Fillable EDI ENROLLMENT FORM

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EDI ENROLLMENT FORM

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The EDI ENROLLMENT FORM form is 4 pages long and contains:

  • 1 signature
  • 12 check-boxes
  • 24 other fields

Country of origin: US
File type: PDF

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Page 1 of 4
How to complete the EDI enrollment form: http://medicare.fcso.com/EDI_forms/137768.asp
Revised September 7, 2018
ELECTRONIC DATA INTERCHANGE (EDI) ENROLLMENT FORM
Reason for request: Line of business: State:
*Contact email address:
*Legal Business Name:
*Contact name:
*Correspondence mailing address:
*City: *Zip Code:
Phone number:
*PTAN:
*State:
*Fax number:
*Tax ID #EIN/SSN
Network Service Vendor (NSV):
Who will be submitting the electronic claim files? Provider Clearinghouse Billing service
*REQUEST TYPE
Assign provider a new submitter ID Enroll in claim status
Electronic Remittance Advice (ERA) change Delete provider from submitter ID:
Add provider to existing submitter number ID:
PC-ACE software distributed by First Coast (must complete PC-ACE software section)
CD-ROM Internet download
Direct Data Entry (DDE) - Part A only. Requires DDE user ID request form.
Other:
MAINTAIN EXISTING SUBMITTER IDS FOR 837 TRANSACTIONS - PART B ONLY
Providers are required to notify First Coast Service Options (First Coast) of changes involving billing agents or
clearinghouses, if the PTAN listed above is associated with any other submitter numbers, First Coast will remove the
other submitter numbers unless indicated below.
Retain existing submitter numbers: (1) (2) (3) (4)
*NPI
Page 2 of 4
How to complete the EDI enrollment form: http://medicare.fcso.com/EDI_forms/137768.asp
Revised September 7, 2018
ELECTRONIC REMITTANCE ADVICE (ERA)
You must designate the ID to which the ERA should be sent. If multiple submitter IDs exist and/or nothing is selected, the
ERA will be sent to the submitter on this request (default). Upon completion of this form, ERA will be available on a daily
basis, based on claim finalization, and is only available for retrieval for 30 days. After 30 days the ERA is no longer
available in your mailbox. Posting problems with the ERA may be encountered if you maintain multiple submitter IDs. For
Part A customers, the paper remittance will continue for 30 days after the effective date of ERA. For Part B customers, the
paper remittance will continue for 45 days after the effective date of ERA. You will no longer receive paper remittances
after these time frames. NOTE: ERA will be sent to only one submitter ID.
An existing submitter ID:
Create new receiver ID:
ENROLL FOR PC-ACE SOFTWARE
If requesting PC-ACE software you agree to the following software terms in addition to the EDI agreement terms.
First Coast is authorized to distribute ABILITY | PC-ACE™ (herein referred to as the "Program") to authorized users.
ABILITY | PC-ACE™ software program is a copyright of ABILITY Network Inc. The Program is distributed for the
purpose of creating electronic Medicare claim files only. Any use not authorized herein is strictly prohibited, including
but not limited to, making copies of any part of the Program, reselling or transferring copies to any party, or creating
any modified or derivative work.
The Program is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to
the implied warranties of merchantability or fitness for particular purpose.
In no event will First Coast be liable for any loss or damage, including but not limited to incidental or consequential
damages, arising out of the use or inability to use the Program even if First Coast has been advised of the possibility
of such damages, or for any claim by any other party.
The authorized user will upgrade this program within 90 days of upgrade availability. This is a CMS requirement.
The authorized user will provide the necessary office space, all electrical and telephone connections, hardware,
telecommunication software and equipment that adhere to the technical requirements located at:
http://medicare.fcso.com/ABILITY_PC-ACE_software/.
Internet download is the preferred method of software installation. Internet download is free and instructions will be
provided upon processing of this enrollment. If you choose to receive the program in CD-ROM format, you will be
invoiced annually each October. Do not send payment with this request. The Program releases four quarterly
updates.
PROVIDER EDI AGREEMENT
The provider agrees to the following provisions for submitting Medicare claims electronically to the Centers for Medicare
and Medicaid Services (CMS) or to CMS's FIs, Carriers, RHHIs, A/B MACs or CEDI:
1. That it will be responsible for all Medicare claims submitted to CMS or a designated CMS contractor by itself, its
employees, or its agents;
2. That it will not disclose any information concerning a Medicare beneficiary to any other person or organization, except
CMS and/or its A/B MACs, DME MACs or CEDI without the express written permission of the Medicare beneficiary or
his/her parent or legal guardian, or where required for the care and treatment of a beneficiary who is unable to provide
Page 3 of 4
How to complete the EDI enrollment form: http://medicare.fcso.com/EDI_forms/137768.asp
Revised September 7, 2018
written consent, or to bill insurance primary or supplementary to Medicare, or as required by State or Federal law;
3. That it will submit claims only on behalf of those Medicare beneficiaries who have given their written authorization to
do so, and to certify that required beneficiary signatures, or legally authorized signatures on behalf of beneficiaries,
are on file;
4. That it will ensure that every electronic entry can be readily associated and identified with an original source
document. Each source document must reflect the following information: Beneficiary's name, beneficiary's health
insurance claim number, date(s) of service, diagnosis/nature of illness, and procedure/service performed.
5. That the Secretary of Health and Human Services or his/her designee and/or the A/B MAC, DME MAC, CEDI, or
other contractor if designated by CMS has the right to audit and confirm information submitted by the provider and
shall have access to all original source documents and medical records related to the provider’s submissions,
including the beneficiary’s authorization and signature. All incorrect payments that are discovered as a result of such
an audit shall be adjusted according to the applicable provisions of the Social Security Act, Federal regulations, and
CMS guidelines;
6. That it will ensure that all claims for Medicare primary payment have been developed for other insurance involvement
and that Medicare is the primary payer;
7. That it will submit claims that are accurate, complete, and truthful;
8. That it will retain all original source documentation and medical records pertaining to any such particular Medicare
claim for a period of at least 6 years, 3 months after the bill is paid;
9. That it will affix the CMS-assigned unique identifier number (submitter ID) of the provider on each claim electronically
transmitted to the A/B MAC, CEDI, or other contractor if designated by CMS;
10. That the CMS-assigned unique identifier number (submitter identifier) or NPI constitutes the provider’s legal electronic
signature and constitutes an assurance by the provider that services were performed as billed;
11. That it will use sufficient security procedures (including compliance with all provisions of the HIPAA security
regulations) to ensure that all transmissions of documents are authorized and protect all beneficiary-specific data
from improper access;
12. That it will acknowledge that all claims will be paid from Federal funds, that the submission of such claims is a claim
for payment under the Medicare program, and that anyone who misrepresents or falsifies or causes to be
misrepresented or falsified any record or other information relating to that claim that is required pursuant to this
agreement may, upon conviction, be subject to a fine and/or imprisonment under applicable Federal law;
13. That it will establish and maintain procedures and controls so that information concerning Medicare beneficiaries, or
any information obtained from CMS or its A/B MAC, DME MAC, CEDI, or other contractor if designated by CMS shall
not be used by agents, officers, or employees of the billing service except as provided by the A/B MAC, DME MAC or
CEDI (in accordance with §1106(a) of the Social Security Act (the Act);
14. That it will research and correct claim discrepancies;
15. That it will notify the A/B MAC, CEDI, or other contractor if designated by CMS within 2 business days if any
transmitted data are received in an unintelligible or garbled form.
CMS AGREES TO:
The Centers for Medicare & Medicaid Services (CMS) will:
1. Transmit to the provider an acknowledgment of claim receipt.
2. Affix the A/B MAC, DME MAC, CEDI or other contractor if designated by CMS number, as its electronic signature, on
each remittance advice sent to the provider;
3. Ensure that payments to providers are timely in accordance with CMS' policies;
4. Ensure that no A/B MAC, CEDI, or other contractor if designated by CMS may require the provider to purchase any
or all electronic services from the A/B MAC, CEDI or from any subsidiary of the A/B MAC, CEDI, other contractor if
designated by CMS, or from any company for which the A/B MAC, CEDI has an interest. The A/B MAC, CEDI, or
other contractor if designated by CMS will make alternative means available to any electronic biller to obtain such
services.
Page 4 of 4
How to complete the EDI enrollment form: http://medicare.fcso.com/EDI_forms/137768.asp
Revised September 7, 2018
5. Ensure that all Medicare electronic billers have equal access to any services that CMS requires Medicare A/B MACs,
CEDI, or other contractors if designated by CMS to make available to providers or their billing services, regardless of
the electronic billing technique or service they choose. Equal access will be granted to any services sold directly,
indirectly, or by arrangement by the A/B MAC, CEDI, or other contractor if designated by CMS;
6. Notify the provider within 2 business days if any transmitted data are received in an unintelligible or garbled form.
Note: Federal law shall govern both the interpretation of this document and the appropriate jurisdiction and venue for
appealing any final decision made by CMS under this document.
This document shall become effective when signed by the provider.The responsibilities and obligations contained in this
document will remain in effect as long as Medicare claims are submitted to the A/B MAC, DME MAC, CEDI, or other
contractor if designated by CMS.
Either party may terminate this arrangement by giving the other party thirty (30) days written notice of its intent to
terminate. In the event that the notice is mailed, the written notice of termination shall be deemed to have been given
upon the date of mailing, as established by the postmark or other appropriate evidence of transmittal.
ATTESTATION
Any provider who submits claims electronically to CMS or its contractors remains responsible for those claims as those
responsibilities are outlined on the EDI enrollment agreement. In accepting claims submitted electronically to the Medicare
program from any billing service or through the use of a particular product which accomplishes this process, neither CMS,
nor any other Medicare contractor are attesting to the appropriateness of the methods used by the billing service or
clearinghouse or to the accuracy of a particular vendor's product used to facilitate such electronic submissions. The
provider furnishing the item or service for which payment is claimed under the Medicare program retains the
responsibility for any claim regardless of the format it chooses to use to submit the claim.
If using Medicare offered, Medicare Remit Easy Print (MREP) Part B, or PC-Print Part A, for translating electronic
remittance, you are required to provide your own communication capabilities to download the X12 835 file.
AUTHORIZED OFFICIAL SIGNATURE REQUIREMENTS
By signing below I certify that I have been appointed an authorized official to whom the provider has granted the legal
authority to enroll it in the Medicare Program, to make changes and/or updates to the provider's status in the Medicare
Program (e.g., new practice locations, change of address, etc.), and to commit the provider to abide by the laws,
regulations, and the program instructions of Medicare. I authorize the above listed entities to communicate electronically
with First Coast on my behalf.
By signing below the provider confirms they have read and agree with the PC-ACE software agreement, if applicable,
the provider EDI agreement, the CMS’ obligations, and the Attestation sections on page 2-4 of this document.
* Authorized official signature:
* Date:
* Name and title of authorized official (Print):
* Required field - If missing or invalid, application will be returned.
Complete form, sign and date, and return all pages to:
Email: MedicareEDI@fcso.com
Fax: (904) 361-0470
Post: First Coast Medicare EDI
P.O. Box 44071
Jacksonville, FL 32231- 4071
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EDI ENROLLMENT FORM

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Completed 18 February 2020

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