Form CMS-10340 CSSC Operations Submitter Application (Form and Instruct

OMB No. 0938-1152

(Expires: TBD)

CSSC Operations Submitter Application Instruction

Welcome to the Submitter Application Form!

Start a New Application

An entity (Plan or Third Party) that has elected to submit data for one or more of the submission types listed below. By completing the application, you are requesting the assignment of a Submitter ID Number for the submission of data to CMS.

Qualifying Data Submitter Types:

• Encounter Data

• Medicare-Medicaid Data (MMP)

• Prescription Drug Event (PDE)

• Risk Adjustment (RAPS)

Submission Types include:

Encounter Data

Medicaid (A, B, DME, Dental)

National Council Prescription Drug (NCPDP)

Prescription Drug Event

Risk Adjustment

The application form consists of 5 steps:

1. Select the submission types.

2. Select the entity type.

3. Complete the general organization information.

4. Review the application.

5. Confirm, print, and submit the application. A submission receipt will be provided for your records.

Find an Existing Application

Begin here if an application has been previously started or completed for the organization. Please have the Application ID and Application Code provided at the start of the application.

Please note the following for submission of data:

Prior to assigning a Submitter ID Number, an EDI Agreement must be completed and on file with CSSC for each contract and entity prior to submitting data. The agreement must be signed by an authorized agent of the organization and returned to CSSC Operations at the address provided.

Please complete the Submitter Application and return the completed EDI Agreement to:

Palmetto GBA
CSSC Operations AG-570
2300 Springdale Drive Bldg. One
Camden, South Carolina, 29020-1728

Connectivity Options

All submitters that submit data must establish a connection to the Front-End System through CMSNet provided by a CMS approved Network Service Vendor (NSV). CMSNet is the secure network linking all data processing entities. Small plans (contracts with enrollment less than 100,000) that elect to submit data may submit data to the secure CMS website.

The submitter is limited to one connectivity type, per assigned submitter ID per qualifying submission types.

FTP:
Lease line connection.

Secure FTP.

Receipt of front-end response report within one business day.

Connect:Direct (NDM):
Mainframe-to-mainframe connection.

Receipt of front-end response report within one business day.
Formerly known as Network Data Mover (NDM).

Gentran/TIBCO (MFT)*:

Secure FTP.

Receipt of front-end response report within one business day.
Only for plans with less than 100,000 enrollees.

*Gentran/TIBCO (MFT) is not available to Third Party Submitters.

Submitter Authorization Form

In the event a contract elects to use a Third Party Submitter to submit data on their behalf, a Submitter Authorization Form must be completed by a representative from the contract. The Submitter Authorization Form can be accessed at the link provided below.

Authorization Form (Hyperlink)

____________________________________________________________________________________________

Start New Application (Hyperlink)

Find Existing Application

Application ID Application Code

Lookup Application (Hyperlink)

OMB No. 0938-1152

(Expires: TBD)

^CSSC Operations Submitter Application

Directions: Please complete each section of the application. By completing the application, you are requesting the assignment of a Submitter ID Number for the submission of data to CMS.

Entity Type	☐ Contract ☐ Third Party Submitter
Data Submission Type	☐ Encounter Data ☐ Medicare-Medicaid Data (MMP) ☐ Prescription Drug Event (PDE) ☐ Risk Adjustment Data
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 ☐ NDM/Connect:Direct ☐ Gentran/TIBCO (MFT); Contract Submitters only

For Contract Submitters Only: Please list additional contracts to be linked to the assigned Submitter ID.

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 0938-1152. The time required to complete this information collection is estimated to average 5 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 any 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. CMS-10340( / )

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