EDI forms
EDI Support
General/password help:
888-670-0940 option-1
ABILITY | PC-ACE ™:
888-670-0940 option-2
DDE:
888-670-0940 option-3
Enrollment:
888-670-0940 option-4
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Modified: 4/11/2018
Only an authorized or delegated official as defined by the Centers for Medicare & Medicaid Services (CMS) can sign the EDI Enrollment form, DDE access request form, agreements, and other EDI forms.
Modified: 4/5/2018
This interactive form is for use by third-party agents such as clearinghouses, billing services, and Network Service Vendors only. All requests for new submitter numbers require provider to complete and sign an EDI enrollment form. [CR 8756]
Modified: 4/2/2018
Use this form for voluntary submission of supporting documentation with a version 5010 electronic claim. This is NOT an EDI enrollment form. [CR 10124]
Modified: 3/16/2018
Use this form for voluntary submission of supporting documentation with a version 5010 electronic claim. This is NOT an EDI enrollment form. [CR 10124]
Modified: 2/17/2018
These completion instructions are for the current electronic data interchange (EDI) enrollment form. This form is intended for provider use only and replaces previous EDI enrollment forms.
Modified: 12/13/2017
This interactive "HTTPS CAQH CORE EDI Enrollment Form” is effective as of April1, 2017. This form is intended for trading partner use only. Please see the HTTPS CAQH CORE Connection Guide for connectivity requirements.
Modified: 11/24/2017
This interactive “Electronic Data Interchange (EDI) enrollment form” has been revised as of November 20, 2018. This form is intended for provider use only and replaces previous EDI enrollment forms. Please see How to complete the EDI enrollment form for completion assistance.
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