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A step-by-step guide to getting started submitting electronic claims for providers
Last Modified: 11/6/2024
Location: FL, PR, USVI
Business: Part A, Part B
For physicians/suppliers/facilities considering submitting claims via 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 the Electronic Remittance Advice and Health Care Claim Acknowledgement reports 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) or the SPOT online portal for connectivity to the EDI Gateway. For a list of known NSV’s please visit “
Getting Started with PC-ACE”. 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:
• EDI SPOT Enrollment Form for provider offices 
: This form is an agreement mandated by the CMS to be completed by each provider requesting access to the SPOT online portal. This form is required for the initial SPOT setup with First Coast. Once this form is processed, the office approver will need to complete the registration process in the identity management (IDM) system. Complete this form if a third party such as a billing service will need access to your office information. The SPOT form has separate detailed
completion instructions and can be faxed, mailed, or emailed.
Note: this form is only for providers. Clearinghouses and billing services needing access to SPOT should complete the
EDI SPOT Enrollment form for third-party organizations using the
third-party portal form instructions • Electronic Data Interchange (EDI) enrollment form : 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.
Note: this form is only for providers. Clearinghouses, billing services, network service vendors and third party vendors should complete the
EDI Third Party Enrollment form.
• Each NPI/PTAN
affiliated group or solo combination must be enrolled for electronic billing prior to submitting claims. If your organization has multiple NPI/PTAN combinations, include one on the EDI Enrollment Form and attach a list of the additional NPI/PTAN combinations. The attached list must include the provider name, PTAN, NPI, and TIN of each provider listed.
• If you are requesting to be assigned a new submitter ID, you must indicate your software vendor. If the software vendor is not yet an approved software vendor with First Coast, the software vendor will need to submit the EDI Third Party Enrollment form for testing purposes only. Once testing is complete and passed, then you may submit the form to be assigned a submitter ID.
3.
Submit production claims: Providers may begin submitting claims electronically in the production environment if using SPOT or if your software vendor has been approved. If the vendor is not yet approved, they must complete the test requirements before you may submit production claims.
4.
Take advantage of other electronic applications available to providers billing electronic claims: The
999 initial acknowledgment and 277CA report must be retrieved after each 837 claim file submission to ensure the file was accepted. 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.
• Initial Acknowledgement (999)
• Electronic receipt of claim submission Health Care Claim Acknowledgement (277CA)
• Electronic remittance advice (ERA) (835)
• Electronic claim status (ECS) (276/277)
All the electronic applications are like 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 these “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.
