Palmetto GBA Railroad Medicare EDI Enrollment Packet
EDI Agreement Form 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;
