Instructions for completing the EDI enrollment form for providers

Thank you for visiting First Coast Service Options' Medicare provider website. This website is intended exclusively for Medicare providers and health care industry professionals to find the latest Medicare news and information affecting the provider community.

To enable us to present you with customized content that focuses on your area of interest, please select your preferences below:

Select which best describes you: Health Care Professional Person(s) with Medicare

Select your location: Florida Puerto Rico U.S. Virgin Islands

Select your line of business: Part A Part B

By clicking Continue below you agree to the following:

LICENSE FOR USE OF "PHYSICIAN'S CURRENT PROCEDURAL TERMINOLOGY" (CPT), FOURTH EDITION End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2022 American Medical Association (AMA).

All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.
You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials:
Local Coverage Determinations (LCDs),
Local Medical Review Policies (LMRPs),
Bulletins/Newsletters,
Program Memoranda and Billing Instructions,
Coverage and Coding Policies,
Program Integrity Bulletins and Information,
Educational/Training Materials,
Special mailings,
Fee Schedules;

internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS), formerly known as Health Care Financing Administration (HCFA). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website. Applicable FARS/DFARS restrictions apply to government use.

AMA Disclaimer of Warranties and Liabilities CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this agreement.

CMS Disclaimer: The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

AMA - U.S. Government Rights

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a )June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

ADA CURRENT DENTAL TERMINOLOGY, (CDT)
End User/Point and Click Agreement: These materials contain Current Dental Terminology (CDTTM), Copyright © 2016 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING ON THE BUTTON LABELED "ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ON THE BUTTON LABELED "DECLINE" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the ADA website.

Applicable Federal Acquisition Regulation Clauses (FARS)\Department of restrictions apply to Government Use.

ADA DISCLAIMER OF WARRANTIES AND LIABILITIES: CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third party beneficiary to this Agreement.

CMS DISCLAIMER: The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

End Disclaimer

This website provides information and news about the Medicare program for health care professionals only. All communication and issues regarding your Medicare benefits are handled directly by Medicare and not through this website. For the most comprehensive experience, we encourage you to visit Medicare.gov or call 1-800-MEDICARE. In the event your provider fails to submit your Medicare claim, please view these resources for claim assistance.

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

Last Modified: 6/24/2024 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.

• 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 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.