Form CMS-10340 Electronic Data Interchange (EDI) Agreement

Medicare Advantage Organization Electronic Data Interchange Agreement
The eligible organization agrees to the following provisions for submitting Medicare and/or
Medicaid data electronically to the Centers for Medicare & Medicaid Services (CMS) or to
its contractors.
A. The Eligible Organization Agrees:
1. That it will be responsible for all Medicare and/or Medicaid data submitted to CMS by itself,
its employees, and/or its agents.
2. That it will use adequate security procedures to ensure that all transmissions of electronic data
are secure and protect all beneficiary-specific data from unauthorized access, as required by
the HIPAA Security regulations (45 C.F.R. Parts 160 and 164, subparts A and C).
3. That it will establish and maintain procedures and controls so that information concerning
Medicare and/or Medicaid beneficiaries, or any information obtained from CMS or its
contractor, shall not be used by the eligible organization, its employees or agents, except as
provided by the contractor and in accordance with all applicable State and Federal laws.
4. That the Secretary of Health and Human Services (HHS), his/her designee and/or contractors
designated by HHS; has the right to inspect, audit and confirm information submitted by the
eligible organization and shall have access at all reasonable times, to all original source
documents, and medical records, when applicable, related to the eligible organization’s
submissions, including the beneficiary's authorization and signature.
5. That it will affix the CMS-assigned unique identifier number of the eligible organization on
each file electronically transmitted to CMS. Affixing the CMS-assigned unique identifier
number constitutes the eligible organizations’ legal electronic signature.
6. That it will ensure that every electronic entry can be readily associated and identified with an
original source document. That it will retain all original source documentation, and medical
records, when applicable, pertaining to any such particular Medicare and/or Medicaid data for
a period of at least 10 years after the data is received and processed.
7. That it will research and correct discrepancies in the event that a record or file is rejected or
found to be in error.
8. That it will notify CMS or its designated contractor within 2 business days if the eligible
organization receives any data from that contractor or CMS in an unintelligible or garbled
form.
9. That it will not disclose any information concerning a Medicare and/or Medicaid beneficiary
to any other person or organization, except CMS and/or its contractors, without the express
written permission of the beneficiary or his/her parent or legal guardian, or where required for
the care and treatment of a beneficiary who is unable to provide written consent, or to bill
insurance primary or supplementary to Medicare and/or Medicaid, or as required by State or
Federal law.
10. Based on best knowledge, that it will submit data that are accurate, complete, and truthful.

B. The Centers for Medicare and/or Medicaid Services Agrees To:
1. Transmit to the eligible organization an acknowledgment of receipt.
2. Ensure that no CMS contractor may require the eligible organization to purchase any or
all electronic services from the CMS contractor or from any subsidiary of the CMS
contractor or from any company for which the CMS contractor has an interest.
3. Ensure that Medicare and/or Medicaid eligible organizations have equal access to any
services that CMS requires Medicare and/or Medicaid contractors to make available to
eligible organizations, regardless of the electronic billing technique or service they
choose.
4. Notify the eligible organization within 2 business days if it receives any electronic data
from that eligible organization in an unintelligible or garbled form.
NOTICE:
Federal law shall govern both the interpretation of this document and the appropriate
jurisdiction and venue for appealing any final decision made by CMS under this document.
This document shall become effective when signed by the eligible organization. The
responsibilities and obligations contained in this document will remain in effect as long as
Medicare and/or Medicaid data are submitted to CMS or the contractor. CMS may suspend
or revoke authorization to submit data at any time if the eligible organization fails to abide
by the terms of this Agreement. Either party may terminate this arrangement by giving the
other party (30) days written notice of its intent to terminate. In the event that the notice is
mailed, the written notice of termination shall be deemed to have been given upon the date
of mailing, as established by the postmark or other appropriate evidence of transmittal.

C. Signature:
I am authorized to sign this document on behalf of the eligible organization, doing business as the
eligible organization, and I have read and agree to the foregoing provisions and acknowledge
same by signing below.
Eligible Organization Name
Address
City/State/ZIP
Phone
Email
Contract Number
Signature
Name
Title
Date
Please retain a copy of all forms submitted for your records. In the event you choose to mail
this document please complete, sign and mail to:

Mailing Address:
EDI Agreement
CSSC Operations – AG570
P.O. Box 100275
Columbia, SC 29202-3275

Express Mailing Address:
EDI Agreement
CSSC Operations – AG570
2300 Springdale Drive, Bldg. One
Camden, SC 29020-1728

In the event you have questions, please contact CSSC Operations at 1-877-534-2772 or by
Email at [email protected].