Electronic Data Interchange (Edi) Enrollment Form (Page 2 of 3) in pdf

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Beneficiary’s name;

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Beneficiary’s health insurance claim number;

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Date(s) of service;

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Diagnosis/nature of illness; and

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Procedure/service performed;

5. That the Secretary of Health and Human Services or his/her designee and/or the CMS contractor has the right to audit

and confirm information submitted by the provider and shall have access to all original source documents and medical

records related to the provider’s submissions, including the beneficiary’s signature. All incorrect payments that are

discovered as a result of such an audit shall be adjusted according to the applicable provisions of the Social Security

Act, Federal regulations, and CMS guidelines;

6. That it will ensure that all claims for Medicare or Section 1011 primary payment have been developed for other

insurance involvement and that Medicare/Section 1011 is indeed the primary payer;

7. That it will submit claims that are accurate, complete, and truthful;

8. That it will retain all original source documentation and medical records pertaining to any such particular Medicare

claim for a period of at least six years, three months after the bill is paid, or, for Section 1011 beneficiaries, in

accordance with the Section 1011 Final Policy Notice;

9. That it will research and correct claim discrepancies;

10. That it will affix the CMS-assigned unique identifier number (submitter identifier) of the provider on each claim

electronically transmitted to the CMS contractor;

11. That it will acknowledge that all claims will be paid from Federal funds, that the submission of such claims is a claim

for payment under the Medicare or Section 1011 program, and that anyone who misrepresents or falsifies or causes to

be misrepresented or falsified any record or other information relating to that claim that is required pursuant to this

Agreement may, upon conviction, be subject to a fine and/or imprisonment under applicable Federal law;

12. That if it chooses to participate in electronic remittance transactions it will notify the CMS contractor of any changes

in third-party services that it has authorized to access this information on their behalf via the EDI Enrollment form;

13. That if it chooses to use a Network Service vendor for eligibility verification transactions it will notify the CMS

contractor of any changes in third-party service arrangements via the EDI Enrollment form;

B. The Centers for Medicare & Medicaid Services (CMS) agrees to:

1. Transmit to the provider an acknowledgment of claim receipt;

2. Affix the CMS contractor number, as its electronic signature, on each remittance advice sent to the provider;

3. Ensure that payments to providers are timely in accordance with CMS’ policies;

4. Ensure that no CMS contractor may require the provider to purchase any or all electronic services from the CMS

contractor or from any subsidiary of the CMS contractor or from any company for which the CMS contractor has an

interest. The carrier or FI will make alternative means available to any electronic biller to obtain such services;

5. Ensure that all Medicare electronic billers have equal access to any services that CMS requires Medicare contractors

to make available to providers or their billing services, regardless of the electronic billing technique or service they

choose. Equal access will be granted to any services the CMS contractor sells directly, or indirectly, or by

arrangement;

6. Notify the provider within two business days if any transmitted data are received in an unintelligible or garbled form.

NOTICE: Federal law shall govern both the interpretation of this document and the appropriate jurisdiction and venue

for appealing any final decision made by CMS under this document. This document shall become effective when signed

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 Page 2

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