EDI E-Signature User Guide

Part A Logon Request Form

Provider/Facility Requesting Access

This form is for Part A providers requesting access to the Fiscal Intermediary Standard System (FISS)/Direct Data Entry (DDE) Online System and check patient eligibility.

Note: Up to 10 individual users and 26 PTAN/NPI combinations within the same Contractor Code can be submitted through this form.

Section I: Action

This section is used to determine to the necessary action taken for the Logon ID(s) entered.

  • Add PTAN(s) - add PTAN(s) to an ID that currently has access to the FISS region PTAN(s) are assigned to
  • Add Region (Dual Access) - add an additional region of FISS access to an ID that is currently active
  • Change Name - update user name based on marriage, divorce, etc.; cannot change name to a new user
  • Change Operator Access - update access level; either Inquiry or Inquiry/Update can be selected
  • Change PIN - JM users only; user has the ability to change the four-digit numeric PIN currently on file
  • Delete Logon ID - to delete all current access to Medicare FISS regions, PTAN(s), inactivate the Logon ID
  • Delete PTAN(s) - to delete only specific PTAN(s), while leaving the Logon ID active
  • New Logon ID - assign a new user a Logon ID (previously assigned inactive Logon IDs will be reinstated)
  • Reinstate Logon ID - user has an existing Logon ID that is currently inactive

Operating as a:

  • Corporate Office – parent company of the PTAN, different physical address information than what is on file for each provider/facility; cannot be a third party of any kind
  • Facility – same physical address information as the PTAN has on file with Medicare

Section II: Requestor

This section is completed with the requestor’s information that is auto-populated from the entries within the Guided Enrollment.

  1. What is a Network Service Vendor?

    The approved NSV that provides access to the NGS EDI gateway that you have a service agreement with.

Section III: Institutional Provider

This section is auto-populated from the entries within the Guided Enrollment.

Section IV: Logon On 

This section is completed with the operator’s information. Any additional users and/or action types will require an additional form to be completed.

  1. What is the Operator Name? This is the first name, middle initial and last name of the operator who will be accessing the FISS/DDE system.
  2. What is the Telephone Number/Extension? This is the direct telephone number and extension of the user.
  3. What do I enter for the Email address? This is the direct email address of the user.
  4. What is the EIN number? The EIN is a unique alpha-numeric validation number assigned to the Logon ID.
  5. What do I enter for the Logon ID? This is the seven-digit Logon ID assigned to the user.
    • two alpha, five numeric (XX11111) or
    • three alpha, four numeric (XXX1111)
  6. What do I choose for Operator Access? Choose either Inquiry or Inquiry/Update from the drop down.
    •  Inquiry gives the ability to check status but not make changes
    •  Inquiry/Update gives the user the ability to check eligibility and make changes, such as sending or correcting a claim

After adding an operator, click the Add button to enter the next operator. You can add up to 10 operators who are requesting the same access per form.

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