Jurisdiction 15 A/B MAC EDI

Jurisdiction 15 A/B MAC EDI Enrollment: CGS Provider EDI Enrollement

Jurisdiction 15 A/B MAC EDI Enrollment goes under CMS instructions and CGS EDI providers must  follow the listed requirements.

CGS will obtain an EDI Enrollment form for each provider prior to electronic transfer of data and issuance of system passwords/billing numbers to protect the security of transferred data. CGS will obtain a new EDI Enrollment package or a written and signed statement from a previously enrolled provider if the provider reports a change in the clearinghouse, billing agent, or other third party agent; termination of use of such an agent; intent to begin to submit/receive additional EDI transactions, or if the provider will begin to use a different software for submission of EDI transactions.

As instructed by CMS, please be aware of the following requirements:

A/B MACs and DME MACs, or other contractors if designated by CMS must notify each provider that applies for permission to obtain eligibility data electronically that:

  • They are permitted to view Medicare eligibility data only for patients currently being treated by or who have requested treatment or supplies from that provider;
  • A provider cannot authorize a billing agent or clearinghouse to submit or obtain data from an A/B MACs and DME MACs that the provider is not entitled to personally submit or obtain;
  • A request for personally identifiable information for any other Medicare beneficiaries would be a violation of Medicare and HIPAA privacy requirements, and subject to the applicable penalties for such violations.
  • A/B MACs and DME MACs must notify each billing service and clearinghouse/VAN/NSV at the time of their application for access to Medicare eligibility data and by also posting information on their web site that:
  • Their access is limited to submission of transactions and receipt of transactions for those providers that are their clients, but only if those providers authorized the billing agent and/or clearinghouse/VAN/NSV to submit or receive each transaction.
  • A billing agent or clearinghouse/VAN/NSV that has provider authorization to submit claim data for a provider cannot obtain eligibility data for that provider unless that was specifically authorized by the provider.
  • Likewise, the billing agent or clearinghouse/VAN/NSV cannot be sent remittance advice transactions for a provider unless specifically authorized to do so by that provider.

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