Trading Partner Profile Form

Revised October 25, 2007

Click here to download the offline, printer friendly version.

The State of Ohio EDI gateway needs specific information in order to begin electronic trading. This information is recorded in the following form. Please tab through the form to complete the required fields.
NOTE: If at any time the technical or business contacts for your company are changed, please fill out this form and submit it so that we may keep your profile up to date.

Data collected in this form is submitted via e-mail. Please make sure your browser is configured to send e-mail.

Trading Partner Company Information

Trading Partner Contact Information

EDI Testing and Connectivity Information

There are testing parameters to which a file must adhere. In addition, you will connect to the ODJFS EDI system through an upload/download directory for file transfers. The upload/download ID and Password will be assigned to you when the Medicaid Trading Partner Profile process is completed.

Click here to download EDI Testing and Connectivity Information.

Business Agreements

This online Medicaid Trading Partner Profile form is to be considered part of the business agreements between a Trading Partner and ODJFS. This form must be completed in order to test with ODJFS.

In addition, two (2) original Trading Partner Agreements must be submitted in hard copy via US Postal Service before ODJFS will process live transactions. Please download the Trading Partner Agreement, send two (2) originals, signed by the proper authorities within your organization, and mail to the following address:

Ohio Department of Job and Family Services
Office of Contract and Acquisitions
Trading Partner Agreements
30 East Broad St., 31st Floor
Columbus, Ohio 43215

NOTE: This Trading Partner Agreement must be on file with ODJFS as a prerequisite to submitting claims in production using EDI.

Certification and/or Validation Testing
(Optional to complete this section)

Are you currently certified with a Third Party Testing Service?

Yes No

Do you currently use a desktop or Internet testing tool for validation?

Yes No

If yes to either question, with what service or product are you currently certified or testing?

Are you certified to submit HIPAA-compliant data to Medicare?

Yes No

Are you certified to submit HIPAA-compliant data with any state agency?

Yes No

Name of state

Name of agency

Are you certified to submit HIPAA-compliant data with any other Payer?

Yes No

Name of other payer

Standards

Transaction Sets Submitted to the Ohio Department of Job and Family Services

Please select the transaction set(s) that you want to submit to ODJFS.

NOTE: ODJFS will acknowledge all transaction set(s) received with a 997 Functional Acknowledgment.

Transaction Sets to be Sent by the Ohio Department of Job and Family Services

The Ohio Department of Job and Family Services will send the following transaction sets:

Other Transactions required by the Ohio Department of Job and Family Services

NOTE: If a Trading Partner sends the 837 transaction set(s), an unsolicited X12-4010 277 transaction set, an X12-4010 824 transaction set and an X12-4010 997 transaction set must be able to be accepted and translated.

*The TA1 will be sent only for rejected transactions.

Comments

Please use the box below for any comments.

Please review all information before submitting this form.

For questions, contact ODJFS MMIS-EDI Support

MMIS-EDI Support
(614) 387-1212
MMIS-EDI-SUPPORT@odjfs.state.oh.us