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Last Modified: 10/2/2022 Location: FL, PR, USVI Business: Part A, Part B

Instructions for completing the EDI SPOT enrollment form for third-party provider organizations

Third-party vendors, such as billing services or clearinghouses should complete the SPOT Enrollment Form for Third-Party Provider Organizations to enroll for access to the SPOT portal or to make changes to their existing SPOT setup.

General Information

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 carefully review the following block-by-block instructions to ensure successful completion. Note: The following screenshots are for instructional purposes only and cannot be completed and submitted for enrollment.
The SPOT Enrollment Form for Third-Party Provider Organizations can be completed online and emailed - or printed - before submitting.
The form must be completed and approved before attempting to register for an IDM User ID.

Third-Party Information

Third-party information
Instructions
Type the legal business name.
Type the full federal Tax Identification Number (TIN) or Employer Identification Number (EIN) of the provider. The full TIN/EIN is required for all SPOT enrollments.
Type the organization’s mailing address, including suite/building numbers/levels.
Type the organization’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 and approved vendor’s list

Third-party contact information
Type the technical contact person’s name who has technical contact name/department that can answer any technical questions.
Type the technical contact person’s name telephone number (including area code) and extension (if applicable).
Type the technical contact person’s name email.
Type the marketing contact’s name
Type the marketing contact’s telephone number (including area code) and extension (if applicable).
Type the marketing contact’s email
Select drop-down and select whether you do or do not want to be included on the approved vendor list.

Billing Approver Designation

 Approver Designation
Information
Approver information is required for all new submitter ID requests. Backup approver information is recommended but not required.
Instructions
Designate the member(s) of your staff who will be the billing office approver and billing backup approver. Carefully review the role descriptions below to ensure that roles are designated to the most appropriate staff members.
Type the first name, last name, and email address for your billing approver and billing backup approver.
Billing Office Approver
Does not have to be the provider/owner, but should be a staff member who is knowledgeable and has tenure with the organization
Should be a staff member who will be utilizing SPOT regularly, due to login requirements for inactivity
Is responsible for creating the organization in Enterprise Identity Management (IDM)
Is responsible for reviewing all end user access requests
Is responsible for certifying all end user access annually
Billing Office Backup Approver
Does not have to be the provider/owner, but should be a staff member who is knowledgeable and has tenure with the organization
Should be a staff member who will be utilizing SPOT regularly, due to login requirements for inactivity
Responsible for reviewing all end user access requests
Responsible for certifying all end user access annually
A billing backup approver is not required if you do not wish to designate one.
SPOT End User
All other staff members are SPOT end users.

Type of Request

 Type of request
Information
This block is required.
A submitter ID is an EDI-specific ID that drives access to SPOT. A submitter ID is required, even if you are not submitting claims or retrieving electronic claim files through SPOT.
If nothing is selected, a new SPOT submitter ID will be assigned.
Complete only one selection: Assign a new electronic ID for 837 claim submission via SPOT or I am currently using submitter ID if you have already been assigned a SPOT submitter ID.
Indicate whether you are a billing service or clearinghouse. If nothing or both are selected, the submitter will be set up as a billing service.
All customers must obtain a new, or link to an existing SPOT submitter ID, to access SPOT – even if you will not be using it to submit your claims.
If you have an existing SPOT submitter ID, all NPI/PTANs under your SPOT submitter ID will be set up for 837 claim submission through the SPOT submitter ID.
If you are requesting to be assigned a SPOT submitter ID, 837 will be available once providers are linked to your SPOT submitter ID. To link providers to your SPOT submitter ID, the EDI SPOT enrollment form for provider organizations must be submitted requesting to add 837 claim submission to your existing submitter ID.
Instructions for new submitter ID requests
Check the box to assign a new electronic submitter ID for 837 claim submission via SPOT.
Optional: Check I am a billing service or clearinghouse.
Instructions for existing submitter ID requests
This option should be used if your organization already has a SPOT submitter ID assigned, or if you want to add 837 claim submission to your SPOT submitter ID. Claim submission will be available for all NPI/PTANs under your SPOT submitter ID Your SPOT submitter ID and SPOT submitter name can be found in your initial SPOT enrollment confirmation letter or under Manage My Roles in IDM.
Check the box I am currently using submitter ID: and include your existing SPOT submitter ID
ERA Change Only is not a valid request at this time as ERA will only be assigned to your SPOT submitter ID if a provider requests the ERA change on the EDI SPOT enrollment form for provider organizations requesting such change.

Features/Contracts

 Features/Contracts
Information
This block is used to indicate what transactions and contracts you wish to be approved for. You are also able to enroll for PC-ACE in this block.
Instructions for Features/Contracts
Check the box to add 837 claim submission via SPOT.
Optional: Check the box to add 276 claims status files and receive 277 claim status files via SPOT.
SPOT includes an additional claim status feature that allows all users to view claim status on a claim-by-claim basis. This box is to request the ability to send and receive the ANSI X12N 276/277 transaction files through the claims submission/ERA feature in SPOT.
Verify that your software vendor supports the 276/277 files before requesting this feature.
Check the boxes for the contracts you provide services for.
Optional: Enroll for PC-ACE. Check this block and select YES from the dropdown in the PC-ACE section to request or maintain use of the free PC-ACE electronic billing software.
Read the software terms carefully.

Signature Requirements

 Signature Requirements
Information
This is a required block. The form will be returned if any of these fields are not completed accurately.
The provider’s authorized or delegated official that was listed on the CMS-855 should complete this section with their printed name and title, then sign and date the form. If you are unsure who your authorized or delegated official(s) on file are, this information can be verified in PECOS. external link This information is in the “Managing Control” section. More information about PECOS can be found on the CMS PECOS information website. external link
Instructions
Read the full agreement, attestation, and authorized official signature requirement.
Review the entire form to verify the information provided is accurate and complete.
Type the date the form was signed. The date must be a full month, day, and year.
Type the printed name of the person signing the form.
Type the professional title of the person signing the form.
Print the form.
Sign in the written signature block with a black or blue ink pen.
Email the form to MedicareEDI@FCSO.com or fax to 904-361-0474.
Allow 10 business days for processing.
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.