Insurance Carrier Or Trading Partner Medical Electronic Data Interchange (EDI) Profile {EDI-02}

DWC EDI-02 Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 · MS-5 Austin, TX 78744-1645 (888) 489-2667 phone · (512) 490-1039 fax For TDI-DWC Use Only Insurance Carrier or Trading Partner Medical Electronic Data Interchange (EDI) Profile (Fax form to TDI-DWC at the number shown above or email to TXCOMP.Help@tdi.state.tx.us) IMPORTANT: Complete all fields designated with an asterisk (*). Form will be returned if any required fields are missing. I. INSURANCE CARRIER OR TRADING PARTNER DESCRIPTION* 1. Insurance Carrier (includes certified self-insureds, certified self insurance groups, and governmental entities) Trading Partner II. INSURANCE CARRIER OR TRADING PARTNER GENERAL INFORMATION 2. EDI Sender's Full Legal Name* 3. EDI Sender's FEIN* 4. EDI Sender's 9-Digit Postal Code* (Zip+4) ­ NOTE: The FEIN and 9-Digit Postal Code will be combined to identify a unique sender (insurance carrier or trading partner) and must match the SENDER ID in the Header Record of the EDI transmissions. 5. Business Physical Address Address Line 1* Address Line 2 State* City* 6. Business Mailing Address (If different from above) Address Line 1 Address Line 2 State City Postal Code* Postal Code III. INSURANCE CARRIER OR TRADING PARTNER EDI CONTACT INFORMATION 7. Medical EDI Business Contact Name Title Phone Fax E-mail 8. Medical EDI Technical Contact* Name Title Phone Fax E-mail Yes No 9. May TDI release your email addresses in response to a public information request? IV. INSURANCE CARRIER OR TRADING PARTNER PROJECTED MEDICAL EDI TRANSACTION VOLUME 10. Projected Annual Number of Transactions: 11. Transmission Frequencies: Daily (Monday through Friday, excluding holidays) Weekly ­ Specify Day(s): SUN MON TUE WED THU FRI SAT NOTE: With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). DWC EDI-02 Rev. 06/11 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com DWC EDI-02 Frequently Asked Questions Insurance Carrier or Trading Partner Medical Electronic Data Interchange (EDI) Profile (DWC EDI-02) Do all trading partners and insurance carriers have to submit the DWC EDI-02 form? All trading partners must submit the DWC EDI-02 form. However, insurance carriers are not required to file this form unless they submit all or part of their own medical EDI records directly to TDI-DWC. When does this form need to be filed? Under the provisions of 28 Texas Administrative Code (TAC) §134.808(d), an insurance carrier or trading partner must submit this information to TDI-DWC at least five days before sending its first test transaction to TDI-DWC. Failure to submit the DWC EDI-02 will prevent the insurance carrier or trading partner from logging into the agency's secure file transfer protocol environment. How do I report a change to the information reported on the DWC EDI-02 form? If any information reported on the DWC EDI-02 form changes, including information regarding the contact person, the insurance carrier or trading partner must file a new DWC EDI-02 within five working days. Why is information regarding transaction volume and frequency important? Information regarding transaction volume and frequency is important in developing a test plan and monitoring production for the insurance carrier or trading partner. TDI-DWC rules at 28 TAC §134.808(e) establish specific thresholds that must be met before an insurance carrier or trading partner is approved for production, including a volume-based metric. Questions? If you have questions about this form or need more information about the Medical Electronic Data Interchange (EDI), contact the EDI Help Desk at TDI-DWC by telephone at 888-4-TXCOMP or by email at TXCOMP.Help@tdi.state.tx.us. DWC EDI-02 Rev. 06/11 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com