CMS-10340 Submitter Authorization (screen shots)

Online Submitter Application

Screen 1 – Screen will display once the ‘Start Application’ option is selected from the
Introduction/Instruction page.
Please select the Data Submission Type for which a Submitter ID is requested. At least one option must be
selected to continue.

Encounter Data
Medicare-Medicaid Data (MMP)
Prescription Drug Event (PDE)
Risk Adjustment Data (RAPS)

Screen 2
Please select the entity type.*

Contract Submitter
Third Party Submitter

* Depending on which option is selected, the user will be routed to either the Contract or Third Party
Submitter application.

Screen 3 – depending on which option is selected

Submitter Information (Contract Version)
Organization Name
Contract Number
Address
Address 2
City, State, Zip
Fax Number
Operations Contact Representative
Name
Contact Number
Email
Technical Contact Representative
Name
Contact Number
Email
Connection Type

FTP – Lease Line; Dial-up Modem
NDM/Connect:Direct
Gentran/TIBCO (MFT)

Please list additional contracts to be linked to the assigned Submitter ID.

Screen 3 – depending on which option is selected
Submitter Information (Third Party Version)
Organization Name
Address
Address 2
City, State, Zip
Fax Number
Operations Contact Representative
Name
Contact Number
Email
Technical Contact Representative
Name
Contact Number
Email
Connection Type

FTP – Lease Line; Dial-up Modem
NDM/Connect:Direct

Step 4 - Review the application.
Step 5 - Confirm, print, and submit application (electronically).