CPID PayerID Payer Type EstDays MultiCH
SubmitterID SubmitterName
TaxID NPI ProviderNumber Name
Address City State Zip
ContactName ContactPhone
PrimaryEmailAddress SecondaryEmailAddress
TSOID ReportType CommunicationProtocol/Output ReportFormat SiteID
Send completed form to:
Fax: (615) 885-3713
DE Medicare Part B (J12 - Highmark
Only authorized personnel may sign the agreement on pg 5.
Please note: Each Line of Business has a different provider transcation access number (PTAN) and cannot be used
for more than one Medicare Enrollment.
Most Common Denial Reasons: 'Provider's Information does not match payor's system.' Please verify that the
provider's information matches the payor's system before submitting agreement.
'Someone signs the enrollment who isn't authorized to do so.' If you question who is able to sign your enrollment,
please contact payer.
Payer will accept ALL, in section G, for which submitters/receiver ID(s) (Clearinghouses) the provider wants to
maintain existing setup.
Will Change Healthcare be receiving your
Distribution Detail:
For Change Healthcare use only
All fields marked with * are required and must be completed. Reference Materials are available on the last page of this document.
*Check all contracts
that apply (Required):
Part A (Institutional) Part B (Professional) J12901
DC (Part A) DCMA (Part B) DE MD
*PROVIDER NAME (Required) (Must match the name for the Group/Billing Provider on file with Medicare as reported on the CMS-855 Enrollment form)
*ZIP CODE/Postal Code
ENVIRONMENTALLY FRIENDLY OPTION: If additional PTANs are linked to my submitter ID in the future, I do not need the
traditional paper mail response. Only mail me my initial enrollment letter.
(Required) Complete using your billing/group PTAN.
*Provider Transaction Access Number (PTAN)
*National Provider Identifier (NPI)
*Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)
The PTAN/NPI reported above should NOT be the Group MEMBER PTAN/NPI. PTANs may also be known as a CMS Certification
Number. For Affiliated PTANs or National Provider Identifiers (NPIs), attach a signed list on company letterhead, if needed.
If the same entity, other than the Provider, is both preparing and submitting the electronic claims, that entity must be reported on the
form in Section 8. Refer to the Web instructions for more information on this requirement.
*REQUEST TYPE: (Required) (Requests will be processed for the PTAN provided above in the most recent HIPAA-compliant format/version.)
Reason for submission:
New Enrollment
Change Enrollment
Add to existing submitter ID:
Assign this provider a new electronic billing submitter ID.
*Name of electronic billing software vendor:
Enroll for Claim Status and Response (for direct submitters only)
Direct Data Entry Only (DDE) (Part A only)
FISS Logon Request Form also Required
Vendor Change-no additional request should be selected in this block.
*Name of electronic billing software vendor:
ERA Change
ERA will be available on a daily basis, based on claim finalization, and is available for retrieval for 60 days. After 60 days from the ERA creation
date, the ERA is no longer available on the telecommunications platform. For Part A customers, the paper remittance will continue for thirty-
one (31) days after initial enrollment for ERA. For Part B customers, the paper remittance will continue for forty-five (45) days after initial
enrollment for ERA. You will no longer receive paper remittances after these time-frames. Designate the ID the ERA should be sent to by
selecting one of the options below. If nothing is selected, existing ERA setup will be maintained, unless you currently receive paper remittance.
Check only one:
Create a new and separate receiver ID for ERA purposes only.
Assign ERA to an existing submitter/receiver ID:
Assign ERA to the new submitter ID being requested in block E of this form.
Maintain existing ERA setup. (This option cannot be selected if currently receiving paper remittance.)
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8292 (R05-18)
Submitter ID Name:
(Required for existing customers)
Providers are required to notify Novitas Solutions of changes involving billing agents or clearinghouses used by the provider. If the PTAN listed
above is associated to any other non-Novitasphere Portal submitter or receiver ID(s), Novitas Solutions will remove the other submitter/receiver
ID(s) immediately, unless indicated below.
Type the submitter/receiver ID(s) or name(s) to be maintained. All other submitter/receiver IDs will be removed. Do not enter PTAN/NPIs in
this box.
Maintain All
z Novitas Solutions, Inc. (Novitas) is authorized to distribute PC-ACE/PRINTLINK/ETRA (herein referred to as the "Program") to authorized users.
PC-ACE and PRINTLINK software programs are copyrights of ABILITY. 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.
z 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.
z In no event will Novitas 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 Novitas has been advised of the possibility of such damages, or for any claim by any other party.
z The authorized user will upgrade this Program within 90 days of upgrade availability. This is a CMS requirement.
z 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:
z Internet download is the preferred method of software installation. Internet download instructions will be provided upon processing of this enrollment.
There is no fee for software installation via Internet download. To receive the Program in CD-ROM format, visit
for ordering instructions. A non-refundable $100
annual service fee is required. This service fee covers four quarterly PC-ACE releases.
Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier)
Provider Tax Identification Number (TIN)
National Provider Identifier (NPI)
The provider agrees to the following provisions for submitting Medicare claims electronically to CMS or to CMS A/B MACs or CEDI:
The Provider Agrees:
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 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
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 identifier) 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.
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8292 (R05-18)
When checking the box to enroll, you are agreeing to the software terms listed below
The Centers for Medicare & Medicaid Services (CMS) agrees to:
1. Transmit to the provider an acknowledgement 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's 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 contractor 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. Novitas reserves the right to
terminate this agreement if there is no EDI activity within a six (6) month period. You agree that Novitas will be entitled to damages, court costs and
reasonable attorney's fees if you breach this agreement. Either party may terminate this agreement 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.
Any provider who submits Medicare claims electronically to CMS or its contractors remains responsible for those claims as those
responsibilities are outlined on the EDI Enrollment. 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
contractors are attesting to the appropriateness of the methods used by the billing service/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 whom 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.
Prior to signing this agreement, please carefully review the technical requirements for electronic billing in Chapter 3 of the
Billing Guide. New EDI submitters must connect to Novitas within 90 days of receiving the logon ID by using the Secure File Transfer
Protocol (SFTP) software provided by your Network Service Vendor.
I understand that any individual who knowingly and willfully makes or causes to be made any false claim or false statement of
false representation of a material fact in any application to the federal government for benefits or payment with respect to the Medicare
program may be subject to civil and/or criminal enforcement action which may result in fines, penalties, damages and/or imprisonment.
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 Novitas Solutions on my behalf.
By signing below, the provider confirms they have read and agree to the Agreement, the Attestation, and the above signature
The Authorized Official signing this form must be an AUTHORIZED OR DELEGATED OFFICIAL that was listed on the
Medicare Enrollment Application (CMS-855).
*WRITTEN SIGNATURE OF PERSON SUBMITTING ENROLLMENT (add after you print out the form) *DATE (add after you print out the form)
Novitas Solutions, Inc. - EDI, P.O. Box 3011, Mechanicsburg, PA 17055-1801
or Fax: 1 (877) 439-5479
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If Providers elect to submit/receive transactions electronically using a third party such as a billing agent or a clearinghouse, the A/B MACs or CEDI must
notify these providers that they are required to have an agreement singed by that third party. The third party must agree to meet the same Medicare security
and privacy requirements that apply to the provider in regard to viewing or use of Medicare beneficiary data. (These agreements are not to be submitted to
Medicare, but are to be retained by the providers.)
Complete agreement, print, and obtain signature.
Instructions for completing this form may be found at
To request the status of your EDI enrollment form, complete the EDI Enrollment Status Inquiry Tool at
For questions, please contact an EDI Analyst at 1-877-235-8073, Option 3.
PAGE 4 of 4
8292 (R05-18)
Get instant access to the world of online Medicare transactions with Novitasphere!
Novitasphere is a FREE, secure internet portal for Part A and B customers to easily connect directly to Novitas Solutions. Novitasphere
provides quick access to beneficiary eligibility, claim submission, claim corrections (Part B), electronic remittance advice, appeals
requests, and many other time saving features. It's free, easy, and secure to perform transactions online, saving your office valuable time.
We encourage everyone to explore and discover the online world of Novitasphere!
To find out more, including how to enroll for Novitasphere, visit the Novitasphere Center at