№ files_lp_3_process_7_084092
Administrative agreement form establishing authorized points of contact for disclosure of Protected Health Information and coordination of retroactive processing and Enrollment Data Validation activities under CMS Medicare Part C & D operations.
Organization or State Information: Parent Organization Name or State Medicaid Office; Contract Number(s); Street Address 1; Street Address 2; City, State, Zip Code
Program: Medicare Part C & D
Subject: Retroactive enrollment transactions and Enrollment Data Validation (EDV) review process
Type of Document: Point of Contact (POC) Agreement Form
Contractor: Reed & Associates, CPA’s – CMS Retroactive Processing Contractor (RPC)
Effective Since: 2007
Related System: CMS Electronic Retroactive Processing Transmission (eRPT) application; CMS Enterprise Identity Data Management (EIDM) portal
EDV Transaction Groups: Enrollment/Disenrollment Activity (Transaction Types 51, 61, 80, 81); Resident Address Change Activity (Transaction Type 76)
Retroactive Processing Transaction Types: Enrollments/Disenrollments/Reinstatements/PBP & Segment Changes; State and County Code (SCC) Updates and Medicaid Status Updates; LIS Deeming Updates
Third Party Contractor (TPC): Optional designation with authorization to disclose PHI for CMS-related retroactive processing work
PHI Disclosure Authorization: Authorization for RPC to disclose Protected Health Information to designated contacts
Signing Requirement: Signature and date required from designated member of Organization or State Medicaid Office responsible for CMS Enrollment Operations
Submission Methods: Email, fax, or mail to Reed & Associates, CPAs – CMS RPC, 11717 Burt Street, Suite 103, Omaha, NE 68154
Contact Information: [email protected]
Note: ; Phone 402-315-3660; Fax 402-315-3700
Price: 8 / 10 USD
The file will be delivered to the email address provided at checkout within 12 hours.

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