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J15 EDI Application Form Instructions

Use this form to enroll providers, software vendors, clearinghouses, and billing services as electronic submitters and recipients of electronic claims data.

Important: Follow the instructions below and 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:
  • Change/Update Submitter Information (to change or add an existing Submitter ID Number; include the Submitter ID Number below)
  • Apply for New Submitter ID (to assign your own Submitter ID Number using an approved software and network service vendor)
Line of Business* Select the appropriate option for which you will transmit:
  • KY Part A 15101
  • OH Part A 15201
  • KY Part B 15102
  • OH PartB 15202
  • HHH 15004
Submitter Information
Input Submitter ID* Options:
  • 837 (submit electronic claims (professional or institutional) to Medicare)
  • 837D (submit electronic claims (dental) to Medicare)
  • 835 (receive electronic remittance notices)
Reason for Submission = Change/Update Submitter Information: Enter an existing Submitter ID Number that belongs to the software vendor, billing service, provider, or clearinghouse in the appropriate fields.

Reason for Submission = Apply for New Submitter ID: If left 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:
  • Software Vendor
  • Billing Service
  • Provider
  • Clearinghouse
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*
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 Contact Name Contact person for the Group Practice/Provider
Provider Email Address* Valid email address for the Provider Contact 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*

When you submit the application form, a printable Provider Authorization Form will open in a separate window.

  1. The information submitted online auto-populates and a tracking number is assigned.
    1. Note the tracking number for your records.
    2. Use the EDI Online Application Status Tool.
  2. Add the Group Practice/Provider Tax Identification Number (TIN).
  3. Include a handwritten signature.
    NOTE: The form must be signed by the Provider Contact or a representative that’s financially responsible for the Group Practice/Provider ONLY.
  4. Fax the form to the appropriate number listed at the bottom.

Please allow up to 7 days for processing.

If the Provider Authorization Form isn’t submitted within 7 days, the EDI Contact Person (Submitter Information) will receive an email advising that the application can’t be processed, and a new application/Provider Authorization Form must be completed.

If you need additional guidance, please contact the EDI Help Desk:

  • 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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