EDI ENROLLMENT FORMS

This page contains information on EDI Enrollment Forms and other valuable EDI information.

NEW EDI ENROLLMENT

If you are enrolling in EDI for the first time, you must obtain a submitter number from NHIC to allow you to submit claims electronically. To obtain a submitter number, please complete the EDI Profile and Enrollment forms.

Many providers are not aware of old or unused enrollment(s) already on file with NHIC. If there is an existing enrollment on file with NHIC for your PTAN number, you are not a new enrollee. Please refer to Adding a New Submitter ID # for instructions on how to add your PTAN to a new/existing submitter number.

NOTE: If you receive a new Medicare PTAN number you are required to complete New EDI Enrollment Forms below, and mail them to EDI.

If you are unsure of your current enrollment status, contact EDI before you apply. Call (213) 593-6950 or (530) 896-7024 Monday – Friday, 8 am – 4 pm (PT).

NEW EDI ENROLLMENT FORMS (151K)

You may type directly on the form. However, you will need to print it to add your original signature and mail it to EDI.
INSTRUCTIONS:

• Both the EDI Profile Form and the Signature portion of the EDI Enrollment Application are REQUIRED for all new EDI Enrollments. Both forms must be submitted together. Incomplete or incorrect enrollment requests will not be processed
• An NPI number is required for enrollment in EDI. The NPI number must be in the NPI field of the application or it will not be processed
• All new enrollment forms must be mailed to EDI. Faxes will not be accepted. Send your forms to: NHIC, Corp. EDI Enrollment, P.O. Box 2807, Chico, CA 95927
• Signature & Title: Please follow the signature / title requirements below to avoid delays in the processing of your request:

  EDI forms must be signed by the billing / pay-to provider and the title must be listed. If a doing-business-as-name (DBA) appears on the professional letterhead, the title must be:

  • Owner, President or CEO
  • Owner/Partner, if the entity is a partnership
  • If the entity does not have an individual who holds one of the titles listed above, the Signature Page may be signed by the Authorized / Delegated Official on file with the Provider Enrollment Department
  • If only the given name is used on the professional letterhead, MD, PhD, DO, etc., will be accepted
  • No other party may sign the form
     

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ADDING A NEW SUBMITTER ID # - CHANGING EDI ENROLLMENT

If your PTAN number is currently linked to a submitter number and you wish to delete or add a new submitter ID number, the request can be made by either completing the Provider/Submitter Agreement Form or using a Change Letter. Both methods of changing enrollment have specific requirements. Please read and follow the instructions to ensure that your request is processed correctly.

The Provider/Submitter Agreement and the Change Letter may be faxed or mailed.

• Fax To: (530) 879-2668
• Mail To: NHIC, Corp. - EDI Change Request, PO Box 2807, Chico CA 95927
  

EDI PROVIDER/SUBMITTER AGREEMENT FORM (55K)

You may type directly on the form, print it for original signature and mailing to EDI, and save a copy to your computer using the “save as” command.

Changing EDI Enrollment Using The Provider/Submitter Agreement Form

INSTRUCTIONS:

• An NPI number is required for enrollment in EDI. The NPI number must be in the NPI field of the application or it will not be processed.
• EDI suggests that a provider have only one submitter ID number at a time. However, there are occasions when a second ID may be required.
  NOTE: A provider may not have more than two submitter ID numbers at the same time
• If a second submitter ID number is needed, make note of why you need a second number in your request
• If you wish to add a billing agency or clearinghouse ID number to an existing enrollment, complete only section 1 of the Provider/Submitter Agreement
  • Section 1 must be signed by the billing provider and the title must be listed, see Signature & Title for guidelines
• Complete sections 1 and 2 of the Provider/Submitter Agreement to change enrollment and allow a billing agency or clearinghouse to receive electronic remittance files (ERA) on your behalf
  • Section 2 of the Provider/Submitter Agreement must be signed by a representative of the billing agency or clearinghouse or the request will not be processed
• Failure to include all required signatures will result in your application not being processed
• You may have to delete one or more existing submitter ID #s to receive an additional number
• You must account for EVERY submitter ID number currently on file or the new request will not be processed. If necessary, call EDI to determine the number of submitter ID numbers on file and how to deal with each ID before you send a change request. Call (213) 593-6950 or (530) 896-7024 Monday – Friday 8 am – 4 pm (PT)

Changing EDI Enrollment Using a Change Letter

A Change Letter from the provider may be used to add or delete a submitter ID number. There are specific requirements for a Change Letter. Please read and follow the instructions below.

NOTE: change requests containing incorrect or insufficient information will not be processed.

A Change Letter may be faxed or mailed to:

• Fax To: (530) 879-2668
• Mail To: EDI Change Request, PO Box 2807, Chico CA 95927

INSTRUCTIONS:

Change Letter process:

• Fax/mail a Change Letter on the provider’s professional letterhead
• EDI suggests that a provider have only one submitter ID number at any given time. There will be situations when a second ID may be required. However, a provider may not have more than two submitter ID numbers at the same time.
  • If a second submitter ID is needed, make note as to why you need a second ID number in your request
• The billing provider’s NPI number and PTAN number are required on the Change Letter. Include all NPI #s and PTAN #s that you wish to be linked or de-linked with your request
• If you will be submitting claims via a billing agency or clearinghouse, list their submitter ID number
• If you are requesting an individual submitter ID number to send your claims directly to Medicare - include the name of the software you will use, the operating system and at least one contact name and phone number in your letter
  • You may wish to have more than 1 contact person on file – only the contact person on file will be able to request changes to the submitter information (ie: password resets)
• The letter must be signed by the provider and the title must be listed, see Signature & Title for guidelines
• You may have to delete one or more existing submitter ID #s to receive an additional number
• You must account for EVERY submitter ID number currently on file or the new request will not be processed. If necessary, call EDI to determine the number of submitter ID numbers on file and how to deal with each ID before you send a change request. Call (213) 593-6950 or (530) 896-7024 Monday – Friday 8 am – 4 pm (PT)

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EDI ENROLLMENT CHECKLIST

NOTE: To view frequently asked questions (FAQs) about EDI visit EDI FAQs,  to view common NPI questions & answers go to NPI FAQs .

Have questions about EDI? Need more information?

(213) 593-6950 or (530) 896-7024 Monday - Friday 8 am - 4 pm (PT)

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ELECTRONIC REMITTANCE ADVICE (ERA)

ERA is an electronic version of the standard paper remittance (SPR) or explanation of Medicare benefits (EOMB). It is an easy and effective way to track Medicare Part B payments made to healthcare providers and can be made available to you on a daily or weekly basis through your mailbox on the Carrier Bulletin Board System (CABBS). ERA will save you time and money by allowing you to use your practice management software to automatically post Medicare payments into your accounts receivable system (check with your software vendor for details). In addition, you can save ERA files to your computer eliminating the need for physical storage space and allowing you to keep records for as long as your office needs.

To sign up for ERA, read the description of each ERA type below and choose the option that is right for your office needs. You may mail or fax the completed form to the EDI Department. Remember, by enrolling in ERA, you are agreeing to receive all of your remittances in an electronic format rather than having them mailed to you on paper.

ERA PROVIDER/SUBMITTER AGREEMENT FORM (90K)

You may type directly on the form, print it for original signature and mailing/faxing to EDI, and save a copy to your computer using the “save as” command.

This form is used by providers who submit claims through a billing agency, clearinghouse or vendor and want the ERA files sent to the submitter. This form may also be used to add a submitter ID # to an existing enrollment and/or delete an existing enrollment(s). See Adding A New Submitter ID #

INSTRUCTIONS:

• Complete sections 1 and 2 of the Provider/Submitter Agreement if you wish to have your billing agency or clearinghouse receive ERA on your behalf.
• Section 1 of the form must be signed by the provider and the title must be listed, see Signature & Title for guidelines.
• Section 2 of the form must be signed by a representative of the billing agency or clearinghouse.

NOTE: Failure to include all required signatures will result in your application not being processed.

ELECTRONIC REMITTANCE ADVICE ENROLLMENT (ERA) FORM (170K)

You may type directly on the form, print it for original signature and mailing/faxing to EDI, and save a copy to your computer using the “save as” command.

This type of ERA is for providers who submit claims directly to Medicare and want to receive their own electronic remittance (ERA) files

• The form must be signed by the provider and include your NPI and PTAN numbers.

EDI PROVIDER / SEPARATE REMITTANCE AGREEMENT FORM (249K)

You may type directly on the form, print it for original signature and mailing/faxing to EDI, and save a copy to your computer using the “save as” command.
NOTE: This is NOT the Provider/Submitter Agreement Form.

This form is used to have your ERA files sent to a different submitter ID # than the one you use to submit your claims. See the examples below.

Example A:

If you submit claims via a billing agency, clearinghouse or vendor submitter ID #, but want to receive your own ERA,

• Complete this form to request a new submitter ID to be used ONLY to receive your ERA, and include a letter with your application form. The letter must be on your professional letterhead
  • Include your NPI # and PTAN # on the letter
  • Request a new submitter ID #, and state that you are aware the new ID is for the sole purpose of receiving your own ERA files
  • List at least one contact name and phone number in your letter
  • The form must be signed by the provider, see Signature & Title for guidelines

NOTE: A provider may never have more than 2 submitter ID #s at a time. You may need to delete one or more ID numbers to receive a new one. If necessary, call EDI to discuss how to proceed before you apply.

Example B:

If you submit your claims via a billing agency, clearinghouse or vendor but don’t want them to receive your ERA files, use this form to allow a different billing agency, clearinghouse or vendor to receive your ERA.

INSTRUCTIONS:

• The printed legal business name and submitter ID # of the current submitter is required on the form
• The printed legal business name, signature and the submitter ID # of the billing agency, clearinghouse or vendor who you wish to receive your ERA is required on the form
  • If you are requesting your own ERA-only submitter ID # enter “applying for” in the submitter ID # section
  • The form must be signed by the provider, see Signature & Title for guidelines
  • Failure to include all required signatures will result in your application not being processed
  • Incomplete or incorrect requests cannot be processed

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FREE MEDICARE-ONLY BILLING SOFTWARE

Medicare offers a free billing software for small practices that may need an electronic billing solution to transmit their Medicare claims. You must meet computer, billing and enrollment requirements to be eligible to receive the software. In addition, the free billing software only allows you to bill claims to Medicare and does not allow you the option to bill to any other insurance(s). Make sure to explore all billing options to find the system that is best suited for your practice. For more detailed information please go to EDI Basics – Free Software.

Medicare-Only Billing Software:

• Only allows billing of Medicare Part B claims
• Cannot bill for more than one group number and
• Is not for use by billing agencies, clearinghouses or vendors.

Computer requirements:

• A Modem with a dial-up connection, NO DSL, no Cable telephone service, no call waiting or call waiting turned off during transmission. YOU MUST HAVE A DIAL-UP MODEM TO USE THIS SOFTWARE.
• Windows XP Professional
• Pentium 4 or better
• Minimum of 256 MEGS of RAM (memory)
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MEDICARE REMIT EASY PRINT (MREP) SOFTWARE

If your billing software does not have the ability to print Electronic Remittance (ERA) files, you may download free Medicare Remit Easy Print (MREP) software, and the MREP User Guide, from the CMS website.

Medicare Remit Easy Print(MREP) software may be used print ERA files, locate claims information quickly, and produce reports on denied, adjusted or deductible-applied claims.

Download free Medicare Remit Easy Print (MREP) software and the MREP User Guide from the Centers for Medicare and Medicaid (CMS) website: www.cms.hhs.gov/AccesstoDataApplication/02_MedicareRemitEasyPrint.asp

Reminder: You must complete an ERA application to receive ERA, go to the ERA section for details on enrollment.

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Electronic Funds Transfer (EFT)

Electronic Funds Transfer allows the direct deposit of Medicare payments into a provider’s bank account. Enrollment in EFT saves providers time and money by:

• Increasing cash flow, funds are available more quickly
• No lost checks
• No bank lines

Enrollment in Electronic Funds Transfer (EFT) is mandatory for

• All new Medicare providers,
• All providers revalidating their Medicare enrollment,
• All established providers making a change to their file

Go to the Electronic Funds Transfer web page for information on submitting an accurate application.

If you are interested in signing up for EFT, please download the EFT form at the Centers for Medicare & Medicaid Services (CMS) web site at http://www.cms.hhs.gov/cmsforms/downloads/CMS588.pdf.

Forward the completed CMS 588 form and required attachments to your local Provider Enrollment department.

SOUTHERN/NORTHERN CALIFORNIA NHIC OFFICE
NHIC, Corp - Provider Enrollment/EFT
PO Box 2812
Chico, CA 95927-2812

If you have questions on EFT enrollment please call NHIC, Corp Customer Service at 1-877-527-6613.

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NETWORK SERVICE AGREEMENTS

If you are a provider that submits Medicare Part B electronic claims via a third party, a

• billing agent
• clearinghouse or
• network service vendor,

you are required to have that third party sign an agreement to meet the same Medicare security and privacy requirements that apply to a provider in regards to view or use of Medicare beneficiary data.

Send the Network Service Agreement to your third party submitter and ask them to return the completed and signed form to you. This agreement should not be submitted to Medicare but retained by your for your files. The Network Services Agreement form is found at http://www.medicarenhic.com/edi/download/networkagree.pdf.

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CMS ELIGIBILITY ENROLLMENT INFORMATION

NHIC Corp. EDI does not support Medicare eligibility transactions, however you can find information on eligibility enrollment from the Centers for Medicare and Medicaid (CMS). Below is an excerpt from the CMS Eligibility information site.

• ".to obtain access to the CMS 270/271 Medicare Eligibility transaction via the MDCN, a Submitter must access the appropriate forms, located on the CMS HIPAA Eligibility Transaction System (HETS) Help (270/271), dedicated website.
  
  • Access to Sign Up page,
    www.cms.hhs.gov/HETSHelp/02_SignUpNow.asp#TopOfPage
• Read and follow the instructions found at the above link to complete the sign up process.
• The Medicare Eligibility Customer Service Help Desk will be available from 7:00 AM to 9:00 PM EST, Monday - Friday. The Help Desk is the single point of contact for all questions or concerns about the system,
  
  • Contact number for Eligibility Help Desk is, 1-866-324-7315
  • Email address for the helpdesk, MCARE@CMS.HHS.GOV.

Have questions? Need more information? call EDI at
 (213) 593-6950 or (530) 896-7024  Monday – Friday 8 am – 4 pm (PT)

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03/06/2008