J15 EDI Application Form Instructions
Corporate

J15 EDI Application Form Instructions

The purpose of the J15 EDI Application Form is to enroll providers, software vendors, clearinghouses and billing services as electronic submitters and recipients of electronic claims data. It is important that instructions are followed and that all required information is completed. Incomplete forms will be returned to the applicant, thus delaying processing.

The field descriptions listed below will aid in completing the form properly. There are two (2) pages to the application form. The first page is required and the second page should be used only if additional providers need to be listed.

Form Field Name Instructions for Field Completion
Line of Business Information Indicate the line of business and state for which you will be transmitting. Select all that apply to this request.

Action Requested:

  • Add Provider(s)
  • Change/Update Submitter Information
  • Delete
  • Apply for New Submitter ID
  • Apply for New Receiver ID

Indicate the action to be taken on the application form.

  • If you need to add additional providers to an existing submitter ID, check Add Provider(s).
  • If you request to change or update information about the Submitter, check Change/Update Submitter Information and be sure to include your current Submitter ID.
  • If you request to delete a provider(s), check Delete and be sure to include your submitter ID.
  • If you are a new applicant, check Apply for New Submitter ID.
  • If you are a new applicant, check Apply for New Receiver ID (This option is available for North Carolina Part A and Virginia Part B only).
Submitter ID The submitter ID is used by the submitter to communicate with CGS electronically. For new applicants, this field should be left blank, as CGS will assign this ID if requested. For changes or additions, enter the Submitter ID to which the change/additions should be applied.
Date Please enter the date the application is completed.
Submitter Name Enter the name of the entity (provider, software vendor, billing service or clearinghouse) that will actually be communicating electronically with CGS.
Owner Name(s) Enter the name of the individual(s) who owns the entity listed above.
Type of Submitter Check the appropriate box.
EDI Contact Person The name of the submitter's primary EDI contact. This is the person CGS will contact if there are questions regarding the application or future questions about their communications.
Phone The area code and phone number of the Contact Person listed.
FAX The FAX number for this location.
Address The mailing address of the submitter.
City, State, Zip The city, state and zip code of the submitter.
Name of Software Vendor Indicate the name of the software vendor you are using, if applicable.
Network Service Vendor Indicate the name of the network service vendor (NSV) you are using, if applicable.
Providers For Whom Submitter Will Be Communicating Electronically
Provider Name Submit one electronic application per PTAN. This name must match the name submitted on the CMS 855 Medicare Enrollment Application.
Provider E-mail address Indicate the e-mail address for the provider listed above. This e-mail address will be the primary source of communications regarding approval of changes to their EDI options.
Provider Number Indicate the Medicare Provider Number for each provider listed.
NPI Include the National Provider Identifier (NPI).

Once you have completed the application form, please retain a copy for your records and fax or mail the original to the address listed below. Your Submitter ID and software (if applicable) will be processed within 5 business days of receipt of completed forms.

FAX completed form (for faster service) to:

1.615.664.5945 Ohio Part A
1.615.664.5927 Ohio Part B
1.615.664.5947 Home Health & Hospice
1.615.664.5943 Kentucky Part A
1.615.664.5917 Kentucky Part B

Or mail completed form to:

J15 — EDI
CGS Administrators, LLC
PO Box 20018
Nashville, TN 37202


Two Vantage Way, Nashville, TN 37228 © CGS Administrators, LLC. All Rights Reserved