available for retrieval (downloading) by accessing the New York State Medicaid Management Information System Electronic Gateway at CSC.
This
manual will be available on the eMedNY.org website at http://www.emedny.org/manuals/index.html.
Throughout
this document various acronyms may be used to represent programs, systems, entities,
and other information. Below is a cross-reference table listing those acronyms.
Abbreviation |
Description |
EG |
Electronic Gateway |
NYS |
New York State |
CSC |
Computer Sciences Corporation |
ETIN |
Electronic Transmission Identification
Number (a/k/a TSN) |
ECSS |
Electronic Claim Submission
System |
MMIS |
Medicaid Management Information
System |
MEDS |
Medicaid Encounter Data Set |
eMedNY |
New York State Medicaid System |
This document has been prepared to help facilitate the electronic submission of information to the eMedNY Contractor. Any comments or suggestions associated with this document should be forwarded to the address listed below:
Computer Sciences Corporation
Department: Provider Services
1 CSC Way
Rensselaer, New York 12144
The New York State Department of Health (DOH) has elected to provide Medicaid providers with the ability to submit data electronically to the Medicaid Management Information System (MMIS) eMedNY Contractor, CSC.
The eMedNY Electronic Gateway and supporting systems offer additional benefits to providers taking advantage of this method of claim submission. Listed below are a few of these benefits:
1. Reduced or eliminated manual handling of claim media and/or and related documents - Because the data is submitted electronically, the data entry of claim forms or the manual processing associated with magnetic media is no longer required, subsequently reducing the time required to prepare the data for entry into a processing cycle.
2. Accelerated return of submission information - Information with regard to the general acceptance of the data submitted will be available through the eMedNY for retrieval (downloading) within a short time frame.
Sources for eMedNY information can be found at the following:
· http://www.health.state.ny.us/
You will find typographical conventions used throughout this eMedNY User Manual. Below is a table of those conventions that may be utilized.
Typographical Convention |
Used for |
Double Quotes "Item" |
Anything that you must type exactly as it appears, including case
sensitivity. |
Single Quotes 'Item' |
Anything related to information that is specific to you, such as your
user identifier and password. |
Less Than, Greater Than <ENTER> |
Used to depict a specific key, or combination of keys, to depress. |
Bracketed [Item] |
Bracketed items depict actual screens or messages that you will
encounter when accessing the NYS-MMIS-EG. |
As enhancements are made to this User Manual, the revised user manual will be available for retrieval (Refer to Section 13.0 for the Informational Documentation Retrieval procedure) by accessing the eMedNY at CSC. This manual will be available on the eMedNY.org website at http://www.emedny.org/manuals/index.html.
Connecting to the EG may be accomplished by utilizing your personal computer, configured with a modem and communication software.
Listed below are the minimum hardware and software requirements necessary to utilize the eMedNY:
Hardware:
· Personal Computer with Windows 98, ME, 2000 or XP Operating System
· MODEM - capable of 1200 through 33600 BPS
· Available Telephone Line
Software:
Telecommunications software package capable of:
· Connection Rate 1200 - 33600 BPS
· Parity None
· Data Bits 8
· Stop Bits 1
· Protocol: Send to CSC Receive from CSC
Xmodem (Text)* Kermit
Ymodem Kermit
Zmodem Kermit
Kermit(BINARY)* Kermit
· Flow Control RTS/CTS
· Terminal Emulation Hyperterminal provided with Microsoft Windows 95 or greater, ANSI, VT100 and VT220.
* The Text/Binary option may not be available with all protocols.
New electronic implementations Providers or Service Bureaus who choose to
submit electronic/magnetic media must first apply for an Electronic Transmitter
Identification Number (ETIN), by completing a “Provider Electronic Transmitter
Identification Number Application” and a “Certification Statement for Provider
Utilizing Electronic Billing,” which must be notarized. Once signed and notarized, the Certification Statement MUST be sent for
each Provider to be enrolled under the ETIN. If you are presently certified
under Medicaid’s current certification process, there will be no need to
recertify until your annual Certification renewal is due.
Please send the signed and notarized “Certification Statement for
Provider Utilizing Electronic Billing” and the “Provider Electronic Transmitter
Identification Number Application” to the following address:
Computer
Sciences Corporation
Attention:
EMC Control, 1st floor
800
North Pearl Street
Albany,
NY 12204
In past implementations, the ETIN was known as TSN
(originally Tape Supplier Number and later Transmission Supplier Number).
Generally speaking, this number is used to identify the entity communicating
the transaction. The ETIN is also used to determine to whom or where the remittance
advice is to be sent.
Submitters wishing to use multiple ETIN’s must have a
Primary Electronic Transmitter Identification Number. The check balancing
information will be returned to the Primary ETIN. More information on the
selection process can be found on the website at https://www.hipaadesk.com/?nymedicaid.
A Primary ETIN selection form can be found there. You will only need to fill out
this form if you have multiple ETINs. Please fill out the form and return to:
Computer
Sciences Corporation
Attention:
EMC Control, 1st floor
800
North Pearl Street
Albany,
NY 12204
The eMedNY system is available 24 X 7. In the event of a system problem,
you may call CSC’s Provider Services Department at 800 343-9000.
User support is available Monday through Friday between 7:00 AM and 10:00 PM, and 8:30 AM to 5:30 PM on Saturday, Sunday and holidays. You may contact CSC’s Provider Services Department at 800 343-9000.
While the intent has been to provide sufficient concurrent telephone connections, it is possible that you may encounter a busy signal. Please try again at a later time.
The eMedNY EG currently supports the HIPAA compliant NCPDP Batch file format. Please refer to the eMedNY website at http://www.emedny.org/HIPAA/index.html for the NCPDP guide to obtain the correct file and record format. The electronic specifications contain the requirements and procedures that must be followed when submitting electronic media.
Access the NCPDP Companion Guides under the "News and Resources" tab on https://www.nyhipaadesk.com.
· National Council for Prescription Drug Programs (NCPDP) Companion Guide (REQUEST)
· National Council for Prescription Drug Programs (NCPDP) Companion Guide (RESPONSE)
Upon completion and subsequent filing of the electronic certification statement you will be given two pieces of information. The first is your user identifier and the second is your initial password. You will be required to change your password when you access the eMedNY the first time. Make sure you record your new password and store it in a secure place.
If you lose or forget any component of your access key, or suspect an unauthorized person may have knowledge of your access key, please call the CSC Provider Services Department immediately. You are responsible for any action taken on behalf of your account.
Refer to Security Packet B containing the forms to obtain an eMedNY user access key.
Connecting to Electronic Gateway |
|
Phone Number |
866-488-3007 |
Access Key |
|
User Identifier |
SUPPLIED BY CSC |
Password |
INITIALLY SUPPLIED BY CSC |
Note: The assigned user identifier and password are case sensitive. All sign on information must be entered exactly as assigned.
Once connected to the eMedNY EG, you will be prompted to login.
At this time you must specify your appropriate access key information (user identifier and password) to gain access to the EG.
The prompts for user identifier and password will resemble the following:
SunOS 5.8
login: 'your user identifier here' <ENTER>
Password: 'your password here' <ENTER>
Upon successfully entering your access key information you will be greeted with the EG banner shown below. After a few seconds the eMedNY system message(s) will be displayed. Please review the system message(s) before proceeding. You must depress the <ENTER> key to proceed beyond the system message screen(s).
ELECTRONIC GATEWAY |
Upon depressing the <ENTER> key while on the eMedNY system message screen(s), you will be presented with the following MAIN MENU:
NEW YORK STATE MEDICAID MANAGEMENT INFORMATION SYSTEM
ELECTRONIC GATEWAY
eMedNY
Tuesday, July 29, 2003 at 08:44:24AM
MAIN MENU
1. TRANSMIT (UPLOAD) FILE(S)
2. RETRIEVE (DOWNLOAD) FILE(S)
3. INFORMATIONAL DOCUMENTS
4. ENVIRONMENT CONFIGURATION
X. EXIT GATEWAY
ENTER OPTION DESIRED ...
The MAIN MENU provides the ability to electronically submit a file (upload), electronically retrieve a response or informational document file (download), customize your environment, and/or exit the EG. If option 1, 2, 3, or 4 is chosen, you will be presented with subsequent screens appropriate for the action chosen.
Selecting the TRANSMIT (UPLOAD) FILE(S) option will yield the following screen and related messages:
NEW YORK STATE MEDICAID MANAGEMENT INFORMATION SYSTEM
ELECTRONIC GATEWAY
eMedNY
Tuesday, July 29, 2003 at 08:49:47AM
eMedNY TRANSMIT MENU
1. TRANSMIT PRODUCTION BATCH FILE
2. TRANSMIT TEST BATCH FILE
X. EXIT TRANSMIT MENU
ENTER OPTION DESIRED ...
| |
The eMedNY TRANSMIT MENU provides the capability of submitting claims for a processing cycle or for electronic front-end testing.
When claims are submitted for production (option 1) they enter the next available payment processing cycle.
Claims submitted for test (option 2) enter the next available test processing cycle. The test submission capability is designed to allow providers to test how accurately their information has been formatted, and to provide minimal editing on the data transmitted, prior to submitting in a processing cycle.
All files submitted will be processed by the electronic front-end, provided the file format is acceptable. Please refer to Section 8.0 ECSS File Formats Supported, for the appropriate electronic media specifications.
A File Transmission Status File will be generated for each file transferred to the ECSS. This file will be prefixed with an "F" as the first character of the file name. Please refer to Section 12.0 for further details of the ECSS file naming convention.
A subsequent Electronic Front-End Response File will also be generated and returned to the eMedNY for each file that was in the correct format for editing. PLEASE NOTE, A RESPONSE FILE WILL ONLY BE GENERATED FOR FILES that are in the correct format for further editing. The response file will be prefixed with an "R" as the first character of the file name.
90-DAY LATE SUBMISSION REASON SELECTION
NEW YORK STATE MEDICAID MANAGEMENT INFORMATION SYSTEM
ELECTRONIC GATEWAY
eMedNY
Tuesday, July 29, 2003 at 08:49:47AM
90-DAY LATE SUBMISSION REASON SELECTION
1. LITIGATION
2. MEDICARE/INSURANCE PROCESSING DELAY
3. MEDICAID ELIGIBILITY DETERMINATION
4. REJECTION/DENIAL OF ORIGINAL CLAIM
5. ADMINISTRATIVE DELAY IN PRIOR APPROVAL
6. IPRO DENIAL/REVERSAL
7. INTERRUPTED MATERNITY CARE
(SELECTED) N. NOT APPLICABLE
X. SELECT AND CONTINUE PROCESSING
ENTER SELECTION ...
The 90-DAY LATE SUBMISSION REASON screen provides the capability of attaching a valid 90 day reason to the file submitted electronically. Simply select one of the valid reasons or N for not applicable, this is also the default value, then press X to continue.
Once the production or test indicator has been selected, you will be prompted to initiate your file upload transfer process with the message depicted below. Please note, the ECSS is designed to accept only one file transfer at a time. Multiple transfers within the same transmit session will not be successful.
Start your local XXXXXXX send. |
You must then begin the file transfer process associated with your communication software. Set your file transfer process to XXXXXXX, where XXXXXXX is your defaulted file transfer selection. Please refer to Section 14.0 for Environment Configuration section of this manual for further details associated with file transfer options. Once the file transfer process is initiated, many telecommunications software packages will generate some kind of file transfer status message. The file transfer status generated will give you an indication of how the actual transfer is progressing. Once the file transfer is completed, the eMedNY will generate one of the file transfer messages listed below.
If the file transfer is successful and is in the correct format for further editing, the following message will be displayed:
FILE TRANSFER SUCCESSFUL - xxxxxxx RECORDS RECEIVED
Please note that the above message does not mean that the records have been accepted into a processing cycle. When the file transfer is successful and in the correct format, further editing will be performed on the records, which will generate a response file. The response file contains the status of your claim submission after all pre-processing editing is complete. Files that successfully pass pre-processing edits will be entered into the next processing cycle for adjudication.
If the file transfer is successful and the file format is in error, the following message will be displayed:
FILE TRANSFER REJECTED - INVALID RECORD/FILE FORMAT
When the file transfer is rejected, the file will NOT be passed on to any subsequent editing routines, and will not be entered into any processing cycle. Therefore, a response file will NOT be generated. The erroneous file format must be corrected and resubmitted to CSC for processing.
Selecting the RETRIEVE (DOWNLOAD) FILE(S) option from the MAIN MENU will yield a screen similar to the following screen, and additional related messages:
NEW YORK STATE MEDICAID
MANAGEMENT INFORMATION SYSTEM
ELECTRONIC GATEWAY
eMedNY
Tuesday, July 29, 2003 at
08:55:38AM
eMedNY RETRIEVE MENU
XXXXX BYTES IN 1
FILE-TRANSFER AND/OR RESPONSE FILE(S)
C. COMPRESS ALL FILES
A. RETRIEVE ALL FILES
X. EXIT RETRIEVE MENU
ENTER OPTION DESIRED ...
Where XXXXX is the total number of bytes or characters in YY files.
Depicting the total number of bytes will help facilitate calculating or projecting the required download time associated with your hardware and software configuration.
When the ALL option is chosen, the eMedNY will begin the process of transmitting all of the files that are available for retrieval. That is, all File Transmission Status File(s), Electronic Front-End Response File(s), and any previously generated Download Log(s) will be transmitted to you.
You will be prompted to initiate your communication software's file transfer process with the following message:
Start your local KERMIT receive.
Once the file transfer is completed, the eMedNY will generate a message
similar to the following:
FILE TRANSFER SUCCESSFUL - xx FILE(S) SENT
All files generated by the eMedNY will be maintained by CSC for a limited time only; therefore, they should be retrieved as soon as possible to ensure availability. Once retrieved, the file(s) will be removed from the eMedNY and will not be available for subsequent retrieval.
An ECSS Download Log (ECSS_DWN) is created each time a request is made to retrieve any files available through the ECSS RETRIEVE MENU. The ECSS Download Log will be available through subsequent iterations of the ECSS RETRIEVE MENU.
All files transmitted to the eMedNY will be named with a Date/Time stamp. That is, a file submitted to the eMedNY at 1:30 PM on October 05, 2003, will receive the file name 031005133000 (YYMMDDHHMMSS format). As a result, all subsequently generated information file(s) associated with the file will be named similarly. For example, the related File Transmission Status File and Electronic Front-End Response File would be named F031005133000 and R031005133000, respectively.
In addition, all files available for retrieval may be suffixed with a 1-3 digit sequence number. Using the example depicted above the File Transmission Status File and Electronic Front-End Response File would be ultimately named F031005133000.1 and R031005133000.2, respectively.
The suffix or
sequence number on the right of the decimal should provide file name uniqueness
for your computer's operating system. Once retrieved, the files depicted above,
on a personal computer using the Disk Operating System (DOS), would appear as F0310051.1 and R0310051.2, respectively.
The file suffix or sequence number will be incremented by one until 999 is reached. Once 999 is reached, the sequencing will begin at 1 again.
Note: Due to restrictions within Terminal for Windows Communication Software, multiple files cannot be downloaded in one file transfer session. Therefore, users in a Windows environment may encounter difficulties when attempting to retrieve response and other files from the EG. You may contact CSC’s Provider Services Department at 800 343-9000 to check the status of these submissions.
Selecting the INFORMATIONAL DOCUMENTS option from the MAIN MENU will yield a screen similar to the following screen, and additional related messages:
NEW YORK STATE MEDICAID MANAGEMENT INFORMATION SYSTEM
ELECTRONIC GATEWAY
eMedNY
Tuesday, July 29, 2003 at 09:00:18AM
INFORMATIONAL DOCUMENTS
1. HIPAA.PDF (16000)
2. HOSTS.TXT (246)
3. USERMAN.HTM (56125)
4. USERMAN.WRI (51712)
A. ALL FILES
X. EXIT INFORMATIONAL DOCUMENTS
ENTER FILE/OPTION DESIRED ...
The INFORMATIONAL DOCUMENTS retrieval facility provides an electronic mechanism for the distribution of eMedNY and related documents (such as the files depicted above).
The screen depicts individual file information such as the associated file number (1), file name (HIPAA.PDF), and the number of bytes or characters associated with the file. The document retrieval facility allows the selection of individual files or all files.
Displaying the number of bytes per file will help facilitate calculating or projecting the required download time associated with the file(s) chosen and your hardware and software configuration.
You will be prompted to initiate your communication software's file transfer process with the following message:
Start your local KERMIT receive.
Once the file transfer is completed, the INFORMATIONAL DOCUMENTS retrieval facility will generate one of the following file transfer messages. The exact message will vary slightly depending on whether the RETRIEVE ALL FILES option or a specific file is chosen.
FILE TRANSFER SUCCESSFUL - xx FILE(S) SENT
FILE TRANSFER SUCCESSFUL - 1 FILE SENT
An Informational Documents Download Log (INFO_DWN) is created each time a request is made to retrieve any files available through the INFORMATIONAL DOCUMENTS MENU. The Informational Documents Download Log will be available through subsequent iterations of the ECSS RETRIEVE MENU.
The file suffix or sequence number described in Section 12.0 will also be applied to the Informational Documents Download Log. For example, a retrieval request for one or more informational documents will result in an Informational Documents Download Log named INFO_DWN.1.
The Environment Configuration option from the Main Menu is designed to facilitate selection of your preferred sending file transfer protocol. As the following graphic depicts, the eMedNY will support incoming file transfers in Kermit (Binary), Xmodem, Ymodem, and Zmodem protocols. Due to Kermit's extensive error correction mechanisms, all outgoing files sent from CSC to you will utilize the Kermit file transfer protocol until further notice.
NEW YORK STATE MEDICAID MANAGEMENT INFORMATION SYSTEM
ELECTRONIC GATEWAY
eMedNY
Tuesday, July 29, 2003 at 09:03:46AM
ENVIRONMENT CONFIGURATION
SEND / RECEIVE
1. KERMIT / KERMIT
2. XMODEM / KERMIT (DEFAULT)
3. YMODEM / KERMIT
4. ZMODEM / KERMIT
X. SAVE AND RETURN TO MAIN MENU
ENTER OPTION DESIRED ...
Until altered, the default sending and receiving file transfer protocols will be Kermit. Select the desired file transfer protocol for sending files to CSC and return to the main menu when finished.
Disconnecting from the eMedNY is accomplished by entering an "X" on the ECSS MAIN MENU. This action will log you off of the eMedNY and disconnect the telephone line.
1. Unable to connect to the eMedNY or supporting systems.
· Make sure all communication software settings are appropriate for your personal computer and modem configuration. For example, has the correct serial port been selected, etc.
· Refer to Section 5.0 Hardware and Software Requirements to ensure compliance.
eMedNY may be unavailable, call CSC’s Provider Services for assistance.
2. Unable to login to the eMedNY.
· Check all user access key information. User identifier and password information are case sensitive.
· Call CSC’s Provider Services for assistance.
3. Random characters showing up on the screen.
· Probably a bad connection. Noise or static on the line can result in bad or unrecognizable characters being transmitted to the Host. Disconnect and try again.
· Make sure your communications software is emulating a VT100 terminal.
· Call CSC’s Provider Services for assistance.
4. File transfers do not complete successfully.
· Check your communication software settings associated with file transfer protocol.
· The eMedNY will support incoming files transferred with Xmodem, Ymodem, Zmodem, and Kermit Binary. Outgoing files will be sent using the Kermit file transfer protocol only.
The following forms are included in the manual:
Certification Statement For Provider Utilizing Electronic Billing
Provider Electronic Transmission
Identification Number (ETIN) application
AGREEMENT for eMedNY System ACCESS
ETIN
______________ BILLING SERVICE NAME
(IF APPLICABLE) _______________________________________________
MEDICAID MANAGEMENT INFORMATION SYSTEM
As of (date) _____________, all claims
electronically submitted to the State’s Medicaid eMedNY Contractor, for
services or supplies furnished by (provider name)
_____________________________________________ (provider number)
_____________________ will be subject to the following certification.
I am (or the business entity named in this form of
which I am a partner, officer, or director is) a qualified provider enrolled
with and authorized to participate in the New York State Medical Assistance
Program and in the profession or specialties, if any, required in connection
with this claim; the persons providing services, care and supplies have the
necessary licensing, certification, training and experience to perform the claimed
services; I have reviewed these claims; I (or the entity) have furnished or
caused to be furnished the care, services, and supplies itemized and done so in
accordance with applicable federal and state laws and regulations; I have read
the Medicaid Management Information Systems Provider Manual and all revisions
thereto; all claims are made in full compliance with the pertinent provisions
of the Manual and revisions; all claims for care, services and supplies
provided at the order of another professional have to the best of my knowledge
been ordered by that professional in bona fide compliance with the procedures
set forth in the manual and revisions. All care, services and supplies for
which claim is made are medically necessary for the treatment of the named
recipient, the amounts listed are due and, except as noted, no part thereof has
been paid by, or to the best of my knowledge is payable from any other source
other than the Medical Assistance Program; payment of fees made in accordance
with established schedules is accepted as payment in full; other than a claim
rejected or denied or one for adjustment, no previous claim for the care,
services and supplies itemized has been submitted or paid; ALL STATEMENTS, DATA AND INFORMATION TRANSMITTED ARE TRUE, ACCURATE
AND COMPLETE TO THE BEST OF MY KNOWLEDGE; NO MATERIAL FACT HAS BEEN OMITTED; I
UNDERSTAND THAT PAYMENT AND SATISFACTION OF THIS CLAIM WILL BE FROM FEDERAL,
STATE AND LOCAL PUBLIC FUNDS AND THAT I MAY BE PROSECUTED UNDER APPLICABLE
FEDERAL AND STATE LAWS FOR ANY FALSE CLAIMS, STATEMENTS OR DOCUMENTS OR
CONCEALMENT OF A MATERIAL FACT; taxes from which the State is exempt are
excluded; all records pertaining to the care, services and supplies provided
including all records which are necessary to disclose fully the extent of care,
services and supplies provided to individuals under the New York State Medical
Assistance Program will be kept for a period of six years from the date of
payment, and such records and information regarding these claims and payment
therefore shall be promptly furnished upon request to the local or State
Departments of Social Services, the State Medicaid Fraud Control Unit or the
Secretary of the Department of Health and Human Services; there has been
compliance with the Federal Civil Rights Act of 1964 and with section 504 of
the Federal Rehabilitation Act of 1973, as amended, which forbid discrimination
on the basis of race, color, national origin, handicap, age, sex and religion;
I agree (or the entity agrees) to comply with the requirement of 42 CFR Part
455 relating to disclosures by providers; the State of New York through its
eMedNY Contractor or otherwise is hereby authorized to (1) make administrative
corrections to claims submitted under this agreement to enable its automated
processing, subject to reversal by the provider, and (2) accept the claim under
this agreement as original evidence of care, services and supplies furnished.
In submitting claims under this agreement I understand and
agree that I (or the entity) shall be subject to and bound by all rules,
regulations, policies, standards, fee codes and procedures of the New York
State Department of Social Services as set forth in title 18 of the Official
Compilation of Codes, Rules and Regulation of New York State and other
publications of the Department, including Medicaid Management Information
System Provider Manuals and other official bulletins of the Department. I
understand and agree that I (or the entity) shall be subject to and shall
accept, subject to due process of the law, any determinations pursuant to said
rules, regulations, policies, standards, fee codes and procedures, including,
but not limited to, any duly made determination affecting my (or my entity’s)
past, present or future status in the Medicaid program and/or imposing any duly
considered sanction or penalty.
I UNDERSTAND THAT MY SIGNATURE HEREON THE ABOVE
CERTIFICATION WILL APPLY TO ALL ELECTRONIC CLAIMS SUBMITTED, USING MY (OR THE ENTITY’S)
MEDICAID PROVIDER IDENTIFICATION NUMBER. THIS CERTIFICATION REMAINS IN EFFECT
AND APPLIES TO ALL CLAIMS UNTIL SUPERSEDED BY ANOTHER PROPERLY EXECUTED
CERTIFICATION STATEMENT.
(Signature)
__________________________________________________ (Date)
____________________________
(Typed Name and Title)
__________________________________________________________________________
STATE OF
________________________
COUNTY OF
______________________
On this _____________ day of
_________________, 20____, before me personally came
__________________________, to me know and known to me to the individual
described in and who executed the foregoing instrument, and (s)he acknowledge
to me that (s)he executed the same.
(SEAL)
______________________________________________________
NOTARY PUBLIC
To apply for your
Electronic Transmission Identification Number (ETIN), which is required in order to submit data electronically
for processing by the New York State MMIS or eMedNY, please complete the items
below and forward along with a Certification Statement to:
ATTN: MAGNETIC MEDIA liaison - FIRST FLOOR
CSC HEALTHCARE SERVICES
800 NORTH PEARL STREET
ALBANY, NY 12204
* PLEASE NOTE: If
you are adding a new Provider ID Number to an existing Electronic
Transmission Identification Number (ETIN) send ONLY the Certification Statement.
1. PROVIDER NAME:
__________________________________________________________
2. PRIVIDER ADDRESS:
_______________________________________________________
(STREET)
________________________________ _____________ _______________________
(CITY) (STATE)
(ZIP CODE + 4)
( )-______________________ _____________ ( )-____________________
(TELEPHONE NUMBER) (EXTENSION) (FAX Number)
3. ADMINISTRATOR'S NAME __________________________________________________
4. CONTACT PERSON'S NAME ____________________________________________
TELEPHONE NUMBER __________________________________________________
5. MMIS PROVIDER NUMBER(S) ____________________________________________
(NOT GROUP #)
SIGNATURE OF PERSON(S)
AUTHORIZED TO SIGN PROVIDER MAGNETIC INPUT TRANSMITTALS.
________________________________________ ______________________________________
(NAME PRINTED) (SIGNATURE)
________________________________________ ______________________________________
(TITLE) (DATE)
________________________________________ ______________________________________
(NAME
PRINTED) (SIGNATURE)
________________________________________ ______________________________________
(TITLE) (DATE)
SECURITY PACKET B
AGREEMENT for
eMedNY System ACCESS
Instructions for
Completion
1. Please read the Agreement. Your signature indicates acceptance to the terms and conditions of this Agreement.
2. Complete the information requested at the bottom of the Agreement form and sign the Agreement. Please print or type the following information:
a) Provider Number (Only for enrolled providers or vendors with an assigned Medicaid ID number. Otherwise leave this field blank.)
Enter your eight-digit Medicaid Provider ID Number, which was assigned by
the Department of Health at the time of your enrollment in the Medicaid
program.
b) Provider/Vendor Name
Enter the name of the Provider/Vendor that will be subject to the agreement. (If you have a Medicaid Provider ID, enter the name associated with the Provider ID Number entered above).
c) Street Address, City, State, Zip
Enter the address where you would like to receive correspondence from CSC. Please note that it must be a Street Address, not a P.O. Box.
d) By
Print the name of the authorized person who signs the Agreement.
e) Title
Print the title of the authorized person who signs the Agreement.
f) Date
Enter the date on which the Agreement is signed.
WHEREAS, the New York State Department of Health (the “Department”) and Computer Sciences Corporation (“CSC”), have entered into an agreement whereby CSC provides direct electronic access to MEDICAID eligibility verification, claims submission, and other electronic transactions, for Medical Providers/Vendors and their agents (Provider/Vendor) to the eMedNY System; and
WHEREAS, Provider/Vendor performs certain medical services and/or provides medical supplies for recipients who are eligible for MEDICAID benefits, or performs data processing services for such entities; and
WHEREAS, Provider/Vendor has requested direct electronic access to the eMedNY System;
NOW, THEREFORE, CSC and Provider/Vendor agree as follows:
1. CSC-eMedNY will supply to Provider/Vendor the technical specifications required to establish the link to the eMedNY System (Exhibit A). Provider/Vendor is responsible for all costs associated with complying with such requirements.
2. Provider/Vendor agrees to comply with the system requirements and any additional terms set forth on Exhibit A.
3. After Provider/Vendor has obtained initial access to the eMedNY System, Provider/Vendor agrees to re-test its link to the System in the event:
· Provider’s/Vendor’s link is changed or modified in any way, or
·
The technical
specifications change in response to Department mandated program changes
Provider/Vendor
agrees to follow CSC’s then current procedures for obtaining such access.
4. Provider/Vendor agrees to pay any damages that are caused by, result from, or are in any way attributable to Provider/Vendor, its employees’, agents’ and independent contractors’ negligent use of the eMedNY System, fraud or intentional misconduct or Provider’s/Vendors’ failure to certify or re-certify its link to the eMedNY System.
5. Provider/Vendor agrees to exercise due diligence in protecting Provider/Vendor systems so that malicious software is not introduced to eMedNY Systems.
6. Provider/Vendor accepts and agrees to comply with the Provisions of the attached eMedNY Security Agreement.
7. This Agreement shall become effective upon approval by CSC-eMedNY, on behalf of the New York State Department of Health and shall continue thereafter until terminated by either party on 60 days notice in writing.
By:
Provider Number Please
print name
By:
Provider/Vendor Name Signature
Title:
Street Address
Date:
City, State, Zip
AGREEMENT for
eMedNY System ACCESS
**EXHIBIT A**
SYSTEM REQUIREMENTS
1. Interactive Host-to-Host (CPU-CPU):
o SNA Protocol (LU6.2)
o Compliance with Data Stream Formats
2. Batch Host-to-Host:
o SNA Protocol
o Compliance with File Formats
3. Interactive PC-to-Host:
o Third Party Software:
· VISA-2 Protocol
· Compliance with Data Stream Formats
o Medicaid Eligibility:
· 233 MHz Pentium
· 32MB RAM
· 20 MB HDD
· 14400 BAUD Modem
· Windows 95
· Analog Telephone Line
4. Batch PC-to-Host (Dial-up FTP):
o Point-to-Point Protocol (PPP)
o TCP/IP Protocol with File Transfer Protocol (FTP)
o Compliance with File Formats
OTHER TERMS
1. Provider/Vendor shall order the telecommunication lines and equipment necessary to link Provider’s/Vendor’s system to the eMedNY System. Provider/Vendor will be responsible for monitoring, diagnosing and establishing dial backup on the telecommunication lines and equipment.
2. CSC does not provide consultation services beyond simple installation troubleshooting. For example, we cannot assist with the installation of the operating system or configuration issues involving the Provider’s/Vendor’s LAN, PC, modem or printer. CSC does not support Provider/Vendor hardware or software.
3. When CSC provides the State of New York Medicaid Eligibility software, the software is supplied “AS IS” AND CSC MAKES NO REPRESENTATIONS OR WARRANTIES, EXPRESSED OR IMPLIED, WITH RESPECT TO THE SOFTWARE. In no event shall CSC be responsible for any damage to Provider’s/Vendor’s property which arises out of or is related to Provider’s/Vendor’s use of the Medicaid Eligibility, claims submission, and other electronic transaction software.
4. For qualified Providers/Vendors, CSC will provide support for the Medicaid Eligibility, claims submission, and other electronic transaction software supplied by CSC, so long as CSC is the State of New York eMedNY contractor and Provider/Vendor has not altered or modified the software in any way.
PROVIDER/VENDOR
eMedNY Access Request Form
Instructions for Completion
Please type or print all required information.
1. User
Information (User is the Provider enrolled in the New York State Medical
Assistance Program [Medicaid] or the Vendor that supplies switch services to a
group of providers)
Name
q If you are an individual Provider, enter your last name, first name, and middle initial (if any)
q If the Medicaid Provider ID number applies to a business (i.e. Pharmacy, DME Supplier, Laboratory, etc.), enter the name of the individual authorized to sign the eMedNY Access Request on behalf of the provider organization.
q If you are a Vendor, enter the Company name.
Address
Enter the address where you would like to receive correspondence from CSC.
Indicate
Check the box (only one box please) that best indicate your user status. If you check the box next to Other, please explain.
Medicaid Provider ID (only
for enrolled providers or vendors with an assigned Medicaid ID number;
otherwise, leave this field blank.)
Enter your (or your organization’s) eight-digit Medicaid Provider ID Number, which was assigned by the Department of Health at the time of enrollment in the Medicaid program.
Phone Number
Enter the phone number at which you can be contacted.
2. Alternate
Access Required
Enter the reason for which you are requesting access to eMedNY.
3. Requestor
Information
Requestor’s Name
Enter the name of the authorized person requesting access to eMedNY.
Date
Enter the date on which the request was completed.
Phone Number
Enter the phone number at which CSC can contact you if necessary.
LEAVE SECTIONS 4 AND 5 BLANK. THESE ARE FOR CSC USE ONLY.
¨ 1.User Information |
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USER |
Last Name: |
First Name: |
Middle Initial: |
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I N F O R M A T I O N |
Address: |
Phone Number: |
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INDICATE:
q Medical Provider q Service Bureau q Connectivity Switch Provider/Vendor q Other _____________________ |
MEDICAID
PROVIDER ID: |
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¨
2.Alternate
Access Required (Please see exhibit A for minimum requirements) |
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P L A T F O R M |
FTP batch submission (Dial-up) |
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Business Reason / description
of access required: |
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¨ 3.Requestor Information |
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Requestor’s Name: |
Date: |
Phone Number: |
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¨ 4.Approvals (For CSC eMedNY Use Only) |
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A P P R 1 |
Approver’s Name: |
Signature: |
Date: |
Phone number: |
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A P P R 2 |
Approver’s Name: |
Signature: |
Date: |
Phone number: |
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¨
5.Administration (For CSC
eMedNY Data Security Use Only) |
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D A T A S E C U R I T Y |
Type of User ID
assigned: |
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Comments: |
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Administrator Name: Administrator Signature: Date: |
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Initial password |
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SECURITY
AGREEMENT FOR
NEW YORK
STATE-eMedNY SYSTEM
Instructions for
Completion
1. Please read the USERID AND PASSWORD RULES. By signing the Agreement you indicate acceptance to the terms and conditions of this Agreement.
2. Complete the information requested at the bottom of the Agreement form and sign the Agreement. Please type or print the following information:
a) Provider Number (only for enrolled providers or vendors with an assigned Medicaid ID number; otherwise leave this field blank).
Enter your eight-digit Medicaid
Provider ID Number, which was assigned by the Department of Health at the time
of your enrollment in the Medicaid program.
b) Provider/Vendor Name
Enter the name of the Provider/Vendor that will be subject to the agreement. (If you have a Medicaid Provider ID, enter the name associated with the Provider ID Number entered above).
c) Street Address, City, State, Zip
Enter the address where you would like to receive correspondence from CSC. Please note that it must be a Street Address, not a P.O. Box.
d) By
Print the name of the authorized person who signs the Agreement.
e) Title
Print the title of the authorized person who signs the Agreement.
f) Date
Enter the date on which the
Agreement is signed.
SECURITY
AGREEMENT
NEW YORK STATE-eMedNY SYSTEM
All users of Medicaid data and systems are required to affirm their understanding and agreement to comply with the following USERID and Password rules before access can be granted.
USERID AND PASSWORD RULES
A USERID and password will
be provided by CSC-eMedNY Data Security upon approval of this security
agreement. CSC, in accordance with the Federal Information Processing Standards
and the Privacy Act of 1974, requires that all users of the system be aware of
and comply with the following rules regarding USERIDS and Passwords:
a. USERIDS
and Passwords must not be shared with anyone. A USERID is assigned by
CSC-eMedNY Data Security solely to an individual and the individual is
responsible for all system activity related to that USERID.
b. After
four consecutive password violations (i.e., entering the wrong password) the
USERID is revoked. If this occurs CSC-eMedNY Data Security Administration
intervention is required to reactivate the USERID. Contact Provider Relations
to activate this intervention.
I have read and fully
understand the USERID and Password rules as set out above.
Please provide a unique identifier, which will be
used to authenticate this Provider/Vendor when corresponding via phone. This
identifier should be something only this Provider/Vendor knows and will be used
to verify that the Provider/Vendor is who they indicate they are when we are
asked to provide sensitive information such as account passwords.
Unique identifier
By:
Provider Number Please
print name
___________________________________
Provider/Vendor Name Signature
Title:
Street Address
Date:
City, State, Zip