Instructions for completing the EDI enrollment form for providers

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Home ► EDI forms ► Instructions for completing the EDI enrollment form for providers

Last Modified: 10/22/2023 Location: FL, PR, USVI Business: Part A, Part B

Instructions for completing the EDI enrollment form for providers

Part A and B providers should complete the EDI Enrollment Form to enroll for electronic billing or to make changes in their existing electronic billing setup.

Part B providers who have multiple NPIs linked to their PTAN need to enroll each NPI/PTAN combination.

Completing the EDI Enrollment form

• Carefully review the following block-by-block instructions for successfully completing the EDI Enrollment form.

• This webpage is for instructional purposes only and cannot be completed and submitted for enrollment.

• The form is designed to be completed online and then printed before submitting.

General Information

It is important that you use the most recent version of any EDI form when enrolling for EDI services or updating your existing EDI status. Please carefully review the following block-by-block instructions to ensure successful completion. Note: The following screenshots are for instructional purposes only and cannot be completed and submitted for enrollment.

The EDI Enrollment Form for Provider Organizations can be completed online and emailed - or printed - before submitting.

The form must be completed and approved before attempting to register for an IDM User ID.

Line of Business/State

Instructions

• Select one from each drop-down depending on your location and the line of business you submit claims for.

Billing Provider Information

Instructions

• Type the (group) provider name.

• Type the contact person’s name who has knowledge and authority to answer questions regarding your enrollment.

• Type the contact person’s telephone number (including area code) and extension (if applicable).

• Type the fax number (including area code) for the provider. This fax number will be used to send your enrollment processing response.

• Type the practice mailing address, including suite/building numbers/levels.

• Type the (group) Provider Transaction Access Number (PTAN) of the provider.

• The PTAN, NPI and TIN/EIN are required and must match the number on file with Medicare.

• Type the (group) NPI of the provider. The number reported MUST match the number on file with Medicare for the provider and MUST be linked to the PTAN provider on the form. This should NOT be the NPI for an individual member of the group.

• Type the full federal Tax Identification Number (TIN) or Employer Identification Number (EIN) of the provider. The full TIN/EIN is required for all enrollments.

Reason for Request

Information

The reason for submission is not required.

The options available in the drop-down are “new enrollment” or “change enrollment.”

Instructions

• Select the most appropriate option from the drop-down box.

Type of Request

Complete only one section: New submitter ID requests or existing submitter ID requests.

• If you are requesting a new submitter ID:

• Check the box to assign this provider a new electronic billing submitter ID if you will be connecting directly to First Coast for electronic billing. Also type the name of your network service vendor and billing software vendor. Both vendors must be listed and must be enrolled with First Coast.

• Check the box to enroll for claim status and response to be setup for the ANSI X12N 276/277 transactions. Verify your software vendor supports the 276/277 files before requesting this feature.

• Check the box for Direct Data Entry Only to request EDI enrollment for FISS/DDE use only.

• This is only available for Part A providers

• The DDE User ID Request Form is also required

• If you are linking to or updating an existing submitter ID:

• Check the Add to an existing submitter ID box and type the submitter ID and submitter ID name.

• The submitter ID and Name must be complete and accurate for the same jurisdiction/contract as the provider being enrolled.

• Check the Vendor Change box and provide the name of your new billing software vendor if being submitted only to report a change in software vendor.

• The software vendor must be enrolled with First Coast.

• Check the Enroll for Claim Status and Response box to be setup for the ANSI X12N 276/277 transactions.

• Verify your software vendor supports the 276/277 files before requesting this feature.

• If the only reason for this enrollment form being submitted is to request a change to the electronic remittance advice (ERA) setup, check the box for ERA Change.

• If the only reason for this enrollment form being submitted is to request the PC-ACE software, check the box for PC-ACE Enrollment Only and provide your existing portal Submitter ID.

• When selecting this option, also be sure to select Yes from the PC-ACE Enrollment dropdown box on page 2.

Electronic Remittance Advice (ERA)

• Click the box “Assign ERA to an existing submitter/receiver ID” to have your ERA sent to an existing ID. Type the ID in the block.

• Click the box “Maintain existing ERA setup” if you do not want any changes made to your ERA. This option cannot be selected if you are currently receiving paper remittances.

• Click the box “Create a new and separate receiver ID” to have a new ID created to retrieve your ERA, separate from the submitter ID used to send claims.

• Click the box “Assign ERA to the new Submitter ID being requested with this form” to have your ERA sent to the same new submitter ID listed in the Type of Request block.

• If nothing is selected, your existing remittance setup will be maintained, unless you currently receive paper remittance.

Maintain Existing Submitter/Receiver ID

• Type the name(s) or submitter/receiver ID(s) in the box to keep them linked to the provider. All other submitter/receiver IDs will be removed immediately.

• If you maintain a submitter to finalize any remaining billing, you can send a request on letterhead to have them removed once billing is completed.

PC-ACE

PC-ACE is a free software that can be used to create electronic claim files for submission, and to interpret electronic claim reports. Information about PC-ACE can be found on our website (JH)(JL).

• To enroll for PC-ACE, select Yes from the dropdown options.

• If a third-party billing service or clearinghouse is submitting your claims, it is not necessary for you to enroll for PC-ACE unless you will also be submitting claims or need it to interpret reports.

• Read the software terms and system requirements carefully before enrolling for PC-ACE.

• PC-ACE does not provide a connection to First Coast. Therefore, you will need to acquire your own SFTP software to connect and send your claims.

Additional Information

• This block is not required.

• Skip or select the appropriate option from the dropdown menu. The options available are:

• Provider Tax Identification Number (TIN)

• National Provider Identifier (NPI)

Signature Requirements

• Read the full agreement, attestation, and authorized official signature requirements.

• Review the entire form to verify the information provided is accurate and complete.

• Only wet or digital signatures are accepted. Typed or stamped signatures are not accepted and will result in rejection of the form.

• Type the date the form was signed. The date must be a full month, day, and year.

• Type the printed name of the person signing the form.

• Type the professional title of the person signing the form.

Submission instructions

• Print the form.

• Email to MedicareEDI@fcso.com or fax to 904-361-0470.

• Allow 10 business days for processing.

• Do not send duplicate forms.

First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.