- Entry Process Questions
- General Information
- Choose Transaction Status
- Submitting the Packet
- EDI Enrollment Agreement Form
- EDI ERA Enrollment Form
- EDI Registration Form
- Part A Logon Request Form: Provider/Facility Requesting Access
- Provider Letter of Authorization
- Part A Logon Request Form: Billing Service Using a Letter of Authorization PIN
- Tracking my Enrollment Packet and Checking Status
- EDI Gateway Self-Service Password Portal
EDI ERA Enrollment Form
The EDI ERA Enrollment Form is required to be on file for each PTAN/NPI currently setup or requesting to be setup for the first time to receive electronic remittances through NGS.
Should I Complete This Form?
- The ERA enrollment form is a required document by CMS that allows a provider to receive ERA from EDI. This form is effective as long as the provider is receiving Medicare ERAs.
- This form is used by providers to enroll their Medicare PTAN and NPI for Medicare ERA.
- Providers requesting to receive ERA for the first time are required to complete this form.
- Providers already setup to receive ERA but are requesting to change the delivery of the remits from one trading partner ID to another trading partner ID (or from one clearinghouse to another clearinghouse) will be required to complete this form if an EDI ERA enrollment is not on file for the NPI and PTAN.
- Providers would need to complete the ERA Enrollment Form for each group NPI/PTAN who will be receiving electronic remittance advises.
- Providers who already have a EDI ERA Enrollment on file but receive a new PTAN number must complete a new EDI Enrollment and the EDI ERA Enrollment for the new PTAN to receive ERA.
- Providers who currently receive ERAs and do not wish to make any changes at this time will not need to complete this form. Remits will continue to be sent under the current setup
- Note: The option is available to proceed in completing an additional agreement.
Provider Information
- What is the DBA?
An alternate business name the provider may go by. This is not a required field.
Provider Identifiers Information
- What information should I use in the Provider Identifiers fields?
Providers will enter either their federal TIN or the EIN.- A TIN is used by the IRS in the administration of tax laws. It is issued either by the SSA or by the IRS.
- An EIN is also known as a federal TIN, and is used to identify a business entity.
- What is the Trading Partner ID?
The ID used to exchange transactions with NGS. This is the 4-9 alpha-numeric ID (only required when the action Update TPID or Link to Third Party is selected in Section I).
ERA Information: Preference for Aggregation of Remittance Data
- What is the Method of Retrieval?
- Billing Service: If you will receive the ERA file from your billing service
- Clearinghouse: If you will receive the ERA file from your clearinghouse
- Direct from Contractor: If ERAs will be downloaded directly using your trading partner ID.
ERA Clearinghouse Information
This section is auto-populated based on whether the PTAN/NPI entered within the Guided Enrollment.
ERA Vendor Information
- What is the Vendor Name?
Please select your software vendor from the drop down list. If your software vendor is not listed, please select “OTHER.”- When using a vendor from the drop-down list the vendor’s demographic information will be auto-populated in this section.
- What information should I put in the Vendor Contact Name field?
First and Last Name of an employee within the software vendor company who would be responsible for questions regarding ERA issues.
- What information should I use in the Email Address field?
An email address that can be used to contact the software vendor company.
Submission Information
This section is auto-populated based on whether the PTAN/NPI entered within the Guided Enrollment already has an ERA Enrollment Form on file with NGS.
- What is the Reason for Submission?
- New Enrollment - PTAN/NPI is not currently receiving ERAs through any TP ID with NGS.
- Change Enrollment - PTAN/NPI is currently receiving ERAs through a TP ID with NGS, but wishes to update their information currently on file.
Authorized Signature
- What is the Name of Person Submitting?
This is the name of the individual completing the form online.
- What is the Title of Person Submitting?
This is the employment title of the individual completing the form online.