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Last Modified: 4/11/2019 Location: FL, PR, USVI Business: Part A, Part B

Top reasons why your Medicare EDI enrollment form is rejected

It can take up to seven days to process your EDI enrollment form. If the EDI enrollment form is rejected a new EDI enrollment form must be submitted. Avoid delays by ensuring the form is completed correctly the first time. Below are the top reasons the EDI enrollment forms pdf file are rejected.
1. Form is outdated: Download the most recent EDI enrollment form pdf file from our website every time a new enrollment form is needed
2. Required information is missing: Every element identified with an asterisk (*) must be completed.
3. Provider information is missing or invalid: Legal business name, National Provider Identifier (NPI), Provider Transaction Access Number (PTAN) and Tax ID must match the Medicare shared systems.
4. NPI and/or PTAN are not the billing entity: Make sure the NPI and PTAN submitted on the form is for the billing entity and not the performing provider.
5. Signature requirements not met: Enrollment forms must be signed and dated by the billing entity’s authorized or delegated official as listed on the CMS 855. Ensure the title is included.
6. Request type not completed: Indicate the type of request. This section indicates the action to be taken on your EDI agreements.
7. Invalid or omitted submitter ID: The delete provider from submitter ID, add provider to submitter ID and maintain existing submitter ID must include a valid Medicare Jurisdiction N submitter ID. Contact your billing service or clearinghouse for the information.
8. Network Service Vendor (NSV) information is missing: If you are requesting a new submitter ID you must provide the name of your NSV.
For step by step instructions on how to complete the EDI enrollment form please visit https://medicare.fcso.com/EDI_forms/137768.asp. If any additional assistance is needed please contact one of our EDI analysts via telephone at 888-670-0940 or via email at MedicareEDI@fcso.com.
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.