EDI Application Instructions
The EDI Application is used to enroll providers, software vendors, clearinghouses, and billing services to submit and receive electronic claims data.
Important: Follow the instructions below to help ensure you complete all required information. Incomplete forms will be returned to the applicant and delay processing.
| Field Name | Instructions |
|---|---|
| Date | Auto-populates |
| Reason for Submission | Select the appropriate option:
|
| Line of Business | Select the appropriate option for which you will transmit:
|
| Submitter Information | |
| Input Submitter ID | Options:
Reason for Submission = Apply for New Submitter ID: If 835 is blank, a Submitter ID number for 837 only will be assigned. If you have a specific request for 837 only, 835 only, or both 837 & 835, enter "REQUESTING" in the appropriate fields. |
| Type of Submitter | Select the appropriate option:
|
| Submitter ID Entity Name | Name of the provider, software vendor, billing service, or clearinghouse that will communicate electronically with CGS |
| EDI Contact Person | First & last name of the person EDI should contact for questions about the application or future communications |
| Submitter Phone Number | Area code, phone number, and extension (required for toll-free numbers) for the EDI Contact Person listed above |
| Submitter Email Address | Valid, direct email address for the EDI Contact Person listed above (no email distribution addresses) |
| Submitter Fax Number | Fax number for the EDI Contact Person listed above (optional) |
| Submitter Address 1 | Mailing address for the Submitter ID Entity Name listed above (must match what's on file) |
| Submitter Address 2 | |
| Submitter City | |
| Submitter State | |
| Submitter ZIP Code | |
| Software Vendor & Network Service Vendor (if requesting a submitter ID#) | |
| Name of Software Vendor | Name of the software vendor you're using (if applicable) |
| Network Service Vendor | Name of the NSV you're using (if applicable) |
| Note: These fields are only required if you're applying for a New Submitter ID. | |
| Provider Information | |
| Group Practice/Provider Name | Group practice/provider name submitted on the CMS 855 Medicare Enrollment Application |
| Provider First Name | First name for a contact person at the Group Practice/Provider |
| Provider Last Name | Last name for a contact person at the Group Practice/Provider |
| Provider Phone Number | Area code, phone number, and extension for the Provider First/Last Name listed above |
| Provider Email Address | Valid email address for the Provider First/Last Name listed above (to receive communications for approval of EDI option changes) |
| Group Provider Number | Group Provider Transaction Access Number (PTAN) assigned after enrolling in the Medicare Program |
| Group NPI | Group National Provider Identifier (NPI) |
| Address 1 | Mailing address for the Group Practice/Provider |
| Address 2 | |
| City | |
| State | |
| ZIP Code | |
When you submit, a printable EDI Application Notice will open in a separate window.
Instructions:
- Please review and retain a copy of this notice for your records.
- To check application status, enter the tracking number from the notice in the EDI Application Status Tool.
- Please allow 24 hours after submitting the EDI Application before using the EDI Application Status Tool.
Please contact the EDI Help Desk for assistance:
- Home Health & Hospice: 1.877.299.4500 (option 2)
- Part A Kentucky/Ohio: 1.866.590.6703 (option 2)
- Part B Kentucky/Ohio: 1.866.276.9558 (option 2)
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