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: 8/27/2024 Location: FL, PR, USVI Business: Part A, Part B

Instructions for completing the EDI enrollment form for providers

Part A and B providers must complete the EDI Enrollment Form pdf file

to enroll for electronic billing or to make changes in their existing electronic billing setup. This form is only for provider organizations. Billing services, clearinghouses, and vendors must use the EDI Third Party Enrollment form pdf file

• Use the most recent version of the EDI Enrollment Form pdf file

. Always open enrollment forms directly from links on our website. Do not save a copy of the form for future use.

• Complete the form online and then submit it by email or print and mail it to the address at the bottom of the form. All fields marked with a red asterisk are required.

• Enroll each group or solo NPI/PTAN combination by including the EDI Enrollment Affiliated Provider List pdf file

if your provider office has multiple NPIs or PTANs.

• Carefully read and follow the block-by-block instructions below. This webpage is for instructional purposes only and cannot be submitted for enrollment.

General Information

This block requires the contract and line of business information for your provider office.

• Select one option from each drop-down.

Provider Information

This block requires the provider address and contact information. The provider’s name given must match the group/billing provider name that was reported on the CMS-855 Medicare enrollment form when initially enrolling as a Medicare provider.

• Type the (group) provider name or legal business name as it is on file with Medicare.

• Type the contact person’s first and last 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 complete practice mailing address, including suite/building numbers/levels.

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

Provider Identification

This block requires the provider identification information. The provider’s transaction access number (PTAN), National Provider Identifier (NPI), and Tax Identification Number (TIN) or Employer Identification Number (EIN) must match the group/billing provider numbers that were reported and/or assigned with the initial Medicare enrollment process.

• Type the complete (group) PTAN assigned by Medicare.

• Type the complete (group) NPI. 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 TIN or EIN of the provider. The full TIN/EIN is required for all enrollments.

Type of Request

• Select one of the boxes to indicate the reason for submission.

• Complete only one of the sections with gray titles: the “If you are requesting a new submitter ID” section OR the “If you are linking to or updating an existing submitter ID” section. At least one option in either section is required. If nothing is selected, the form will be returned.

If you are requesting a new submitter ID for sending ANSI X12N 837 electronic claim files:

• Check the “Assign this provider a new electronic submitter ID” box if you will be connecting directly to First Coast for electronic billing.

• Type the name of your network service vendor and billing software vendor. Both vendor names are required to receive an electronic submitter ID and they both 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.

• Check the “Direct Data Entry only” box 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 existing Submitter ID” box and type the submitter ID and submitter ID name to be linked to an existing direct Submitter ID or to an existing billing service or clearinghouse Submitter ID. Both the Submitter ID and Submitter ID Name are required for this option. The information must be accurate and for the same jurisdiction/contract as the provider being enrolled.

• Check the “Add Claim Status and Response” box and type your existing direct Submitter ID 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 “Add PC-ACE to my existing direct Submitter ID” box and type your existing direct Submitter ID if only requesting the PC-ACE software. Then check the “Yes, enroll for PC-ACE” box in the PC-ACE section on page two to agree to the software terms.

• Check the “Vendor Change only” box and provide the name of your new billing software vendor if only requesting to report a change in your software vendor. The new software vendor must be enrolled with First Coast.

• Check the “ERA Change only” box if only requesting to change to the electronic remittance advice (ERA) setup. Then provide the ERA change details in the ERA block on page two.

Dental Claims

This block is not required. It is needed only if requesting to bill ANSI X12N 837D electronic dental claims. Skip this block if you do not need to submit electronic dental claims to First Coast.

• Type the Network Service Vendor and the Dental Billing Software vendor that will be used for the creation and submission of the dental claims. Both vendor names are required when enrolling to submit dental claims and must they both must be enrolled with First Coast.

• At least one of the three boxes in the dental must be checked to be setup for billing dental claims. Check only one to enroll for dental claim submission:

• Check the “Assign this provider a new/separate electronic submitter ID for 837D claim files” box if you will be connecting directly to First Coast for electronic billing only or would like a separate electronic billing Submitter ID for dental claims.

• Check the “Add 837D to existing direct Submitter ID” box and type your existing direct submitter ID. An accurate direct Submitter ID for the same provider office and contract is required for this option.

• Check the “Assign 837D to the new Submitter ID being requested with this form” box if you will be submitting dental claims using the same new Submitter ID requested in the Type of Request block on page one.

Electronic Remittance Advice (ERA)

This block requires the setup detail for your ANSI X12N 835 Electronic Remittance Advice (ERA). ERA is a requirement for all providers billing electronically unless an exception or waiver was previously approved by First Coast. If nothing is selected, your existing remittance setup will be maintained. If you do not have an existing ERA setup, the enrollment form will be returned.

• Check the “Assign ERA to an existing submitter/receiver ID” box and type the submitter/receiver ID to be linked to an existing direct Submitter ID or to an existing billing service or clearinghouse Submitter ID. An accurate Submitter ID is required for this option, and it must be for the same jurisdiction/contract as the provider being enrolled.

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

• Check the “Create a new and separate receiver ID” box if you will be connecting directly to First Coast and would like a new receiver ID setup only for ERA purposes that is separate from the submitter ID used to send electronic claims.

• Check the “Assign ERA to the new Submitter ID being requested with this form” box to have your remittance file sent to the same new Submitter ID requested in the Type of Request block on page one.

Maintain Existing Submitter/Receiver ID

This block requires providers who are already setup for electronic billing to list any existing submitter/receiver IDs that they want to maintain. Any submitter/receiver IDs not referenced will be removed. Skip this block if you are new to electronic billing with First Coast.

• Type the company name(s) and/or submitter/receiver ID(s) of any existing electronic billers that should remain setup for the provider. All other submitter/receiver IDs will be removed when the enrollment form is processed.

• If you maintain a submitter to finalize any remaining billing, please submit a written request on company letterhead to have them removed once billing is completed.

PC-ACE

This block is to request the PC-ACE software. PC-ACE is a free software that is used to create electronic claim files and/or interpret electronic claim reports. PC-ACE does not provide a connection to First Coast, nor does it support 276/277 claim status files. To submit and/or receive the electronic files, you will need to connect using the SPOT online portal or acquire your own connection through one of the Network Service Vendors (NSV) on our approved 5010 vendor list.

• Check the “Yes, enroll for PC-ACE” box to enroll for the PC-ACE software. Read the software terms and system requirements carefully before enrolling for PC-ACE. By checking this box, you are agreeing to the software terms shown on the form.

• Check the “No, do not enroll for PC-ACE” box if you do not want to enroll for PC-ACE.

• Check the “I already have PC-ACE” box if the provider previously enrolled for PC-ACE.

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.

Additional Information

This block is not required.

• Skip this block or check the Provider Tax Identification Number or National Provider Identifier box. Neither option will have any impact to your electronic billing setup.

Required Signature

This block requires the signature, printed name, and printed title of the person submitting the enrollment form as well as the date it was signed. This form must be signed by an authorized or delegated official of the provider office. Clearinghouse and billing service representatives are not permitted to sign this form.

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

• Sign using the adobe digital signature feature or using a blue or black ink pen after printing the completed form. An official digital ID or original signature is required. Signatures stamped or typed in any font are not acceptable.

• Type or use the calendar dropdown to select the date the form was signed. The date must be a full month, day, and year.

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

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

Submission instructions

• Review the entire form to verify the information provided is accurate and complete. All fields with a red asterisk must be completed.

• Print the form and mail it to the address provided or fax it to 904-361-0470 or email the form to MedicareEDI@FCSO.com. Complete only one form of submission. Do not mail paper forms if it was faxed or emailed.

• Do not send duplicate forms.

• Allow up to two weeks for processing.

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.