Electronic Data Interchange (Edi) Enrollment Form printable pdf download

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Electronic Data Interchange (EDI) Enrollment Form

This Agreement notifies (fill in contractor name here) of the provider’s consent to participate in Electronic Data

Interchange (EDI). EDI may include claims and claims attachments, remittances, eligibility/benefits, claim status,

and any other electronic information for Centers for Medicare and Medicaid Services (CMS) federal program data

(

(including but not limited to Title XVIII of the Social Security Act

Medicare), and/or Section 1011 of the Medicare

Modernization Act) covered under Health Insurance Portability and Accountability Act (HIPAA) Transactions

and Code Sets or Section 1011 of the Medicare Modernization Act (MMA) legislation.

A. The provider agrees:

1. That it will establish and maintain procedures and controls so that information concerning Medicare and/or Section

1011 beneficiaries, or any information obtained from CMS or its contractors, shall not be used by agents, officers, or

employees of a business associate except as provided by the contractor (in accordance with §1106(a) of the Social

Security Act (the Act));

2. That it will use sufficient security procedures (including compliance with all provisions of the HIPAA security

regulations) to ensure that all electronic transmissions are authorized and protect all beneficiary-specific data from

improper access;

3. That it will notify the contractor or CMS within two business days if any transmitted data are received in an

unintelligible or garbled form.

4. The provider agrees to the following provisions for submitting and retrieving/receiving Medicare and/or Section 1011

information electronically to/from CMS or CMS contractors:

a) That it will be responsible for all Medicare and/or Section 1011 transactions submitted to CMS by the provider,

its employees, or its business associates;

b) That it will not disclose any information concerning a Medicare and/or Section 1011 beneficiary to any other

person or organization, except CMS and/or its contractors, without the express written permission of the

Medicare/Section 1011 beneficiary or his/her parent or legal guardian, or where required for the care and

treatment of a beneficiary who is unable to provide written consent, or to bill insurance primary or supplementary

to Medicare and/or Section 1011, or as required by State or Federal law;

c) That it will submit claims only on behalf of those Medicare and/or Section 1011 beneficiaries who have given

their written permission to do so, and to certify that required beneficiary signatures, or legally authorized

signatures on behalf of beneficiaries, are on file;

d) That it will submit/request electronic transactions on only those beneficiaries with whom the provider has a

professional relationship;

e) That the CMS-assigned unique identifier number (submitter identifier) constitutes the provider’s legal electronic

signature and when used for claims submission, it constitutes an assurance by the provider that services were

performed as billed;

f) That it will ensure that every electronic claim can be readily associated and identified with an original source

document. Each source document must reflect the following information (except if not required for Section

1011):

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.

The valid OMB control number for this information collection is 0938-0983. The time required to complete this information collection is estimated to average

(hours) (minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the

information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500

Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850

Electronic Data Interchange (Edi) Enrollment Form

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