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
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:
- 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).
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 provider’s EDI number and password serve as a provider’s 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 provider’s EDI number.
We shared the basics of EDI enrollment with Medicare FFS from the 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@medicalbillersandcoders.com/888-357-3226.
FAQs
1. What is EDI Enrollment for Medicare FFS?
EDI Enrollment is the process of establishing an agreement to electronically exchange data with Medicare using standardized formats, ensuring security and privacy under HIPAA and ASCA.
2. What forms are required for Medicare FFS EDI Enrollment?
Providers must complete the EDI Registration and EDI Enrollment forms as part of the Medicare Trading Partner Agreement to begin electronic transactions with Medicare.
3. Do I need an NPI for EDI Enrollment?
Yes, a provider must have an active NPI and provide it to their Medicare Administrative Contractor (A/B MAC) before completing the EDI Enrollment Agreement.
4. Can third parties handle my Medicare EDI transactions?
Yes, providers can use third parties like billing agents or clearinghouses, but the third party must sign an agreement and adhere to Medicare’s security and privacy requirements.
5. What should I do if I leave the Medicare Program?
Providers must notify their A/B MAC to deactivate their EDI number, as it serves as their electronic signature for Medicare transactions.
