Basics of EDI Enrollment with Medicare FFS

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Basics of EDI Enrollment with Medicare FFS
What is EDI Enrollment? For a provider is
trying to enroll with Medicare FFS, they must
first establish an Electronic Data Interchange
(EDI) agreement with Medicare. EDI is the process
of using nationally established standards to
exchange electronic information between business
entities. The Department of Health and Human
Services (HHS) adopted certain electronic
standards for use in health care under the Health
Insurance Portability and Accountability Act of
1996 (HIPAA). The Administrative Simplification
Compliance Act (ASCA) prohibits payment of
services or supplies that a provider did not bill
to Medicare electronically. Prime reasons for EDI
are, ensuring the security of electronic data
transmitted between covered entities and ensuring
the privacy of individuals who are the subject of
electronic information being transmitted between
covered entities. You can either submit a paper
CMS form 855 or submit an Internet-based
application via the Provider Enrollment, Chain
and Ownership System (PECOS) system. EDI
Enrollment and Registration
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Basics of EDI Enrollment with Medicare FFS

• Medicare FFS Trading Partner Agreement is
  comprised of two forms i.e., EDI
  Registration and EDI Enrollment. EDI registration
  and enrollment shall be instituted by the A/B
  MACs (Medicare Administrative Contractor) and
  shall accomplish the following
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• Document the specific type of transactions and
  transmission methods to be utilized and secure
  authorizations from the provider or other trading
  partner requesting to exchange electronic
  administrative transactions, and
• Designate the A/B MACs with whom the provider or
  other trading partner agrees to engage in EDI and
  implement standard policies and practices to
  ensure the security and integrity of the
  information to be exchanged.
• A provider must obtain an NPI and furnish that
  NPI to their A/B MAC prior to completion of an
  initial EDI Enrollment Agreement and issuance of
  an initial EDI number and password by that
  contractor. The A/B MACs are required to verify
  that NPI is active in the Provider Enrollment,
  Chain, and Ownership System (PECOS).

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Basics of EDI Enrollment with Medicare FFS
If the A/B MAC is not able to verify the NPI as
active in PECOS, the EDI Enrollment Agreement is
denied and the provider is encouraged to contact
the A/B MAC provider enrollment department (for
Medicare Part A and Part B providers) or the
National Supplier Clearinghouse (for DME
suppliers) to resolve the issue. Once the NPI is
properly verified, the provider can reapply the
EDI Enrollment Agreement. A providers EDI number
and password serve as a providers electronic
signature. When leaving the Medicare Program, a
provider must notify their MAC to deactivate the
EDI number. If providers elect to submit/receive
transactions electronically using a third party
such as a billing agent or a clearinghouse, the
A/B MACs or CEDI must notify those providers that
they are required to have an agreement signed by
that third party. The third-party must agree to
meet the same Medicare security and privacy
requirements that apply to the provider in regard
to viewing or use of Medicare beneficiary
data. The providers must also be informed that
they are not permitted to share their personal
EDI access number and password with any billing
agent or clearinghouse. Providers must also not
share their personal EDI access number to anyone
on their own staff who does not need to see the
data for completion of a valid electronic claim,
to process remittance advice for a claim, to
verify beneficiary eligibility, or to determine
the status of a claim. No other non-staff
individuals or entities may be permitted to use a
providers EDI number.
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Basics of EDI Enrollment with Medicare FFS
We shared the basics of EDI enrollment with
Medicare FFS from Medicare Claims Processing
Manual- Chapter 24. If you just started your
independent practice and need help in
credentialing and enrollment with Medicare, then
we can assist you.   Medical Billers and Coders
(MBC) is a leading medical billing company
providing complete revenue cycle services. We can
assist you in provider credentialing and
enrollment for the government as well as private
payers. To know more about our medical billing
services, contact us at info_at_medicalbillersandcode
rs.com/888-357-3226.