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Instructions for completing the EDI enrollment form for third-party organizations
Last Modified: 10/22/2023
Location: FL, PR, USVI
Business: Part A, Part B
Who should complete this form?
Software vendors, billing services, and clearinghouses should complete the Electronic Data Interchange (EDI) Third Party Enrollment form to initially enroll for electronic billing with First Coast or make changes to their current EDI setup. Additionally, providers using in-house software that will be requesting multiple submitter IDs should complete this form to be added to our database.
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 always complete the forms directly from our website to ensure you are using the most up-to-date documents.
Completing the EDI Third Party Enrollment form (8291)
Please carefully review the following block-by-block instructions for successfully completing the EDI Third Party Enrollment form. The screen images are for instructional purposes only and cannot be completed and submitted for enrollment.
This is an interactive form that should be completed online and must be printed and signed before submitting.
• Select one from each drop-down depending on your location and the line of business you submit claims for.
• Complete the legal business name with the vendor/billing service/clearinghouse company name.
• Type the Tax ID.
• Type the complete mailing address for the billing service/clearinghouse enrolling for First Coast, including the city, State and Zip Code.
• Type the company’s website address.
• Type the fax number (including area code) for the provider. This fax number will be used to send your enrollment processing response.
Third-party contact information
• Complete the technical contact person’s name or department name, telephone number and email address. This information will be added to our electronic mailing lists for important EDI related information and an email will be sent to this address when the form has been processed.
• Complete the marketing contact person’s name, telephone number and email address. This information will be added to the Approved Vendor List on our website.
• If you do not want to be added to our
approved vendor list, select the option to not be included from the dropdown list next to “Approved vendor list on EDI’s website:”
• of Request
• the “I am a Software Vendor” box if you are a software vendor enrolling for a submitter ID to test your software.
• the “I am a…” box if you are a billing service or clearinghouse enrolling for a submitter ID to submit claims directly to First Coast.
• Click the appropriate box for billing service or clearinghouse. If nothing is selected, the submitter ID will be setup as a billing service.
• Type the name of your software vendor.
• the “I am currently…” box if you already have a submitter ID and would like to make changes.
• Type your current submitter ID.
• Click the “ERA Change Only” box to add only 835/ERA to your submitter ID.
• Click the “Other Feature or Contract Change Only” box if you are only making changes identified on page 2.
• Click the “Vendor Change Only” box and type the name of the new vendor if you are only changing the software used.
• the “Assign a new ERA receiver ID only” box if you are only requesting to have a new ERA receiver ID assigned. Click the appropriate box for billing service or clearinghouse.
• all applicate feature requests.
• Select the “Create…837” box if you create and/or send electronic claim files.
• Select the “Retrieve…835” box if you want to receive electronic remittance advice (ERA) files.
• Note: You cannot be sent remittance advice transactions for a provider unless specifically authorized to do so by that provider.
• the “Create…270” box if you create and/or send the 270 beneficiary eligibility files and want to receive the 271 response files to verify patient eligibility.
• Note: Your access is limited to submission of transactions and receipt of transactions for those providers that are your clients, but only if those providers authorized you to submit or receive each transaction.
• Note: If you have provider authorization to submit claim data for a provider, you cannot obtain eligibility data for that provider unless that was specifically authorized by the provider.
• the “Create…276” box if you create and/or send the 276 claim status files and want to receive the 277 response files to research claim status.
• the "Enroll for PC-ACE" box to request or maintain the free PC-ACE Medicare billing software.
• Note: Read the technical requirements and software terms (on the enrollment form) carefully before requesting to enroll for PC-ACE.
Information
This is a required block. The form will be returned if any of these fields are not completed accurately.
Instructions
• the full agreement, attestation, and authorized official signature requirement.
• the entire form to verify the information provided is accurate and complete.
• the date the form was signed. The date must be a full month, day, and year.
• the printed name of the person signing the form.
• the professional title of the person signing the form.
• the form.
• in the written signature block with a black or blue ink pen.
• 10 business days for processing.
• 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.
