EDI E-Signature User Guide

Part A Logon Request Form 

Billing Service Using a Letter of Authorization PIN

This option allows a billing service to complete the Part A Logon Request Form after the Letter of Authorization has been completed by the provider/facility which authorizes a third party billing service to perform FISS/DDE functions on their behalf.  

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

Section II: Requestor

This section is completed with the information of the employee within the billing service who would be responsible for questions regarding FISS/DDE access and the annual logon recertification.

  1. What do I enter for the Primary Contact First and Last Name? The first and last name of the employee within the billing service who would be responsible for questions regarding FISS/DDE access and the annual logon recertification.
  2. What is the Primary Title? The employment title of the primary contact entered for the billing service.
  3. What information should I use in the Email Address field? An email address that can be used to contact the primary contact entered for the billing service
  4. What is the Facility Name? This is the name of the billing service
  5. What do I enter for the Street Address, City, State and ZIP? This is the billing service’s information; physical location/business address and contact phone numbers where the entity can be contacted upon completing the processing of the request.
  6. What do I enter for Telephone Number and Telephone Number Extension? The direct telephone number for the billing service where the primary contact can be reached. If a Telephone Extension is used, it should be entered as well.
  7. 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 that the provider/facility entered on the Letter of Authorization.

Section IV: Logon On 

This section is completed with the operator’s information. Any additional users and/or action types will require an additional Letter of Authorization and Part A Logon Request 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 E-mail 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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