CEDI Enrollment Agreement Form

- Required

Medicare Supplier Name

Contact Name

Address

City/State/Zip

Verify Email

Phone

Ext

Submitter Status

Submitter ID

Submitter Name

Submitter Type

PTAN(s)

NPI(s)

The provider agrees to the following provisions for submitting Medicare claims electronically to CMS or to CMS’ FIs, Carriers, RHHIs, A/B MACs or CEDI:

That it will be responsible for all Medicare claims submitted to CMS or a designated CMS contractor by itself, its employees, or its agents;
That it will not disclose any information concerning a Medicare beneficiary to any other person or organization, except CMS and/or its FIs, Carriers, RHHIs, A/B MACs, DME MACs or CEDI without the express written permission of the Medicare beneficiary or his/her parent or legal guardian, or where required for the care and treatment of a beneficiary who is unable to provide written consent, or to bill insurance primary or supplementary to Medicare, or as required by State or Federal law;
That it will submit claims only on behalf of those Medicare beneficiaries who have given their written authorization to do so, and to certify that required beneficiary signatures, or legally authorized signatures on behalf of beneficiaries, are on file;
That it will ensure that every electronic entry can be readily associated and identified with an original source document. Each source document must reflect the following information:

Beneficiary’s name;
Beneficiary’s health insurance claim number;
Date(s) of service;
Diagnosis/nature of illness; and
Procedure/service performed.

That the Secretary of Health and Human Services or his/her designee and/or the FI, Carrier, RHHI, A/B MAC, DME MAC, CEDI, or other contractor if designated by CMS has the right to audit and confirm information submitted by the provider and shall have access to all original source documents and medical records related to the provider’s submissions, including the beneficiary’s authorization and signature. All incorrect payments that are discovered as a result of such an audit shall be adjusted according to the applicable provisions of the Social Security Act, Federal regulations, and CMS guidelines;
That it will ensure that all claims for Medicare primary payment have been developed for other insurance involvement and that Medicare is the primary payer;
That it will submit claims that are accurate, complete, and truthful;
That it will retain all original source documentation and medical records pertaining to any such particular Medicare claim for a period of at least 6 years, 3 months after the bill is paid;
That it will affix the CMS-assigned unique identifier number (submitter identifier) of the provider on each claim electronically transmitted to the FI, Carrier, RHHI, A/B MAC, CEDI, or other contractor if designated by CMS;
That the CMS-assigned unique identifier number (submitter identifier) or NPI constitutes the provider’s legal electronic signature and constitutes an assurance by the provider that services were performed as billed;
That it will use sufficient security procedures (including compliance with all provisions of the HIPAA security regulations) to ensure that all transmissions of documents are authorized and protect all beneficiary-specific data from improper access;
That it will acknowledge that all claims will be paid from Federal funds, that the submission of such claims is a claim for payment under the Medicare program, and that anyone who misrepresents or falsifies or causes to be misrepresented or falsified any record or other information relating to that claim that is required pursuant to this agreement may, upon conviction, be subject to a fine and/or imprisonment under applicable Federal law;
That it will establish and maintain procedures and controls so that information concerning Medicare beneficiaries, or any information obtained from CMS or its FI, Carrier, RHHI, A/B MAC, DME MAC, CEDI, or other contractor if designated by CMS shall not be used by agents, officers, or employees of the billing service except as provided by the FI, Carrier, RHHI, A/B MAC, DME MAC or CEDI (in accordance with §1106(a) of Social Security Act (the Act);
That it will research and correct claim discrepancies;
That it will notify the FI, Carrier, RHHI, A/B MAC, CEDI, or other contractor if designated by CMS within 2 business days if any transmitted data are received in an unintelligible or garbled form.

The Centers for Medicare & Medicaid Services (CMS) agrees to:

Transmit to the provider an acknowledgment of claim receipt;
Affix the FI, Carrier, RHHI, A/B MAC, DME MAC, CEDI or other contractor if designated by CMS number, as its electronic signature, on each remittance advice sent to the provider;
Ensure that payments to providers are timely in accordance with CMS’ policies;
Ensure that no FI, Carrier, RHHI, A/B MAC, CEDI, or other contractor if designated by CMS may require the provider to purchase any or all electronic services from the FI, Carrier, RHHI, A/B MAC, CEDI or from any subsidiary of the FI, Carrier, RHHI, A/B MAC, CEDI, other contractor if designated by CMS, or from any company for which the FI, Carrier, RHHI, A/B MAC, CEDI has an interest. The FI, Carrier, RHHI, A/B MAC, CEDI, or other contractor if designated by CMS will make alternative means available to any electronic biller to obtain such services;
Ensure that all Medicare electronic billers have equal access to any services that CMS requires Medicare FIs, Carriers, RHHIs, A/B MACs, CEDI, or other contractors if designated by CMS to make available to providers or their billing services, regardless of the electronic billing technique or service they choose. Equal access will be granted to any services sold directly, indirectly, or by arrangement by the FI, Carrier, RHHI, A/B MAC, CEDI, or other contractor if designated by CMS;
Notify the provider within 2 business days if any transmitted data are received in an unintelligible or garbled form.

NOTE: Federal law shall govern both the interpretation of this document and the appropriate jurisdiction and venue for appealing any final decision made by CMS under this document. This document shall become effective when signed by the provider. The responsibilities and obligations contained in this document will remain in effect as long as Medicare claims are submitted to the FI, Carrier, RHHI, A/B MAC, DME MAC, CEDI, or other contractor if designated by CMS. Either party may terminate this arrangement by giving the other party thirty (30) days written notice of its intent to terminate. In the event that the notice is mailed, the written notice of termination shall be deemed to have been given upon the date of mailing, as established by the postmark or other appropriate evidence of transmittal.

Signature

I certify that I have been appointed an authorized individual to whom the provider has granted the legal authority to enroll it in the Medicare Program, to make changes and/or updates to the provider's status in the Medicare Program (e.g., new practice locations, change of address, etc.) and to commit the provider to abide by the laws, regulations and the program instructions of Medicare. I authorize the above listed entities to communicate electronically with (MAC name) on my behalf.

I have read and accept the terms of the above agreement.

Authorized Signature Name

ALL pages of ALL forms must be SIGNED, DATED, and FAXED to 315-442-4299 within 10 business days or the request will be rejected. Please be sure to fax multiple forms for the same request TOGETHER and include a cover letter. Faxes not received within 10 days of submitting the form(s) on line will be rejected and new forms will be required to be submitted.

IMPORTANT: Once you click on the "Submit" button, this form must be printed, signed, dated, and then faxed to CEDI using the fax number located on the form. Forms that are not printed, signed, dated, and faxed to CEDI will not be processed.
Per CMS regulations, it is required to submit both pages 1 and 2 of the EDI Enrollment Agreement. Failure to submit both pages may delay processing.

REMINDER: CMS strictly prohibits the outsourcing of system functions outside the United States and its territories, unless explicitly authorized, in writing, by the CMS CIO. System functions include the transmission of electronic claims, receipt of electronic remittance advice or the access to any system for beneficiary and/or eligibility information. Any request for access received from outside the United States and its territories will be immediately denied by National Government Services pending authorization from CMS.

Signer of this form must be authorized to sign on behalf of the supplier, as reported to the National Supplier Clearinghouse. If you are unsure who your authorized official is, please contact the NSC at 866-238-9652.