Medicare EDI

Medicare EDI Enrollment Information Required

EDI Enrollment Information Required for Inclusion at a Minimum in Each A/B MAC, and CEDI EDI Enrollment Form. Medicaid state agencies are not required to complete an EDI Enrollment Form as a condition for receipt of COB claims.

In accord with a particular MAC’s business processes, providers who have a signed EDI Enrollment Form on file with a particular A/B MAC or CEDI may or may not be required to submit a new signed EDI Enrollment Form to the same A/B MAC or CEDI each time they change their method of electronic billing or begin to use another type of EDI transaction, e.g., changing from direct submission to submission through a clearinghouse or changing from one billing agent to another.

Additionally, providers may or may not be required to notify their A/B MAC (HHH), A/B MAC or CEDI if their existing clearinghouse begins to use alternate software; the clearinghouse is responsible for notification in that instance. A/B MACs and CEDI must inform providers that providers are obligated to notify their A/B MAC or CEDI in writing in advance of a change that involves a change in the billing agent(s) or clearinghouse(s) used by the provider, the effective date on which the provider will discontinue using a specific billing agent and/or clearinghouse, if the provider wants to begin to use additional types of EDI transactions, or of other changes that might impact their use of EDI.

When an A/B MAC or CEDI receives a signed request from a provider or supplier to accept EDI transactions from or send EDI transactions to a third party, the A/B MAC or CEDI must verify that an EDI Enrollment Form is already on file for that provider or supplier, and that the third party has already been issued an EDI number and password to permit submission/receipt of EDI transactions. The request cannot be processed until both are submitted/issued.

The binding information in an EDI Enrollment Form does not expire if the person who signed that form for a provider is no longer employed by the provider, or that A/B MAC or CEDI is no longer associated with the Medicare program. Medicare responsibility for EDI oversight and administration is simply transferred in that case to that entity that CMS chooses to replace that A/B MAC or CEDI, and the provider as an entity retains responsibility for those requirements mentioned in the form regardless of any change in personnel on staff. An organization comprised of multiple components that have been assigned more than one Medicare provider number, supplier number, or National Provider Identifier (NPI) may elect to execute a single EDI Enrollment Form on behalf of the organizational components to which such numbers have been assigned. The organization is responsible for the performance of its components.

To learn more about EDI and become a certified EDI Professional please visit our course schedule page.

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