EDI E-mail Inquiry Form Assistance
*Required Field - An asterisk adjacent to the form field indicates that completion is required.
| Line of Business | List the line of business for this inquiry or issue. Choose from the drop-down box. |
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| Medicare Contractor Code | List the state and contractor number. Choose from the drop-down box. |
| Provider Transaction Access Number (PTAN) | List the PTAN associated with this inquiry. |
| National Provider Identifier (NPI) | List the NPI associated with this inquiry. |
| Submitter ID | List the Sender/Submitter or User ID associated with this inquiry. |
| Organization Name | List your facility or company name. |
| Contact Name | List the name of the contact person submitting the inquiry. |
| Email Address | List the email address of the contact person submitting the inquiry. |
| Telephone Number | List the telephone number of the contact person submitting the inquiry. When necessary, National Government Services will use this telephone number to obtain additional information from the customer. |
| Fax Number | List the fax number of the contact person submitting the inquiry |
| Reason for Inquiry | Select from the drop-down menu provided the issue that best describes this inquiry |
| Detailed Description of Issue | List as much detail as possible about this issue/inquiry. To begin a new line, press the “Enter” key
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