Medicare EDI Enrollment

Medicare EDI Enrollment Basic Guidelines

Medicare EDI Enrollment process for the Medicare beneficiary inquiry system (HETS 270/271) is currently a separate process. A/B MACs and CEDI are required to furnish new providers that request Medicare claim privileges information on EDI. A/B MACs and CEDI are required to assess the capability of entities to submit data electronically, establish their qualifications and enroll and assign submitter EDI identification numbers to those approved to use EDI. All providers are required to submit their claims electronically, per ASCA, unless they qualify for a waiver.

A provider must obtain an NPI and furnish that NPI to their A/B MAC and CEDI prior to completion of an initial Medicare EDI Enrollment Agreement and issuance of an initial EDI number and password by that contractor. The A/B MACs and CEDI are required to verify that NPI is on the NPI Crosswalk. If the NPI is not verified on the NPI Crosswalk, the EDI Enrollment Agreement is denied and the provider is encouraged to contact the A/B MAC provider enrollment department (for Medicare Part A and Part B providers) or the National Supplier Clearinghouse (for DME suppliers) to resolve the issue. Once the NPI is properly verified, the provider can reapply the EDI Enrollment Agreement.

A provider’s EDI number and password serve as a provider’s electronic signature and the provider would be liable if any entity with which the provider improperly shared the ID and password performed an illegal action while using that ID and password. A provider’s EDI access number and password are not part of the capital property of the provider’s operation, and may not be given to a new owner of the provider’s operation. A new owner must obtain their own EDI access number and password. When leaving the Medicare Program, a provider must notify their MAC to deactivate the EDI number.

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 those providers that they are required to have an agreement signed 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. The providers must also be informed that they are not permitted to share their personal EDI access number and password with any billing agent or clearinghouse. Providers must also not share their personal EDI access number to anyone on their own staff who does not need to see the data for completion of a valid electronic claim, to process a remittance advice for a claim, to verify beneficiary eligibility, or to determine the status of a claim. No other non-staff individuals or entities may be permitted to use a provider’s EDI number and password to access Medicare systems. Clearinghouse and other third party representatives must obtain and use their own unique EDI access number and password from those A/B MACs or CEDI to whom they will send or receive EDI transactions.

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