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Last Modified: 5/18/2018 Location: FL, PR, USVI Business: Part A, Part B

How to complete the EDI enrollment form

The following instructions will guide you through the process of completing the EDI enrollment form pdf file
The Electronic Data Interchange (EDI) enrollment form is an interactive form to be completed on-screen. After completion this form can be printed for signatures then faxing or mailed. This interactive form now allows an authorized electronic signature and can be emailed. Please see guidelines of authorized signature further in these instructions. This form is intended for provider use only and only the owner of the NPI/PTAN may inquire the status of the application.
* (red asterisk) on the form indicates a required field, if information is missing or invalid from these fields the application will be rejected. Once an application has been rejected you will need to correct the issue and re-send the entire application as a new request.
Revision Date The current form was revised on November 20, 2017. Any forms received with a previous revision date will be rejected.

Reasons for request

New Enrollment: If a new request, such as provider new to electronic submission, provider requesting their own submitter number, or connecting to a billing service or clearinghouse. If clearinghouse or billing service is requesting new enrollment, they should use the Network Service Vendor Agreement (NSA) and the provider should complete the EDI enrollment form, these forms are required to be sent in together.
Change Enrollment: Provider is changing existing electronic relationship. For example; changing who is submitting claims or receiving remittance information or a change in providers address or contact information.
Cancel Enrollment: Used to cancel a relationship to a previous clearinghouse or billing service, or cancel usage of a transaction.

Line of business and state

Choose one line of business from the drop-down menu, Medicare Part A or Medicare Part B. Choose one state from the drop down menu, Florida, Puerto Rico, U.S. Virgin Islands or Other. If additional states or line of business (LOB) are needed, please use a separate form.

Provider information

Enter the complete legal business name of institution, corporation, group or solo practice, or supplier enrolling for EDI. The legal business name listed must match the (National Provider Identifier (NPI), Provider Transaction Access Number (PTAN), Federal Tax ID TIN) that is on file with Medicare.
Enter the contact person's name and email address that has the knowledge and authority to answer questions regarding your enrollment. This contact information is only for EDI enrollment and will not update the provider’s Medicare file. Application status will only be provided to the contact as listed on the application.
Enter correspondence street address including suites or building numbers if needed, city, state and ZIP code. The address may be used for mailing approval letters.
Enter a reachable telephone number including area code and extension if applicable.
Enter the fax number (including area code). Fax may be used for sending approval information. If a fax number is not provided, notification letter shall be mailed to the correspondence address listed on the form. Notification letters are no longer emailed.

Provider Identifiers

Enter the TIN, Employer Identification Number (EIN) or Social Security Number (SSN) as is on the Medicare files.
NPI of the group, solo provider, or supplier enrolling in EDI. The NPI is a unique identification number for covered health care providers.
Enter the PTAN, of the group, solo provider, or supplier enrolling in EDI.
If you are requesting approval for multiple NPI/PTAN combinations, a separate EDI form must be completed for each NPI/PTAN combination. If you are billing under a group NPI with different PTANs you will need separate EDI forms. The legal business name, NPI, PTAN, and TIN/SSN/EIN on the application must match Medicare files.

Sending of files

Enter the name of your Network Service Vendor (NSV) that will be providing connectivity to send your electronic files.
Indicate who will be submitting electronic claim files, the provider with or without NSV, clearinghouse, or billing service. If you choose clearinghouse or billing service you will not need an NSV.

Request type

Choose as many as apply, unless deleting provider linkage:
Assign this provider a submitter ID: If you are requesting a new electronic submitter ID and have a NSV for connectivity.
Electronic Remittance Advice (ERA): All submitters, billing services, clearinghouses and providers set up for 837 transactions must receive ERA. All submitters will be set up with ERA defaulting to the submitter indicated on the request unless otherwise indicated. Use the ERA section if you are requesting a change in the way you receive ERA. You may request an existing submitter/receiver ID to receive your ERAs. ERAs will only be sent to one submitter/receiver ID no matter how many submitters you may have.
Add to existing: If you want to add this provider to existing submitter choose this and enter submitter number.
Requesting free or low cost ABILITY | PC-ACE™ software supported by First Coast. Must have Network Service Vendor (NSV) for communication purposes. See full article in EDI news. Choose one of the methods of receipt.
Receive the software on CD-ROM -- there is a charge associated with this option, and you will be invoiced annually
Receive software as an internet download -- this is the preferred method because it is free of charge.
DDE (Direct Data Entry): For additional information on getting started with DDE and User ID Request form, refer to https://medicare.fcso.com/Direct_data_entry external link
Other: This section allows for additional information such as changing software vendors, changing submitter address phone or fax numbers. Adding an additional contact or removing a contact. Requesting a reinstate of previously deleted submitter. Other information you feel is necessary for the processing of your application. When using this section please ensure you indicate the submitter ID you are making changes to.

Maintain existing Submitter ID

Existing submitter - Part B only: If this provider is linked electronically to any other submitter, clearinghouse or billing service, the link will be removed unless otherwise indicated in this section. Please confirm and indicate the submitter that you want to maintain. If this section is not completed; any submitter’s that are linked the the NPI/PTAN will be removed. This cannot be reversed once the application has been processed; a new request will need to be submitted with this submitter indicated to be maintained.

Electronic remittance advice (ERA)

Choose one:
submitters will be set up with ERA defaulting to the submitter indicated on the request unless otherwise indicated.
An existing submitter/receiver: Indicate the submitter/receiver ID to receive ERA. This can be the submitter requesting to send claims or another existing submitter. If not indicated, the remittance advice will be returned to the submitter on this request.
Create a unique receiver ID for ERA only: Used to request a unique receiver ID for remittances only.

Enroll for ABILITY | PC-ACE™

If requesting PC-ACE software you agree to the software terms in addition to the EDI agreement terms.
For additional information on getting started with ABILITY | PC-ACE™, refer to: https://medicare.fcso.com/ABILITY_PC-ACE_software/ external link
you are not requesting PC-ACE software supported by First Coast this section does not apply to you.

Provider Agreement

Please read this section for the responsibilities of submitting Medicare claims electronically.

The Centers for Medicare & Medicaid Services (CMS) agrees to:

Please read this section of the EDI enrollment form for detailed information.

Attestation

Any provider who submits Medicare claims electronically to CMS or its contractors remains responsible for those claims as those responsible are outlined in the EDI enrollment. Please read this section of the form for details.

Authorized Official Signature Requirements

The authorized official or a delegated official, as listed on the CMS 855, must sign the Electronic Data Interchange (EDI) enrollment form. Use cursive to sign the name and print the name and title along with the current date. Failure to do so will result in the reject of your application.

Completing form, sign and date, return all pages to:

Fax: 904-361-0470
Post: First Coast Medicare EDI
P.O. Box 44071
Jacksonville, FL 32231- 4071

Additional assistance:

Questions regarding the completion of this form or inquiries regarding the status of an application may be directed to Medicare EDI enrollment at 888-670-0940, option 4.
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.