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Last Modified: 10/31/2022 Location: FL, PR, USVI Business: Part A, Part B

A step-by-step guide to getting started submitting electronic claims

For those physicians/suppliers/facilities considering submitting Electronic Data Interchange (EDI), the following information outlines procedures related to getting started along with additional electronic features available to EDI providers.
1. Changing from paper to EDI: Evaluate your current office methods of paper claims submission.
Computer-generated paper claims? If your office has a computer that is used to generate paper claims, and you maintain the services of a vendor who services your software and/or hardware, contact your vendor first. The vendor may have already developed electronic capabilities and could help you set up and get started billing electronically. In fact, your existing system may already possess electronic claim submission capabilities.
Medicare’s free electronic claim submission software, PC-ACE is available free of charge if downloaded. You can also take advantage of other electronic applications such as “Electronic Remittance Notification” and “Health Care Claim Acknowledgement” that will assist you in maximizing your office efficiency. All Medicare EDI Trading Partners submissions and retrievals are required to use a Network Service Vendor (NSV) for connectivity to the EDI Gateway. For a list of known (NSV’s) please visit “Getting Started with PC-ACE pdf file”. Specific services and financial arrangements must be made between the Submitter and (NSV).
Handwritten or typed paper claims? If your office does not have a computer and you need to know where to start, refer to the article “Choosing a Vendor.”
2. Complete the proper form: Once you decide to submit claims electronically, you will need to complete the following form:
Electronic Data Interchange (EDI) enrollment form pdf file”: This form is an agreement mandated by the CMS to be completed by each provider. This form will allow you to receive a sender/submitter number, mailbox ID and a password, which allows you to access different applications. Complete this form if your office will perform the electronic billing. This form will also allow you to add a provider number to an existing sender code. Complete this form if a third party such as a clearinghouse will perform the electronic billing on your behalf. The EDI form has separate detailed completion instructions and can be faxed, mailed or emailed.
New clearing houses, billing services, network service vendors and third party vendors should complete the EDI Third Party Enrollment form. This form is located at pdf file.
3. Submit test claims: Once you have been assigned an EDI sender/submitter number you will be required to submit a batch of test claims (from your office to our office not the vendor location), for evaluation. The Medicare EDI testing area will evaluate the test and contact you with the results. The test must meet accuracy requirements to be approved to submit production electronic claims for processing.
Test claims do not need to be new claims. If you are unable to collect enough new claims for a test, you may use claims that have already been processed. Your test is submitted into a separate testing system and is not processed for payment.
You should receive the test results within three working days from the date the test data is received by First Coast EDI.
4. Submit production claims: Upon approval to submit production claims (passed the test), providers should begin submitting claims electronically in the production environment, as soon as possible (normally within 30 days). We request that you transmit at least one production batch per month to keep your sender number and password active.
5. Take advantage of other electronic applications available to providers billing electronic claims: You can take advantage of other electronic applications that will assist you in maximizing your efficiency. These applications are listed in the order of provider needs.
Electronic receipt of claim submission (Health Care Claim Acknowledgement) (277)
Electronic remittance advice (ERA) (835)
Electronic claim status (ECS) (276/277)
All of the electronic applications are similar to electronic claims submission in the fact that you will need to obtain the software application from your software support vendor. Medicare only makes the applications available for use and does not provide the actual software application.
If you have any questions concerning “Getting Started Steps” or other electronic applications, contact Medicare EDI at 888-670-0940.
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.