CGS EDI Enrollment

CGS EDI Enrollment Provider Guidelines

CGS 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.

CGS EDI Enrollment General Instructions:

  1. Please ensure that you include your Medicare Provider Number and National Provider Identifier [NPI] where requested on the EDI Enrollment Form.
  2. If the submitter will be submitting for multiple providers, this form must be completed by each provider whose claim data will be submitted.
  3. If a provider is a member of a group, only one agreement per group is required.
  4. The entire form must be read carefully, dated with day, month and year.
  5. The name of the provider must be printed in the space provided, an authorized officer’s name (printed), authorized officer’s title and signature.
  6. When completed, the properly executed 3-page EDI Enrollment Form must be returned with the EDI Application form. 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.

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.

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