Wyoming Medicaid Edi Application PDF Details

The Wyoming Medicaid EDI Application sets forth a meticulous framework for providers to electronically interact with Wyoming Medicaid, emphasizing the absolute necessity for detailed and accurate completion of the form. This application is a primary step for providers or their intermediaries, such as billing agents or clearinghouses, to partake in electronic data interchange (EDI) for various transactions, including claims submissions and receiving remittance advices. Significantly, the application encompasses detailed instructions for providers on how to properly fill out the form, reinforcing the requirement for all fields to be completed in ink with original signatures, and highlights the implication of potential delays in approval if submitted incompletely. Additionally, it introduces the ACS EDI Call Center as a resource for applicants needing assistance, outlining the process to return the completed form and includes a comprehensive section dedicated to the agreement with ACS EDI Gateway, Inc. This portion elaborates on mutual obligations, paving the way for secure and efficient data exchange in compliance with respective regulations. Providers are also advised on the technological requirements and steps to gain access to the Wyoming EqualityCare Secure Web Portal, underscoring the shift towards digital remittance advices through the 835 Health Care Claim Payment files, which signifies a move away from paper-based processes. Overall, the application and accompanying agreement mandate a collaborative, compliant, and secure environment for electronic transactions with Wyoming Medicaid.

Form NameWyoming Medicaid Edi Application
Form Length6 pages
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesSubmitter, wyoming medicaid application pdf, DHHS, Florida

Form Preview Example

Wyoming Medicaid EDI Application

Please type or block print the requested information as completely as possible. If any field is not applicable, please enter N/A. An incomplete form may delay the approval of this application. Please direct questions to the ACS EDI Call Center at (800) 672-4959, press 3. Please return the completed form and Trading Partner Agreement to ACS - Provider Enrollment, PO Box 667, Cheyenne, WY 82003-0667. Please note: All fields must be completed in ink, and all signatures must be original – no copies, stamps, etc.


For Fiscal Agent Use Only

ACS Assigned Trading Partner Number

Completed Date




Provider Information:

1.Enter your business or provider name and address below. (Physical address is required.)




Address 1


Address 2


CityState Nine-Digit Zip


Provider Contact E-mail address

(________) ________ - _________________

Phone (Primary)

3.Enter your NPI and/or EqualityCare Provider ID Please note: If you have group AND treating provider information, enter ONLY the group information.

NPI Number: _______________________________

Wyoming Medicaid Provider ID: _____________________

(if known)

2.Enter your name and contact information here.


EDI Contact Name


Address 1


Address 2


CityState Nine-Digit Zip


EDI Contact E-mail address

(________) ________ - _________________

Phone (EDI Contact Person)

Tax-ID (required for web portal access): _________________________

Page 1

Revised: November 2011

Remittance Advices and 835 Health Care Claim Payment files

By signing the provider agreement and returning this application, you will automatically be given access to the Wyoming EqualityCare Secure Web Portal and will be mailed an EDI Welcome Letter containing the necessary user information to register on the secure web portal, which will include access to Wyoming Medicaid’s Proprietary Remittance Advice. If you choose to make use of the 835 Health Care Claim

Payment/Advice, you will no longer receive copies of these Remittance Advices through postal mail, and will be directed to retrieve them through the Secure Web Portal.

1. The 835 Health Care Claim Payment/Advice is the electronic transmission of remittance data from Wyoming Medicaid to a provider (or clearinghouse). This remittance data is often referred to as an EOB (Explanation of Benefits). It is used to reconcile a payment against the claims a provider submitted to Wyoming Medicaid. To use the 835 Health Care Claim Payment/Advice requires special computer software capable of processing it.

Will you or a third party use the 835 Health Care Claim Payment/Advice? Please note – the 835 can only be delivered to a single trading partner number – i.e. either the clearinghouse OR the provider, but not both, can retrieve the 835 file. Regardless of where the 835 file is being delivered, Wyoming Medicaid’s Proprietary Remittance Advice will continue to be available via the Secure Web Portal to the provider.

I will retrieve my 835 (deliver to the Secure Web Portal and stop my mailed paper remittance advices)

A third party (e.g., clearinghouse) will retrieve my 835 (deliver to the clearinghouse/third-party and stop my mailed paper remittance advices): _____________________________________

(trading partner of third-party/clearinghouse)

I do not wish to use the 835 at this time (I wish to continue receiving mailed paper remittance advices. I am aware that in the future there may be a cost associated with this selection).


My 835 files are ALREADY being delivered to trading partner ____________________________ and I wish to stop the delivery

(trading partner name and number)

to this trading partner number and begin the delivery to a new trading partner number ____________________________,

(trading partner name and number)

effective ____________________.

(date change is effective)

Page 2

Revised: November 2011

Claims and other Transactions

1.If you or your organization is already billing claims electronically to Wyoming Medicaid, enter your 5-digit Submitter or 6-digit Trading Partner ID: __________________

2.If you are not already submitting your claims or other HIPAA 5010 transactions electronically but wish to OR need to update your submission information, indicate how you would like to submit:

Billing Agent

-Billing Agent Trading Partner ID: ____________________


-Clearinghouse Trading Partner ID: ___________________

Vendor Supplied Software

-Vendor Software Trading Partner ID: _________________

Secure Web Portal (free web-based billing application)


WINASAP Billing Software (free PC-based billing software – dial up modem and analog phone line required)

-Download the software from http://wyequalitycare.acs-inc.com. Call 800-672-4959, press 3 if you require a CD to be mailed to you instead


1.Complete the attached Trading Partner Agreement form.

Return By Mail To:

ACS – Provider Enrollment

PO Box 667

Cheyenne, WY 82003-0667

Page 3

Revised: November 2011



THIS TRADING PARTNER AGREEMENT (“Agreement”) is by and between SUBMITTER (“Submitter”), and ACS EDI Gateway, Inc. ("Trading Partner”), collectively “the Parties.”

Whereas, Submitter desires to transmit Transactions to Trading Partner for the purpose of submitting data to a Health Plan;

Whereas, Trading Partner desires to receive such Transactions for this purpose recognizing that Trading Partner performs such services on behalf of the Health Plan; and

Whereas, Submitter is subject to the Transaction and Code Set Regulations with respect to the transmission of such Transactions.

Now, therefore, the Parties agree as follows:


Trading Partner means ACS EDI Gateway, Inc.

Submitter means the party identified as “Submitter” on the signature line of this Agreement who is a Health Care Provider as defined in 45 CFR 164.103.

Standard is defined in 45 CFR 160.103. Transaction is defined in 45 CFR 160.103.

Transactions and Code Set Regulations means those regulations governing the transmission of certain health claims transactions as published by DHHS under HIPAA.

2.Obligations of the Parties Effective Upon Execution of this Agreement by Submitter

A.The Parties agree, in regard to any electronic Transactions between them:

(1)They will exchange data electronically using only those Transaction types as selected by Submitter on the ACS EDI Gateway, Inc. Trading Partner Enrollment Form (TPEF).

(2)They will exchange data electronically using only those formats (versions) as specified on the TPEF.

(3)They will not change any definition, data condition, or use of a data element or segment in a Standard Transaction they exchange electronically.

(4)They will not add any data elements or segments to the Maximum Defined Data Set.

(5)They will not use any code or data elements that are not in or are marked as “Not Used” in a Standard’s implementation specification.

(6)They will not change the meaning or intent of a Standard’s implementation specification.

(7)Trading Partner may reject a Transaction submitted by Submitter if the Transaction is not submitted using the data elements, formats, or Transaction types set forth in the TPEF. Trading Partner may refuse to accept any claims from Submitter if Submitter repeatedly submits Transactions which do not meet the criteria set forth in a TPEF or if Submitter repeatedly submits inaccurate or incomplete Transactions to Trading Partner.

B.Submitter understands that Trading Partner or others may request an exception from the Transaction and Code Set Regulations from DHHS. If an exception is granted, Submitter will participate fully with Trading Partner in the testing, verification, and implementation of a modification to a Transaction affected by the change.

C.Trading Partner understands that DHHS may modify the Transaction and Code Set Regulations. Trading Partner will modify, test, verify, and implement all modifications or changes required by DHHS using a schedule mutually agreed upon by Submitter and Trading Partner.

D.Neither Submitter nor Trading Partner accepts responsibility for technical or operational difficulties that arise out of third party service

November 17, 2011

Page 1

providers’ business obligations and requirements that undermine Transaction exchange between Submitter and Trading Partner.

E. Submitter and Trading Partner will exercise diligence in protection of the identity, content, and improper access of business documents exchanged between the two parties. Submitter and Trading Partner will make reasonable efforts to protect the safety and security of individually assigned identification numbers that are contained in transmitted business documents and used to authenticate relationships between the parties.

F. Wyoming Medicaid may publish data clarifications (“Medicaid Provider Manuals”) to complement the ASC X12N Standards for Electronic Data Interchange Technical Report Type 3 (TR3). Submitter should use Medicaid Provider Manuals in conjunction with the TR3

documents available at http://wyequalitycare.acs-inc.com/manuals.html and http://www.wpc-edi.com, respectively.

G. Transactions are considered properly received only after accessibility is established at the designated machine of the receiving party. Once transmissions are properly received, the receiving party will promptly transmit an electronic acknowledgment that conclusively constitutes evidence of properly received transactions. Each party will subject information to a virus check before transmission to the other party.

H. Each party will implement and maintain appropriate policies and procedures and mechanisms to protect the confidentiality and security of PHI transmitted between the parties.


A.This Agreement is effective on the date last signed below. This Agreement shall continue until such time as either party elects to give written notice of termination to the other party or termination of Transaction services provided by Trading Partner to Submitter, whichever is earlier.

B.This Agreement incorporates, by reference, any written agreements between the parties relating to the subject matter hereof.

C.This Agreement shall be interpreted consistently with all applicable federal and state privacy laws. In the event of a conflict between applicable laws, the more stringent law shall be applied. This Agreement and all disputes arising from or relating in any way to the subject matter of this Agreement shall be governed by and construed in accordance with Florida law, exclusive of conflicts of law principles. THE EXCLUSIVE JURISDICTION FOR ANY LEGAL


D.Unless otherwise prohibited by statute, the parties agree that this Agreement shall not be affected by any state’s enactment or adoption of the Uniform Computer Information Transaction Act, Electronic Signature or any other similar state or federal law. Each party agrees to comply with all other applicable state and federal laws in carrying out its responsibilities under this Agreement.

E.This Agreement is entered into solely between, and may be enforced only by, Submitter and Trading Partner. This Agreement shall not be deemed to create any rights in third parties or to create any obligations of Submitter or Trading Partner to any third party.


November 17, 2011

Page 2

G. Trading Partner may provide proprietary software to Submitter to allow Submitter to submit Transactions to Trading Partner. Submitter will protect the software as it protects its own confidential information and will not, directly or indirectly, allow access to or the use of the software or any portion thereof, on any computer, server, or network, by any person, corporation, or business entity other than Submitter. Submitter may permit use of the software by contractors or agents of Submitter provided that any such contractors or agents are not competitors of Trading Partner and further provided that any such persons agree to protect the confidentiality of the software. Submitter and its contractors and agents are not permitted to use the software for any purpose other than submitting Transactions solely to Trading Partner.

H. Agreement contains the entire agreement between the parties and may only be modified by an agreement signed by both parties.

I.Submitter may elect to execute either a hard copy or an electronic copy of this Agreement. Hard Copy Execution: Submitter will sign a hard copy of this Agreement and mail to Trading Partner at the address indicated below. Trading Partner will return a copy of the fully executed Agreement to Submitter. The effective date of the hard copy Agreement is the date on which the Agreement is signed by Trading Partner. Electronic Copy Execution: Submitter should execute this Agreement by clicking on the “I AGREE” button that appears at the bottom of the Agreement. The effective date of the electronic copy agreement is the date Trading Partner receives the electronic transmission of Submitter’s acceptance to the terms of this Agreement.


Provider Number/Trading Partner ID


Printed Name and Title


Mail Completed Agreement To:


Attention: EDI Enrollment

PO Box 667

Cheyenne, WY 82003

For ACS EDI Enrollment Use Only:


Printed Name and Title


November 17, 2011

Page 3

How to Edit Wyoming Medicaid Edi Application Online for Free

It won't be challenging to get wyequalitycare through our PDF editor. Here's how you will be able rapidly develop your template.

Step 1: The web page has an orange button that says "Get Form Now". Please click it.

Step 2: You will discover all of the options you can take on your document when you have entered the wyequalitycare editing page.

Complete the following segments to prepare the file:

Florida fields to complete

Type in the information in the Enter your NPI andor EqualityCare, NPI Number, Wyoming Medicaid Provider ID, if known, TaxID required for web portal, Page, and Revised November area.

part 2 to entering details in Florida

Jot down the expected data when you find yourself within the I will retrieve my deliver to, A third party eg clearinghouse, I do not wish to use the at this, My files are ALREADY being, to this trading partner number and, trading partner name and number, and effective date change is effective part.

step 3 to finishing Florida

Describe the rights and obligations of the sides inside the field If you or your organization is, If you are not already submitting, Billing Agent, Billing Agent Trading Partner ID, Clearinghouse, Clearinghouse Trading Partner ID, Vendor Supplied Software, Vendor Software Trading Partner ID, Secure Web Portal free webbased, httpwyequalitycareacsinccom, WINASAP Billing Software free, Download the software from, mailed to you instead, and Agreement.

stage 4 to completing Florida

End by reviewing all of these areas and submitting the pertinent information: G Trading Partner may provide, for any purpose other, solely, H Agreement contains, the entire agreement between the, I Submitter may elect to execute, SUBMITTER, Provider NumberTrading Partner ID, Signature, Printed Name and Title, Date, and Mail Completed Agreement To.

Florida G Trading Partner may provide, for any purpose other, solely, H Agreement contains, the entire agreement between the, I Submitter may elect to execute, SUBMITTER, Provider NumberTrading Partner ID, Signature, Printed Name and Title, Date, and Mail Completed Agreement To fields to complete

Step 3: Press "Done". You can now transfer the PDF document.

Step 4: You will need to create as many copies of your form as you can to remain away from possible issues.

Watch Wyoming Medicaid Edi Application Video Instruction

Please rate Wyoming Medicaid Edi Application

1 Votes
If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .