CMS-10164 Accessible EDI Enrollment Form

Medicare
Contractor’s
Logo Here
Electronic Data Interchange (EDI) Enrollment Form
This Agreement notifies (fill in contractor name here) of the provider’s consent to participate in Electronic Data
Interchange (EDI). EDI may include claims and claims attachments, remittances, eligibility/benefits, claim status, and any
other electronic information for Medicare data covered under Health Insurance Portability and Accountability Act (HIPAA)
Transactions and Code Sets legislation.
A. The provider agrees:
1.

That it will establish and maintain procedures and controls so that information concerning Medicare beneficiaries, or any
information obtained from CMS or its A/B MAC (Medicare Administrative Contractors), CEDI (Common Electronic Data
Interchange), hereafter referred to as Contractors, shall not be used by agents, officers, or employees of a business associate except
as provided by the Contractors (in accordance with §1106(a) of the Social Security Act (the Act);

2.

That it will use sufficient security procedures to ensure that all electronic transmissions are authorized and protect all beneficiaryspecific data from improper access, and that these procedures are in compliance with the mandates of the HIPAA Privacy Rule,
HIPAA Security Rule, and the American Recovery and Reinvestment Act (ARRA)/Health Information Technology and Economic
and Clinical Health (HITECH),

3.

That it will notify Contractors of breaches of protected health information caused by itself, its employees, or its business
associates.

4.

That it will notify Contractors within two business days if any transmitted data are received in an unintelligible or garbled form.

5.

The provider agrees to the following provisions for submitting and retrieving/receiving Medicare information electronically
to/from CMS or CMS' contractors:

6.

a)

That it will be responsible for all Medicare transactions submitted to CMS by itself, its employees, or its business associates;

b)

That it will not disclose any information concerning a Medicare beneficiary to any other person or organization, except CMS
and/or its Contractors, without the express written permission of the Medicare beneficiary or his/her parent or legal guardian,
or where required for the care and treatment of a beneficiary who is unable to provide written consent, or to bill insurance
primary or supplementary to Medicare, or as required by State or Federal law;

c)

That it will submit claims only on behalf of those Medicare beneficiaries who have given their written permission to do so,
and to certify that required beneficiary signatures, or legally authorized signatures on behalf of beneficiaries, are on file;

d)

That it will submit/request electronic transactions on only those beneficiaries with whom the provider has a professional
relationship;

e)

That the CMS-assigned unique identifier number (submitter identifier) constitutes the provider’s legal electronic signature and
when used for claims submission it constitutes an assurance by the provider that services were performed as billed;

f)

That it will ensure that every electronic claim can be readily associated and identified with an original source document. Each
source document must reflect the following information:
• Beneficiary’s name;
• Beneficiary’s Medicare Beneficiary Identifier;
• Date(s) of service;
• Diagnosis/nature of illness; and
• Procedure/service performed;

That the Secretary of Health and Human Services or his/her designee and/or the Contractor has the right to audit and confirm
information submitted by the provider and shall have access to all original source documents and medical records related to the
provider’s submissions, including the beneficiary’s signature. All incorrect payments that are discovered as a result of such an
audit shall be adjusted according to the applicable provisions of the Social Security Act, Federal regulations, and CMS guidelines;

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938- 0983. This form expires on xx/xx/xxxx. The time required to complete this
information collection is estimated to average (20 minutes) per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving
this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850

7.

That it will ensure that all claims for Medicare primary payment have been developed for other insurance involvement and that
Medicare is the primary payer;

8.

That it will submit claims that are accurate, complete, and truthful;

9.

That it will retain all original source documentation and medical records pertaining to any such particular Medicare claim for a
period of at least six years, three months after the bill is paid;

10. That it will research and correct claim discrepancies;
11. That it will affix the CMS-assigned unique identifier number (submitter identifier) of the provider on each claim electronically
transmitted to the Contractor;
12. That it will acknowledge that all claims will be paid from Federal funds, that the submission of such claims is a claim for payment
under the Medicare program, and that anyone who misrepresents or falsifies or causes to be misrepresented or falsified any record
or other information relating to that claim that is required pursuant to this Agreement may, upon conviction, be subject to a fine
and/or imprisonment under applicable Federal law;
13. That if it chooses to participate in electronic remittance transactions it will notify the Contractor of any changes in third-party
services that it has authorized to access this information on their behalf via the EDI Enrollment form;
14. That if it chooses to use a Network Service vendor for eligibility verification transactions it will notify the Contractor of any
changes in third-party service arrangements via the EDI Enrollment form;
B. The Centers for Medicare & Medicaid Services (CMS) agrees to:
1.

Transmit to the provider an acknowledgment of claim receipt;

2.

Affix the Contractor number, as its electronic signature, on each remittance advice sent to the provider;

3.

Ensure that payments to providers are timely in accordance with CMS’ policies;

4.

Ensure that no Contractor may require the provider to purchase any or all electronic services from the Contractor or from any
subsidiary of the Contractor or from any company for which the Contractor has an interest. The Contractor will make alternative
means available to any electronic biller to obtain such services;

5.

Ensure that all Medicare electronic billers have equal access to any services that CMS requires Medicare Contractors to make
available to providers or their billing services, regardless of the electronic billing technique or service they choose. Equal access
will be granted to any services the Contractor sells directly, or indirectly, or by arrangement;

6.

Notify the provider within two business days if any transmitted data are received in an unintelligible or garbled form.

NOTICE: Federal law shall govern both the interpretation of this document and the appropriate jurisdiction and venue for
appealing any final decision made by CMS under this document. This document shall become effective when signed by the provider.
The responsibilities and obligations contained in this document will remain in effect as long as Medicare claims or any other EDI
transactions are submitted to CMS or the carrier or FI. Either party may terminate this arrangement by giving the other party thirty
(30) days written notice of its intent to terminate. In the event that the notice is mailed, the written notice of termination shall be
deemed to have been given upon the date of mailing, as established by the postmark or other appropriate evidence of transmittal.
C. Signature
I am authorized to sign this document on behalf of the indicated party and I have read and agree to the foregoing provisions and
acknowledge same by signing below.
Provider’s Name
Title
Address
City/State/Zip
Medicare provider number:
Submitter number (if applicable):
Signed By:
Printed Name:
Title
Date
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0938- 0983. xx/xx/xxxx. The time required to complete this information collection is estimated to
average (20 minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850