| Direct Data Entry (DDE) |
12/07 |
Agreement forms for the Med A on-line Direct Data Entry System. |
| Med A Registration Package for New EDI Submitters |
12/07 |
Registration package for new EDI submitters. |
| Med A Registration Package for Existing EDI Submitters |
12/07 |
Registration package for existing EDI submitters to:
Update customer contact information
Change software vendor information
Add claims data format and/or 276/277
Add or change to ERA/835 ANSI 4010A1
Add Electronic Funds Transfer
Change data transmission/retrieval method
|
| EDI Enrollment Form |
12/07 |
EDI Enrollment Form for existing EDI submitters to: Add a new provider number(s) to an existing EDI sender ID. |
| Electronic Funds Transfer (EFT)* |
12/07 |
Agreement forms for Electronic Funds Transfer
For EFT enrollment, National Government Services must receive:
- A valid Medicare Identification number and NPI
- One EFT request form for each Medicare Identification number
- A voided blank check or bank affidavit (a pre printed deposit slip will not be accepted)
NOTE: This form cannot be faxed.
Mail forms to:
National Government Services
Attention: EDI Unit
P.O. Box 7165
Indianapolis, IN 46207-7165
|
| Electronic Remittance Advice (ERA) |
12/07 |
Agreement forms for Electronic Remittance Advice |
| PC-ACE forms |
12/07 |
Agreement forms necessary to obtain AdminaStar Federal's HIPAA compliant PC-ACE software. |
| Part A Outbound Report Request |
12/07 |
Agreement form to receive 201 Pend reports, and/or Additional Development Letters (ADR) |
| Part A PS&R E-Mail Request Form |
09/07 |
Request form to receive Provider Statistical & Reimbursement Reports (PS&R) report via e-mail. |
