Fillable MEDICARE TENNESSEE PART B (MR034) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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MEDICARE TENNESSEE PART B (MR034) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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• The EDI Enrollment Packet
Depending on what kind of submitter you are, you will need to fill out the following forms:
o New EDI Submitter
EDI Enrollment Agreement
EDI Application
Provider Authorization form
o Existing Submitter switching to Office Ally
EDI Application
Provider Authorization Form
o Please Note: Only the owner or authorized personnel can sign the form
• Email to EDIENROLL.PARTB@PalmettoGBA.com; OR
• Fax to (803) 870-0164
• Standard processing time is 4-6 weeks.
• Call the EDI Department at (877) 567-7271 and ask if you have been linked to Office Ally’s Submitter ID
TN200864.
• Once you receive confirmation that you have been linked to Office Ally, you MUST email
Support@officeally.com with the below information BEFORE submitting claims electronically.
Email Subject: Medicare Tennessee Part B (MR034) – EDI Approval
Body of Email:
Please log my EDI approval for Medicare Tennessee Part B.
Provider Name
NPI
Tax ID
• In order to receive ERAs from Palmetto through Office Ally, make sure to check the box on the bottom of the
Medicare EDI Application for “Receive Electronic Remittances”. If you do not wish to receive ERAs through
Office Ally, do not check this box.
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
MEDICARE TENNESSEE PART B (MR034)
PRE-ENROLLMENT INSTRUCTIONS
WHICH FORM(S) SHOULD I DO?
WHERE SHOULD I SEND THE FORM(S)?
WHAT IS THE TURNAROUND TIME?
HOW DO I CHECK STATUS?
HOW DO I ENROLL TO RECEIVE ELCTRONIC REMITTANCE ADVICE (ERA)?
Part A/Part B/HHH EDI Enrollment Packet
Attention: Please Read Before Completing Paperwork
This enrollment packet is for use in the following Jurisdictions/states:
Jurisdiction J
• Parts A and B: Alabama, Georgia and Tennessee
Jurisdiction M
• Parts A and B: South Carolina, North Carolina, Virginia* and West Virginia*
• Home Health & Hospice (HHH): Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky,
Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee
and Texas
• Review Choice Demonstration (RCD) for HHH: Illinois, Ohio, Texas and North Carolina
*Virginia (VA) & West Virginia (WV) Part A: Palmetto GBA has subcontracted with National
Government Services (NGS) to continue EDI support of the Virginia and West Virginia Part A
workload for Palmetto GBA. Please contact the NGS Help Desk at 855-696-0705 for EDI support.
Enrollment Submission
We are now accepting completed enrollment paperwork via fax or email (do not submit more than once).
Jurisdiction J Part A (AL, GA, TN)
Jurisdiction J Part B (AL, GA, TN)
803-870-0163
EDIENROLL.PARTA@PalmettoGBA.com
803-870-0164
EDIENROLL.PARTB@PalmettoGBA.com
Jurisdiction M Part A (SC, NC) & HHH
Jurisdiction M Part B (SC, NC, VA, WV)
803-699-2429
EDIPartA.ENROLL@PalmettoGBA.com
803-699-2430
EDIPartB.ENROLL@PalmettoGBA.com
Email Enrollment Monitoring
Your email address will be the primary method of communication with Palmetto GBA EDI Operations.
We will send you a Tracking Number via email that you can use to monitor your enrollment process
through the website at www.palmettogba.com/EDI. Be sure to include your email address on all EDI
Enrollment forms. Please add @palmettogba.com and @bcbssc.com to your email contact list to ensure
our emails are not filtered into your spam or junk mail folder.
Take Control of your Accounts Receivable and Become Compliant Now!
Sign up today to receive your remittances electronically and be ahead of the game. Download and print
your remits more quickly. CMS is focused on increasing the number of providers who receive their
remittances electronically and decreasing the printing and mailing costs associated with hardcopy
remittances. Complete your forms today!
Support
We are committed to making your transition to EMC as smooth as possible. If you have any questions
regarding the information contained in this package, please feel free to contact the Palmetto GBA EDI
Provider Contact Center toll free at:
Jurisdiction J Part A and Part B: 877-567-7271
Jurisdiction M Part A, Part B and HHH: 855-696-0705
Thank you for your interest in Electronic Data Interchange!
Palmetto GBA
Part A/Part B/HHH EDI Operations
www.palmettogba.com
A CMS Medicare
Administrative Contractor
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
Page 1 June 2020
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
Using Electronic Data Interchange Services
Palmetto GBA has prepared this packet for Part A, Part B and HHH submitters. Palmetto GBA
administers the Part A & Part B contracts for Alabama, Georgia, South Carolina, North Carolina,
Tennessee, Virginia* and West Virginia*, in addition to home health and hospice (HHH) services
provided in the following states: Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky,
Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee and
Texas.
*Virginia (VA) & West Virginia (WV) Part A: Palmetto GBA has subcontracted with National
Government Services (NGS) to continue EDI support of the Virginia and West Virginia Part A workload
for Palmetto GBA. Please contact the NGS Help Desk at 855-696-0705 for EDI support.
The Part A/Part B EDI Enrollment packet contains forms and explanations for each of the services offered
by our Electronic Data Interchange (EDI) department. For further information regarding any of this
material, please call the Palmetto GBA EDI Provider Contact Center toll-free at:
Jurisdiction J Part A and Part B: 877-567-7271
Jurisdiction M Part A, Part B and HHH: 855-696-0705
When submitting completed forms, please allow a processing time of approximately 15 business days.
Remember – Palmetto GBA cannot process incomplete applications or agreements! Please fill in all
appropriate blanks and make all checks payable to Palmetto GBA.
If you are a provider waiting for a provider number, please wait before submitting any EDI forms! You
must be assigned your provider number before completing any of the paperwork below. To apply for a
provider number, please call the Provider Contact Center toll-free at:
Jurisdiction J Part A and Part B: 877-567-7271
Jurisdiction M Part A, Part B and HHH: 855-696-0705
The Administrative Simplification Compliance Act (ASCA) prohibits Medicare coverage of claims
submitted to Medicare on paper, except in limited situations. All initial claims for reimbursement from
Medicare must be submitted electronically, with limited exceptions.
For more information on Palmetto GBA EDI options, please visit our website at
www.palmettogba.com/EDI or email us at Medicare.EDI@PalmettoGBA.com. The CMS Electronic Billing
& EDI Transactions Web page at https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/index.html
also includes detailed information on EDI and the Administrative Simplification provision.
You can check the status of Palmetto GBA’s EDI Systems by visiting the Palmetto GBA website.
Under Electronic Data Interchange (EDI), select “EDI System Status.” This pop-up window will display
the current status of several systems. The pop-up window will automatically refresh every 60 seconds so
you can keep it up during the day. We will update the EDI System Status window with information on
any system-related issue. When a problem occurs, such as a delay with posting remittance files, a detailed
informational message will display below the affected system. This message will be updated until the
problem has been corrected. Please visit this area on the Palmetto GBA website prior to calling the
Palmetto GBA Provider Contact Center with system status questions.
Please register on our website (www.palmettogba.com/EDI) to receive EDI news electronically. By
selecting “Email Updates” (which displays at the top of all pages) and completing a user profile, you will
be notified via email when new or important EDI information is added to our website. If you have already
registered, please ensure your profile has been updated for applicable EDI categories. Users of PC-ACE
Pro32, PCPrint or Medicare Remittance Easy Print (MREP) should select the Palmetto GBA Software
Users topic located under the General category. This category also includes a special topic created for
Vendors, Clearinghouses and Billing Services.
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
Page 2 June 2020
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
1. EDI Application
Please Note: The EDI Application Form is used for initial EDI set up. The information on this form is
also used to verify requester information submitted on additional EDI applications. Please retain a copy
of the EDI Application Form for your records. You must submit a completed EDI Application Form
when submitting the EDI Enrollment Agreement or Provider Authorization Form.
A Submitter ID number is a unique number identifying electronic submitters. A Submitter ID can be used
to transmit Part A, Part B and HHH EDI transactions to Palmetto GBA. You must request a Submitter ID
if you will be submitting claims directly to Palmetto GBA. However, if you are a provider and will be
using a billing service or clearinghouse to submit your claims, do not complete this form to request a
Submitter ID. Billing services, not their customers, need electronic submitter numbers. Providers, Billing
Services, Clearinghouses and Vendors must complete the EDI Application Form when requesting a
change to your current EDI setup.
Providers are not permitted to share their personal EDI access number (Submitter ID) or password with:
• Any billing agent, clearinghouse/network service vendor
• Anyone on their own staff who does not need to see the data for completion of a valid electronic
claim, to process a remittance advice for a claim, to verify beneficiary eligibility or to determine the
status of a claim
• Any non-staff individual or entity
The EDI Submitter ID and password act as an electronic signature; therefore, the provider would be liable
if any entity performed an illegal action while using that EDI Submitter ID and password. Likewise, a
provider’s EDI Submitter ID and password is not transferable, meaning that it may not be given to a new
owner of the provider’s operation. New owners must obtain their own EDI Submitter ID and password.
GPNet is the HIPAA-compliant EDI gateway used by Palmetto GBA. The GPNet platform is available 24
hours a day, seven days a week. The real time editing system is down from 11:30 p.m. to 5:00 a.m. EST.
If the editing system is not available, you may still upload a file to GPNet. As soon as the editing system
resumes processing, files in GPNet will be edited. The response files will be built and loaded into your
mailbox for retrieval at your convenience within 24 hours.
The GPNET Communications Manual includes information about connecting to Palmetto GBA’s EDI
Gateway. The GPNet Communications Manual is available for download from
www.palmettogba.com/EDI under Software & Manuals.
Note: Palmetto GBA supports file transfers via Network Service Vendors and CONNECT:Direct (also
known as Network Data Mover or NDM).
2. EDI Enrollment Agreement
Every provider who submits electronic claims to Palmetto GBA, whether directly or through a billing
service or clearinghouse, must complete this agreement. Please indicate your provider or group number
and National Provider Identifier (NPI) so the contract may be logged correctly. Billing services should not
complete the EDI Enrollment Agreement unless they are a Medicare provider as well as a billing agency.
Only one agreement per group is required.
Palmetto GBA EDI cannot process any of the enclosed forms for a provider without a completed EDI
Enrollment Agreement on file.
Providers who have contracted with a third party (clearinghouse/network service vendor or a billing
agent) are required to have an agreement signed by that third party in which the third party has agreed to
meet the same Medicare security and privacy requirements that apply to the provider in regard to the
viewing or use of Medicare Beneficiary data. These agreements are not to be submitted to Medicare, but
are to be retained by the provider.
Providers are obligated to notify Medicare by hardcopy of:
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
Page 3 June 2020
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
• Any changes in their billing agent or clearinghouse
• The effective date of which the provider will discontinue using a specific billing agent or
clearinghouse
• If the provider wants to begin to use additional types of EDI transactions
• Other changes that might impact their use of EDI
Providers are not required to notify Medicare if their existing clearinghouse begins to use alternate
software; the clearinghouse is responsible for notification in this instance.
Note: The binding information in an EDI Enrollment Agreement does not expire if the person who signed
the form for a provider is no longer employed by the provider.
3. Provider Authorization Form
Every provider who authorizes a billing service and/or clearinghouse to act on their behalf must complete
the provider authorization form. This form must be completed by the provider and submitted with the EDI
application.
Please Note: CR3875 requires that each provider be notified when a clearinghouse and/or billing service
has requested access to the provider’s claims, responses, electronic remittances or online services access.
4. Software Download Information
Please Note: All software listed below can be downloaded from our website free of charge. For
additional software information and download instructions, please visit www.PalmettoGBA.com/EDI and
select your line of business. Software information and files are located under Software & Manuals. If you
are unable to download the software from our website, please call our Provider Contact Center at:
Jurisdiction J Part A and Part B: 877-567-7271
Jurisdiction M Part A, Part B and HHH: 855-696-0705
4.A. PC-ACE Pro32 Software
Palmetto GBA offers PC-ACE Pro32, a claims-entry software that allows providers to enter their claims.
Pro32 does not integrate into office systems such as accounts receivable, inventory or billing. This
software is HIPAA compliant and allows for all types of claims to be submitted electronically. This soft-
ware is not supported when installed on a network. The software must be installed on a stand-alone PC.
Minimum system requirements for Pro32 include:
• SVGA monitor resolution (800 x 600)
• Windows 10, Windows 8.1, Windows 7 or Vista operating system
• Adobe Acrobat Reader Version 4.0 or later (for overlaid claim printing)
This free software can be downloaded from the Adobe website (www.adobe.com)
4.B. PCPrint for Part A Electronic Remittances
PCPrint is a software product designed to operate on Windows based personal computers. The PCPrint
translator program allows viewing and printing of ASC X12 835 version 5010A1 remittance data. This
software does not support systematic posting of the 835 data. It was developed by the Fiscal Intermediary
Standard System (FISS) for the Centers for Medicare & Medicaid Services (CMS). With PCPrint, you
can view and print:
• Single claims – Detail line-item activity for each claim. Compressed font is incorporated in order to
display the detail line item activity of a claim.
• All claims – An abbreviated format for all claims in a transmission file, shown in increments of 25.
• Bill summary – Sub-totals for each payment category per provider fiscal year and the total remittance
found within the Single Claim format, accumulated and displayed by TOB (type of bill).
• Provider summary – Total payment to the provider for each billing cycle in a transmission file.
Nonclaim payment adjustments are listed when applicable. These adjustments allow for provider
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
Page 4 June 2020
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
payments when claims are not present (such as Periodic Interim Payments, Cost Report Settlements,
etc.). The adjustments also allow for various other financial transactions required between Fiscal
Intermediaries and providers.
4.C. Medicare Remittance Easy Print (MREP) Software for Part B Electronic Remittances
The Centers for Medicare & Medicaid Services (CMS) has made available the Medicare Remittance Easy
Print (MREP) software to enable Medicare providers to view and print an 835 Health Care Claim
Payment / Advice (also referred to as Electronic Remittances). Using the HIPAA 835 files, MREP
enables providers to view and print 835 in the current Standard Paper Remittance (SPR) format Medicare
uses. MREP provides the ability to view, search and print the 835 in a format providers are familiar, as
well as view and print special reports.
Providers who use MREP can print reports to reconcile accounts receivable as well as create documents
that can be included with claim submission to Coordination of Benefits (COB) payers. MREP is available
free to Medicare providers, and it can be installed on a personal computer (PC) or network.
5. Online Inquiry Services
Online Inquiry Services are two online computer inquiry systems that provide easy and immediate access
to claims processing and beneficiary eligibility information for Medicare providers, including:
eServices by Palmetto GBA
Part A, B & HHH
Direct Data Entry (DDE)
Part A & HHH
Check Eligibility
Claims Status
Remittances Online
Financial Information
Electronic Claims Submission
Claim Status
Submitter/Provider File Inquiry
Beneficiary Eligibility Inquiry
Correcting RTPs (Return to Provider)
5.A. Palmetto GBA eServices for Part A, B & HHH
Palmetto GBA is pleased to offer eServices by Palmetto GBA, a free Internet-based, provider self-
service portal. Our goal is to give the provider secure and fast access to their Medicare information
seamlessly via our website through the eServices application. The eServices application provides
information access over the Web for the following online services:
• Eligibility
• Claims Status
• Remittances Online
• Financial Information (payment floor and last three checks paid)
eServices will generally be available 24 hours a day, seven days week. Please visit the eServices webpage
at www.PalmettoGBA.com/eServices for function availability and registration information. To be eligible
to participate in eServices, you must have a completed an EDI Enrollment Agreement (included in the
packet) that is actively on file with Palmetto GBA. An enrollment agreement processed by EDI will not
automatically enroll a provider in eServices. eServices registration information is available online at
www.PalmettoGBA.com/eServices. Only one Provider Administrator per EDI Enrollment Agreement
related to a PTAN/NPI combination performs the registration.
Note: Palmetto GBA has the right to terminate any user’s eServices access if suspicious or improver
activity is suspected or determined.
5.B. Direct Data Entry (DDE) for Part A & HHH
Palmetto GBA makes Part A & HHH claim entry available directly into the claims processing system via
on-line Direct Data Entry (DDE). Access is available to DDE through many of Palmetto GBA approved
Network Service Vendors (NSVs). See the Connectivity Options section for more information on NSVs.
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
Page 5 June 2020
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
Providers use DDE for claim submission by signing on to Palmetto GBA’s claims processing system and
entering claims on-line, similarly to the way data entry operators enter paper claims submitted to Palmetto
GBA. DDE is also available to all providers who use other methods of electronic claim submission but
wish to check status of claims, beneficiary eligibility and correct claims on-line through the DDE system.
The DDE User’s Manual is available for download from the Palmetto GBA website under EDI Software
& Manuals.
Each user must have an individual DDE number. You must include an individual’s name with each user
ID requested. For security reason, you cannot share your DDE ID Number, nor can the ID be transferred
to another person. If that individual leaves your company or no longer needs access, please contact EDI
to delete the ID. One DDE or ID can access multiple provider numbers.
6. Connectivity Options
To assist submitters in finding a Network Service Vendor (NSV) best suited to their needs, contact
information for approved NSVs who have successfully tested with Palmetto GBA is posted on our
website (under EDI Enrollment).
This list is updated periodically and is subject to change between publications. This list should not be
construed as a recommendation or sponsorship by BlueCross BlueShield of South Carolina, Palmetto
GBA, nor CMS, for any of the organizations that appear on the listing. Specific services and financial
arrangements must be made between vendors and providers. Palmetto GBA will not be a party to any
such arrangement. The posted listing is provided solely for your convenience.
7. Testing
Submitter testing is required to ensure that the flow of data from the submitter to Palmetto GBA works
properly. Testing also ensures the data submitted is valid and formatted correctly. New submitters are
required to test prior to sending their first production dataset. New submitters are also required to have
completed the Palmetto GBA enrollment process prior to testing.
Begin testing once you have software and a Submitter ID number. You must submit a minimum of 25
claims that are representative of your practice (they do not have to be “real” or current claims) and you
must score 95% or better to get certified for “live” claims production. You should submit test claim files
using your Medicare provider number. Do not notify Palmetto GBA before you test – just start!
Response reports are available within 24 hours of transmission. Submitters should retrieve their reports,
correct any errors, and re-submit the claims until a single file of at least 25 claims is 95% error free. You
must contact the Palmetto GBA Provider Contact Center once you have successfully passed testing.
8. Change of Ownership, Address or Phone Number
When you have a change of ownership, address or phone number, you must notify Palmetto GBA. If the
change of ownership results in different provider number(s), please inform the Provider Contact Center
when you call:
Jurisdiction J Part A and Part B: 877-567-7271
Jurisdiction M Part A, Part B and HHH: 855-696-0705
9. Notice to Billing Services, Clearinghouses and Vendors
If you will be submitting claims for more than one provider and you do not have a financial relationship
with those providers (other than a billing relationship), you will be classified as a billing service. Each
provider must complete an EDI Enrollment Agreement and the Provider Authorization Form. Palmetto
GBA EDI Operations will verify provider authorization.
Clearinghouses and Network Service Vendors (NSVs) must use their own EDI Submitter ID /Receiver ID
Number and password to submit and receive EDI transactions on behalf of providers. You may not use a
number or password that has been assigned to a provider. If you currently use or have knowledge of an
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
Page 6 June 2020
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
EDI Submitter ID or Receiver ID number and password issued to a provider by Palmetto GBA, you must
disclose that information to the EDI Operations Department.
Clearinghouses and NSVs can submit or receive EDI Medicare transactions for providers who have filed
an EDI Enrollment Agreement and EDI forms which authorizes the Clearinghouse or NSV to conduct
specified transactions on their behalf. A Clearinghouse or NSV will be in violation of CMS and HIPAA
privacy and security requirements for the following actions:
• Attempting to conduct EDI transactions for a provider that has not authorized it to perform such
actions on their behalf
• Conducts an authorized transaction for a provider who did not request the specific transaction (such
as submission of a request for eligibility data when that request was not originated by the provider
identified as the source of the request)
Violators may be subject to penalties established by HIPAA and could lose all access rights to Medicare
contractor systems nationally.
Clearinghouses and NSVs who do not translate non-HIPAA transactions or prepare claims are not
permitted to read the content of data transmitted between a provider and Medicare, beyond accessing
basic fields needed to determine inbound or outbound routing.
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
EDI Application Form
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
Part A/Part B/HHH EDI Application Form Instructions
The purpose of the Part A/Part B/HHH EDI Application Form is to enroll providers, software vendors,
clearinghouses and billing services as electronic submitters and recipients of electronic claims data. It is
important that instructions are followed and that all required information is completed. Incomplete
forms will be returned to the applicant, thus delaying processing.
Please retain a copy of this completed form for your records.
You must submit a completed EDI Application Form when submitting additional EDI forms.
The field descriptions listed below will aid in completing the form properly. There are two pages to the
application form. The first page is required and the second page should be used only if additional
providers need to be listed.
Form Field Name
Instructions for Field Completion
Line of Business
Information
Indicate the line of business and state for which you will be transmitting.
Select all that apply to this request.
Action Requested:
Add Provider(s)
Change/Update
Submitter
Information
Delete
Apply for New
Submitter ID
Apply for New
Receiver ID
Indicate the action to be taken on the application form.
• If you need to add additional providers to an existing submitter ID,
check Add Provider(s).
• If you request to change or update information about the Submitter,
check Change/Update Submitter Information and be sure to include
your current Submitter ID.
• If you request to delete a provider(s), check Delete and be sure to
include your submitter ID.
• If you are a new applicant, check Apply for New Submitter ID.
• If you are a new applicant, check Apply for New Receiver ID (This
option is available for North Carolina Part A and Virginia Part B only).
Submitter ID
The submitter ID is used by the submitter to communicate with Palmetto
GBA electronically. For new applicants, this field should be left blank, as
Palmetto GBA will assign this ID if requested. For changes or additions,
enter the Submitter ID to which the change/additions should be applied.
Date
Please enter the date the application is completed.
Receiver ID
This option is available for North Carolina Part A and Virginia Part B
only. The receiver ID is used by the remittance receiver to download
remittance advices/notices via Palmetto GBA electronically. For new
applicants, this field should be left blank, as Palmetto GBA will assign this
ID if requested. For changes or additions, enter the Receiver ID to which
the change/additions should be applied.
Submitter Name
Enter the name of the entity (provider, software vendor, billing service or
clearinghouse) that will actually be communicating electronically with
Palmetto GBA.
Owner Name(s)
Enter the name of the individual(s) who owns the entity listed above.
Type of Submitter
Check the appropriate box.
EDI Contact Person
The name of the submitter’s primary EDI contact. This is the person
Palmetto GBA will contact if there are questions regarding the application
or future questions about their communications.
Phone
The area code and phone number of the Contact Person listed.
Fax
The fax number for this location.
Address
The mailing address of the submitter.
City, State, ZIP
The city, state and ZIP Code of the submitter.
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
EDI Application Form
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
Form Field Name
Instructions for Field Completion
Submitter Email
Address
The email address of the contact person listed. Note: This will be the
primary method of communication. The email address will also receive EDI
Tracking Numbers used to monitor the processing status of your EDI forms.
Report Response
Format
Check the format in which you will receive GPNet Claims Acceptance
Responses.
Data Compression
To receive files compressed for faster transmission, indicate which data
compression utility you support.
Name of Software
Vendor
Indicate the name of the software vendor you are using, if applicable.
Vendor ID
Include Vendor ID number if known.
Name of Network
Service Vendor
Indicate the name of the network service vendor you are using, if
applicable.
Providers For Whom Submitter Will Be Communicating Electronically:
Provider Name
List each provider whose bills will be submitted by the submitter named
above. (If additional providers need to be listed, indicate each one
separately on the Multiple Providers List form.) This name must match the
name submitted on the CMS 855 Medicare Enrollment Application.
Tax ID
Enter the Tax Identification Number for the provider.
Provider Email
address
Indicate the email address for the provider listed above. This email address
will be the primary source of communications regarding approval of
changes to their EDI options.
Provider Number
Indicate the Medicare Provider Number for each provider listed.
NPI
Include the National Provider Identifier (NPI).
Enrollment Form
Attached:
Y/N
Indicate “Y” for Yes or “N” for No. A properly executed 3-page EDI
Enrollment Agreement must be attached for each provider listed.
Palmetto GBA will not activate a submitter ID for any provider
without a properly executed enrollment form.
Provider Authorization
Form Attached:
Y/N
Indicate “Y” for Yes or “N” for No. A provider authorization form is
required to authorize a clearinghouse and/or billing service as an electronic
submitter and recipient of electronic claims data.
Submit Claims
Check this box if the application is for the submitter to submit claims
electronically for this provider.
Receive Reports
Check this box if the submitter wants to receive response reports
electronically for the provider indicated.
Receive Electronic
Remittances
Check this box if the submitter wants to receive Electronic Remittances for
the provider indicated. Provider must be submitting claims electronically to
receive Electronic Remittances.
Online Inquiry
Check this box if the submitter currently uses or plans to use the Online
Inquiry Services (DDE). Note: The Online Inquiry Form must be submitted
if this option is selected. (Part A only)
Once you have completed the application form, please retain a copy for your records and fax or email the
original via the appropriate fax number or email address below. Your Submitter ID and software (if
applicable) will be processed within 15 business days of receipt of completed forms.
Completed forms must be faxed or emailed to:
Jurisdiction J Part A (AL, GA, TN)
Jurisdiction J Part B (AL, GA, TN)
803-870-0163
EDIENROLL.PARTA@PalmettoGBA.com
803-870-0164
EDIENROLL.PARTB@PalmettoGBA.com
Jurisdiction M Part A (SC, NC) & HHH
Jurisdiction M Part B (SC, NC, VA, WV)
803-699-2429
EDIPartA.ENROLL@PalmettoGBA.com
803-699-2430
EDIPartB.ENROLL@PalmettoGBA.com
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
EDI Application Form
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
Part A/Part B/HHH
EDI Application
Line of Business Information: HHH: Review Choice Demonstration (RCD):
Part A: AL
GA SC NC TN
Part B: AL GA SC NC TN VA WV
Action Requested: Add Provider(s) Change / Update Submitter Information
Delete Apply for New Submitter ID Apply for New Receiver ID (NC Part A and VA Part B Only)
Submitter ID (if available): Date:
Receiver ID:
Submitter Name:
Owner Name:
Type of Submitter: Software Vendor Billing Service Provider Clearinghouse
EDI Contact Person:
Phone: Fax:
Address:
City: State: ZIP:
Submitter Email Address:
Note: Email will be the primary method of communication.
Report Response Format: File Report
Data Compression:
Uncompressed
PKZIP UNIX-Compress
Name of Software Vendor:
Vendor Security ID:
Name of Network Service Vendor:
Providers for Whom Submitter Will Be Transmitting
Provider Name:
Tax ID:
Provider Email Address:
Provider Number:
NPI:
Enrollment Form Attached? Yes No Provider Authorization Form Attached? Yes No
Submit Claims Receive Reports Receive Electronic Remittances
Online Inquiry Services RCD Submissions
Submit completed forms via fax or email to:
Jurisdiction J Part A (AL, GA, TN)
Jurisdiction J Part B (AL, GA, TN)
803-870-0163
EDIENROLL.PARTA@PalmettoGBA.com
803-870-0164
EDIENROLL.PARTB@PalmettoGBA.com
Jurisdiction M Part A (SC, NC) & HHH
Jurisdiction M Part B (SC, NC, VA, WV)
803-699-2429
EDIPartA.ENROLL@PalmettoGBA.com
803-699-2430
EDIPartB.ENROLL@PalmettoGBA.com
Notes: Please retain a copy for your records.
You must submit a completed EDI Application Form when submitting additional EDI forms.
TN200864
TN200864
Office Ally, Inc
Brian O'Neill
Customer Service
360-975-7000 Option 1
360-896-2151
PO Box 872020
Vancouver
WA
98687
info@officeally.com
ECC
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
EDI Application Form
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
Part A/Part B/HHH
EDI Application
Multiple Providers List
Date: ________________________
Additional Providers for Whom Submitter Will Be Transmitting
Provider Name: Tax ID:
Provider Email Address:
Provider Number: NPI:
Enrollment Form Attached? Yes No Provider Authorization Form Attached? Yes No
Submit Claims Receive Reports Receive Electronic Remittances
Online Inquiry Services RCD Submissions
Provider Name: Tax ID:
Provider Email Address:
Provider Number: NPI:
Enrollment Form Attached? Yes No Provider Authorization Form Attached? Yes No
Submit Claims Receive Reports Receive Electronic Remittances
Online Inquiry Services RCD Submissions
Provider Name: Tax ID:
Provider Email Address:
Provider Number: NPI:
Enrollment Form Attached? Yes No Provider Authorization Form Attached? Yes No
Submit Claims Receive Reports Receive Electronic Remittances
Online Inquiry Services RCD Submissions
Provider Name: Tax ID:
Provider Email Address:
Provider Number: NPI:
Enrollment Form Attached? Yes No Provider Authorization Form Attached? Yes No
Submit Claims Receive Reports Receive Electronic Remittances
Online Inquiry Services RCD Submissions
Submit completed forms via fax or email to:
Jurisdiction J Part A (AL, GA, TN)
Jurisdiction J Part B (AL, GA, TN)
803-870-0163
EDIENROLL.PARTA@PalmettoGBA.com
803-870-0164
EDIENROLL.PARTB@PalmettoGBA.com
Jurisdiction M Part A (SC, NC) & HHH
Jurisdiction M Part B (SC, NC, VA, WV)
803-699-2429
EDIPartA.ENROLL@PalmettoGBA.com
803-699-2430
EDIPartB.ENROLL@PalmettoGBA.com
Notes: Please retain a copy for your records.
You must submit a completed EDI Application Form when submitting additional EDI forms.
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
EDI Enrollment Agreement
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
Part A/Part B/HHH EDI Enrollment (Agreement) Form and
Instructions
The EDI Enrollment Form (commonly referred to as the EDI Agreement) should be submitted when
enrolling for electronic billing. It should be reviewed and signed only by the providers to ensure each
provider is knowledgeable of the enrollment request and the associated requirements.
Providers that have contracted with a third party (clearinghouse/network service vendor or a billing
agent) are required to have an agreement signed by that third party in which the third party has agreed to
meet the same Medicare security and privacy requirements that apply to the provider in regard to the
viewing or use of Medicare Beneficiary data. These agreements are not to be submitted to Medicare, but
are to be retained by the providers.
Providers are obligated to notify Medicare by letter of:
• Any changes in their billing agent or clearinghouse.
• The effective date of which the provider will discontinue using a specific billing agent or
clearinghouse.
• If the provider wants to begin to use additional types of EDI transactions.
• Other changes that might impact their use of EDI.
Providers are not required to notify Medicare if their existing clearinghouse begins to use alternate
software, the clearinghouse is responsible for notification in this instance.
Note: The binding information in an EDI Enrollment Form does not expire if the person who signed the
form for a provider is no longer employed by the provider.
General Instructions
• Please ensure that you include your Medicare Provider Number and National Provider Identifier
(NPI) where requested on the EDI Enrollment Form.
• If the submitter will be submitting for multiple providers, this form must be completed by each
provider whose claim data will be submitted.
• If a provider is a member of a group, only one agreement per group is required.
• The entire form must be read carefully, dated with day, month and year.
• The name of the provider must be printed in the space provided, an authorized officer’s name
(printed), authorized officer’s title and signature.
• When completed, the properly executed 3-page EDI Enrollment Form must be returned with the
EDI Application form to the following address:
• Fax or email completed forms to:
Jurisdiction J Part A (AL, GA, TN)
Jurisdiction J Part B (AL, GA, TN)
803-870-0163
EDIENROLL.PARTA@PalmettoGBA.com
803-870-0164
EDIENROLL.PARTB@PalmettoGBA.com
Jurisdiction M Part A (SC, NC) & HHH
Jurisdiction M Part B (SC, NC, VA, WV)
803-699-2429
EDIPartA.ENROLL@PalmettoGBA.com
803-699-2430
EDIPartB.ENROLL@PalmettoGBA.com
Note: If the submitter will be an entity other than the provider, the submitter must complete the EDI
Application form and the provider(s) must complete the EDI Enrollment Form(s). The EDI Application
form must be returned with the EDI Enrollment Form enclosed for each applicable provider.
IMPORTANT NOTE
The address shown on the EDI Enrollment Form must match the address that was submitted to our
Provider Enrollment Department when enrolling for a provider number. If the address on the completed
EDI Enrollment Form does not match, your entire EDI Enrollment Packet will be returned.
The National Provider Identifier (NPI) must be printed in the space provided on the EDI Enrollment
Form. If this information is missing, the EDI Enrollment Form will not be processed.
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
EDI Enrollment Agreement, Page 1 of 3
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
Medicare Electronic Data Interchange Enrollment
Agreement
A. The provider agrees to the following provisions for submitting Medicare claims
electronically to CMS’ 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 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 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;
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
EDI Enrollment Agreement, Page 2 of 3
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
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 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
B. The Centers for Medicare & Medicaid Services (CMS) agrees to:
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.
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.
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
EDI Enrollment Agreement, Page 3 of 3
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
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.
C. Signature
I certify that I have been appointed an authorized individual 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 Palmetto
GBA on my behalf.
Provider’s Name: ________________________________
Address: ________________________________
______________________________
_____________________________________
____________________________________________________________________________
City/State/ZIP: ________________________________________________________________
Authorized Signature: __________________________________________________________
By (Print Name): ______________________________________________________________
Title: ________________________________________________________________________
Email: ________________________________
__________________
_______________________________________
Date: Medicare Provider Number ______________________________
National Provider Identifier (NPI): _________________________________________________
Complete ALL fields above and submit via fax or email, the entire agreement (three pages) with
original signature and with a copy of the EDI Application form to:
Jurisdiction J Part A (AL, GA, TN)
Jurisdiction J Part B (AL, GA, TN)
803-870-0163
EDIENROLL.PARTA@PalmettoGBA.com
803-870-0164
EDIENROLL.PARTB@PalmettoGBA.com
Jurisdiction M Part A (SC, NC) & HHH
Jurisdiction M Part B (SC, NC, VA, WV)
803-699-2429
EDIPartA.ENROLL@PalmettoGBA.com
803-699-2430
EDIPartB.ENROLL@PalmettoGBA.com
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
Provider Authorization Form
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
Part A/Part B/HHH Provider Authorization Form Instructions
The purpose of the notice is to authorize a clearinghouse and/or billing service as an electronic submitter
and recipient of electronic claims data. It is important that instructions are followed and that all required
information is completed. Incomplete forms will be returned to the applicant, thus delaying processing.
Please retain a copy of this complete notice for your records.
Please retain a copy of this completed form for your records.
You must submit a completed EDI Application Form when submitting this form. The Provider
Authorization form must be completed and signed by the Provider.
The field descriptions listed below will aid in completing the notice properly.
Form Field Name
Instructions for Field Completion
Line of Business
Information
Indicate the line of business and state for which you will be transmitting. Select
all that apply to this request.
Action Requested
Indicate the type of service(s) you are authorizing the Submitter to access. Check
all that apply.
Provider Name
List the provider name for which this Provider Authorization Form is being
completed. This name must match the name submitted on the CMS 855
Medicare Enrollment Application.
Tax ID
Enter the Tax Identification Number for the provider.
Provider Email
Address
The email address of the provider to receive EDI notifications.
Provider Number
List the provider PTAN whose Medicare claims, electronic remittances, response
reports or DDE will be accessed by the submitter listed on the EDI Application.
A separate Provider Authorization Form is required for each PTAN.
NPI
Indicate the National Provider Identifier (NPI).
Name/Title
The name and title of the person Palmetto GBA will contact if there are
questions regarding this Authorization Form.
Address
The mailing and/or the physical address of the provider. (Only one valid address
has to be submitted.)
City, State, ZIP
The city, state and ZIP Code of the provider.
Phone Number
The area code and phone number of the Contact Person listed.
Submitter’s Name
The name of the Submitter you are authorizing for the above services.
Signature
The signature of the listed provider’s authorized contact.
Date
The date the form was signed.
Palmetto GBA Part A, Part B & HHH EDI Enrollment Packet
Provider Authorization Form
This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services
(CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.
Part A/Part B/HHH
Provider Authorization Form
This form must be completed and signed by the Provider ONLY.
Line of Business Information: HHH: Review Choice Demonstration (RCD):
Part A: AL
GA SC NC TN
Part B: AL GA SC NC TN VA WV
Action Requested: Electronic Claims Submissions Electronic Remittance
Electronic Response Reports Online Inquiry Services (DDE – Part A only) ☐RCD Submissions
Provider for whom Submitter will be granted access:
Provider Name:
Tax ID:
Provider Email Address:
Provider Number:
NPI:
Name:
Title:
Address:
City: State: ZIP:
Phone:
Submitter Name:
I hereby authorize the above submitter to receive the items notated above on my behalf. I understand that
these items contain payment information concerning my processed Medicare claims. I am authorized to
endorse this access on behalf of my company, and I acknowledge that is my responsibility to notify
Palmetto EDI in writing if I wish to revoke this authorization.
Signature: Date:
Please complete, sign and submit this form via fax or email, with the EDI Application Form to:
Jurisdiction J Part A (AL, GA, TN)
Jurisdiction J Part B (AL, GA, TN)
803-870-0163
EDIENROLL.PARTA@PalmettoGBA.com
803-870-0164
EDIENROLL.PARTB@PalmettoGBA.com
Jurisdiction M Part A (SC, NC) & HHH
Jurisdiction M Part B (SC, NC, VA, WV)
803-699-2429
EDIPartA.ENROLL@PalmettoGBA.com
803-699-2430
EDIPartB.ENROLL@PalmettoGBA.com
Office Ally, Inc
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MEDICARE TENNESSEE PART B (MR034) PRE-ENROLLMENT INSTRUCTIONS (Office Ally)

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Completed 8 April 2021

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