Jurisdiction 15 A/B MAC EDI Enrollment

Jurisdiction 15 A/B MAC EDI Enrollment

Attention: Please Read and Accept Before Completing EDI Enrollment

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, as outlined in IOM 100-04, Ch. 24, § PDF

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.

IOM 100-04, Ch. 24, §
D. Providers must be notified that:

  • They may obtain eligibility data only for the approved use of preparing accurate Medicare claims;
  • Access to eligibility data is limited to individuals within a provider's organization who are involved in claim preparation and submission; and
  • they and their authorized third party agents must agree not to request eligibility data for a beneficiary unless the provider has been contacted by the beneficiary, a personal representative of a beneficiary such as a relative or friend, or a health care provider currently treating the beneficiary concerning provision of health care services or supplies to the beneficiary.

The Benefits of EDIPDF

Availability of free software:

Availability of batch claims status inquiries.The information must be updated on a regular basis.

IOM 100-04, Ch. 24, §

CGS provides information available to potential user for each EDI transaction supported by Medicare with detailed information within:

IOM 100-04, Ch. 24, §

A/B MACs, DME MACs, and CEDI Web pages must include a link to the CMS Web site, which provides record formats and transactions information. If the information is available on the CMS Home page, A/B MACs, DME MACs, and CEDI should link to it rather than duplicating development and maintenance.

IOM 100-04, Ch. 24, §40.2.5

A/B MACs, HIPAA Eligibility Transaction System (HETS) ASC X12 270/271 eligibility and CEDI must make EDI information available to new users that describe the various steps in the testing process (see §30 and §60) and discloses: http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/index.htmlExternal Website

HETS (HIPAA Eligibility Transaction System) – A Centers for Medicare & Medicaid Services (CMS) system, based on the HIPAA 270/271 transaction.

HETS requires the provider to obtain an IP connection from an authorized Network Service Vendor.

MCARE Help Desk

CMS HETS Web pageExternal Website

The Help Desk contact information, including telephone number, email address, and website to help with:

Using Electronic Data Interchange Services

CGS has prepared this packet for Jurisdiction 15 A/B MAC submitters. J15 includes the Part A & Part B contracts for Kentucky and Ohio and Region B for Home Health and Hospice (HHH).

Please visit theCGS website or contact the CGS Help Desk for EDI support:

  • Ohio/Kentucky Part B: 1-866-276-9558 Option 2
  • Ohio/Kentucky Part A: 1-866-590-6703 Option 2
  • Home Health/Hospice: 1-877-299-4500 Option 2

When submitting completed forms, please allow a processing time of approximately 7 Calendar days. Remember – CGS cannot process incomplete applications or agreements! Please fill in all appropriate blank.

If you are a provider waiting for a provider number, please wait before submitting any EDI forms! You must be assigned your provider number before completing any of the paperwork below. To apply for a provider number, please call the Provider Customer Service toll-free at the following phone number:

  • Ohio/Kentucky Part A: 1-866-590-6703
  • Ohio/Kentucky Part B: 1.866.276.9558
  • Home Health and Hospice: 1.877.299.4500

The Administrative Simplification Compliance Act (ASCA) prohibits Medicare coverage of claims submitted to Medicare on paper, except in limited situations. All initial claims for reimbursement from Medicare must be submitted electronically, with limited exceptions.

For more information on CGS EDI options, please visit our website at https://www.cgsmedicare.com The CMS Electronic Billing & EDI Transactions Web page at https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/index.htmlExternal Website also includes detailed information on EDI and the Administrative Simplification provision.

Please join the ListServ Notification Service to receive EDI news electronically!

IOM 100-09, Ch. 6, §20.4.3

Contractors shall offer training that is tailored to the needs of new Medicare providers and billing staff. Medicare Learning Network® products or content shall be used to the extent practicable. (See section 20.4 of this chapter.)This training shall deal with fundamental Medicare policies, programs, and procedures and shall concentrate on and feature information on billing Medicare.

IOM 100-09, Ch. 6, §

Contractors shall conduct training for providers or their staff in electronic claims submission. The contractor shall conduct training activities for providers to educate them on, and expand their use of, Medicare billing software and the EDI transactions supported by Medicare.

Medicare Electronic Data Interchange (EDI) Enrollment Agreement

  1. The provider agrees to the following provisions for submitting Medicare claims electronically to CMS or to CMS' A/B Mac's or CEDI:
    1. That it will be responsible for all Medicare claims submitted to CMS or a designated CMS contactor by itself, its employees, or its agents;
    2. That it will not disclose any information concerning a Medicare beneficiary to any other person or organization, except CMS and/or its A/B MAC's, DME MACS or CEDI or another contractor if so designated by CMS without the express written permission of the Medicare 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, or as required by State or Federal law;
    3. That it will submit claims only on behalf of those Medicare beneficiaries who have given their written authorization to do so, and to certify that required beneficiary signatures, or legally authorized signatures on behalf of beneficiaries, are on file;
    4. That it will ensure that every electronic entry can be readily associated and identified with an original source document. Each source document must reflect the following information:
      • Beneficiary's name;
      • Beneficiary's Medicare beneficiary identifier;
      • Date(s) of service;
      • Diagnosis/nature of illness; and
    5. That the Secretary of Health and Human Services or his/her designee and/or the A/B MAC, DME MAC, CEDI or other contractor if designated by CMS 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 authorization and 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 primary payment have been developed for other insurance involvement and that Medicare is 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 6 years, 3 months after the bill is paid;
    9. That it will affix the CMS-assigned unique identifier number (submitter identifier) of the provider on each claim electronically transmitted to the A/B MAC, CEDI or other contractor if designated by CMS;
    10. That the CMS-assigned unique identifier number (submitter identifier) or NPI constitutes the provider's legal electronic signature and constitutes an assurance by the provider that services were performed as billed;
    11. That it will use sufficient security procedures (including compliance with all provisions of the HIPAA security regulations) to ensure that all transmissions of documents are authorized and protect all beneficiary-specific data from improper access;
    12. 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 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;
    13. That it will establish and maintain procedures and controls so that information concerning Medicare beneficiaries, or any information obtained from CMS or its A/B MAC, DME MAC, CEDI or other contractor if designated by CMS shall not be used by agents, officers, or employees of the billing service except as provided by the A/B Mac, DME MAC or CEDI (in accordance with §1106(a) of the Social Security Act (the Act);
    14. That it will research and correct claim discrepancies;
    15. That it will notify the A/B Mac, CEDI, or other contractor if designated by CMS within 2 business days if any transmitted data are received in an unintelligible or garbled form.

  2. The Centers for Medicare & Medicaid Services (CMS) agrees to:
    1. Transmit to the provider an acknowledgment of claim receipt;
    2. Affix the A/B Mac, DME MAC, CEDI or other contractor if designated by CMS 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's policies;
    4. Ensure that no A/B MAC, CEDI, or other contractor if designated by CMS may require the provider to purchase any or all electronic services from A/B MAC, CEDI, or from any subsidiary of A/B MAC, CEDI, other contractor if designated by CMS, or from any company for which the A/B MAC, CEDI has an interest. The A/B MAC, CEDI, or other contractor if designated by CMS 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 A/B MAC, CEDI, or other contractors if designated by CMS 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 A/B MAC, CEDI, or other contractor if designated by CMS sells directly, or indirectly, or by arrangement;
    6. Notify the provider within 2 business days if any transmitted data are received in an unintelligible or garbled form;

    Note: 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 by the provider. The responsibilities and obligations contained in this document will remain in effect as long as Medicare claims are submitted to the A/B Mac, DME MAC, CEDI, or other contractor if designated by CMS. Either party may terminate this arrangement by giving the other party thirty (30) days written notice of its intent to terminate. In the event that the notice is mailed, the written notice of termination shall be deemed to have been given upon the date of mailing, as established by the postmark or other appropriate evidence of transmittal.


The Trading partner has executed Business Associate Agreements (contracts), as mandated by HIPAA and ARRA/HITECH, with each of its business associates. Moreover, the trading partner attests that it has full responsibility, as mandated by HIPAA and ARRA/HITECH, for notification of breaches of protected health information caused by the trading partner or its business associates.

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