J11 Form PDF Details

In today's increasingly digital healthcare environment, navigating the paperwork associated with Medicare Part A can seem like a daunting task. Enter the J11 EDI Enrollment Packet, a crucial tool for providers looking to streamline this process through Direct Data Entry (DDE). Designed to facilitate easy and immediate access to claims processing and beneficiary eligibility information, the J11 form is a gateway for Medicare Part A providers to manage their submissions efficiently. To use this system, each provider must obtain an individual DDE or User ID, ensuring a secure and personalized experience in handling sensitive information. The application form itself spans two pages, with the first being mandatory and the second reserved for additional requests. It's tailored to meet the needs of various entities by accommodating a range of actions, such as requesting new IDs, deleting or updating existing ones, or adding provider numbers to an already established ID. Moreover, the form also emphasizes security and confidentiality in its operations. With its comprehensive approach to EDI Enrollment, the J11 form encapsulates a pivotal resource for healthcare providers in Palmetto GBA's jurisdiction, streamlining administrative tasks and enhancing the overall efficiency of Medicare data management.

QuestionAnswer
Form NameJ11 Form
Form Length9 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 15 sec
Other namesj11 dde, medicare private contract form j11 part b, j11 edi application form application, palmetto j11 provider authorization form jurisdiction edi enrollment packet

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Palmetto GBA

Jurisdiction 11 EDI Enrollment Packet

J11 Direct Data Entry (DDE) Enrollment Form

DDE for Part A Customers

Direct Data Entry (DDE) is an online computer inquiry system that provides easy and immediate access to claims processing and beneficiary eligibility information for Medicare Part A providers. Each user must have an individual DDE or User ID. You must include an individual’s name with each user ID requested. For security reason, you should not share your DDE User ID. One ID can access multiple provider numbers.

There are two (2) pages to the application form. The first page is required and the second page should be used only if additional DDE ID action requests need to be listed.

 

Form Field Name

 

Instructions for Field Completion

 

Line of Business

 

Indicate the line of business and state for which you will be transmitting.

 

Information

 

 

 

 

 

Submitter ID

 

Enter the Submitter ID if available. For new applicants, this field should be left

 

 

 

 

 

 

blank, as Palmetto GBA will assign this ID if requested.

 

Date

 

Please enter the date the application is completed.

 

Entity Name

 

Enter the name of the entity (provider, corporate office, vendor, billing service

 

 

 

or clearinghouse) who is requesting the DDE ID.

 

Type of Entity

 

Check the appropriate box.

 

EDI Contact Person

 

The name EDI contact. This is the person Palmetto GBA will contact if there are

 

 

 

questions regarding the online inquiry services form.

 

Phone

 

The area code and phone number of the Contact Person listed on this form.

 

Fax

 

The fax number for this location.

 

Address

 

The mailing address of the entity.

 

City, State, ZIP

 

The city, state and ZIP Code of the entity.

 

Email Address

 

The email address of the contact person listed. Note: This will be the primary

 

 

 

method of communication.

 

Provider Name

 

List each provider for whom Online Inquiry Services access is being requested.

 

PTAN

 

(If additional room is needed, please attach a list of PTANs and NPIs)

 

NPI

 

 

 

Action Requested:

 

Check only one request for the individuals listed below:

 

Requesting New ID

 

Requesting New ID – Check this box if you are requesting an ID for an

 

Delete Existing ID

 

 

 

individual who has never had a DDE ID established for them by either

 

Delete PTAN(s)

 

 

 

Palmetto GBA or another Medicare contractor.

 

from Existing ID

 

 

 

Delete Existing ID – Check this box to delete the DDE ID assigned to the

 

Add PTAN(s) to

 

 

 

individual.

 

Existing ID

 

 

 

Delete PTAN(s) from Existing ID – Check this box to remove the

 

Reinstate/Reactivate

 

 

Existing ID

 

Providers listed on this form from the DDE ID assigned to the individual

 

 

listed.

 

 

 

 

 

 

Add PTAN(s) to Existing ID – Check this box to add the Providers listed

 

 

 

on this form to the DDE ID assigned to the individual listed.

 

 

 

Reinstate/Reactivate Existing ID - Check this box if you are requesting to

 

 

 

Reinstate/Reactivate a DDE ID that was established for the individual listed

 

 

 

either by Palmetto GBA or another Medicare contractor. NOTE: Please

 

 

 

make sure to include the PTAN(s) to be linked to the

 

 

 

Reinstate/Reactivated ID.

DDE Enrollment Form

This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services (CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.

 

Palmetto GBA

Jurisdiction 11 EDI Enrollment Packet

 

 

 

 

Form Field Name

Instructions for Field Completion

 

First Name

Please list the name of the person for whom the DDE ID is or will be

 

MI

assigned by Palmetto GBA. Full name including middle initial is required

 

Last Name

before a DDE ID can be assigned.

 

Existing ID/PIN

Each person accessing Online Inquiry Services must have his or her own

 

Email Address

unique ID. If the individual was previously assigned an ID, please include

 

 

 

 

that ID in the Existing ID field and the personal identification number (PIN).

 

 

NOTE: We cannot accept a “generic” name for a DDE Online Inquiry

 

 

Services ID.

 

 

Email-address of the individual.

Submit completed DDE Online Inquiry Services Form via mail or fax to:

Mailing address:

Fax number:

Palmetto GBA

EDI Part A: 803-699-2429

J11 EDI Operations, AG-420

EDI Part B: 803-699-2430

PO Box 100145

 

Columbia SC 29202-3145

 

Important Note: As part of our security recertification process, providers are required to certify user access biannually. If this recertification information is not verified and returned, access will be terminated.

DDE Enrollment Form

This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services (CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.

Palmetto GBAJurisdiction 11 EDI Enrollment Packet

DDE Enrollment Form

Line of Business Information:

SC Part A

NC Part A

 

HHH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Submitter ID (if available):

 

 

 

 

 

 

Date:

Entity Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Entity:

Individual Provider

Corporate Office

Vendor

Billing Service

 

Clearinghouse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EDI Contact Person:

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

Fax:

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

State:

 

 

 

ZIP:

Email Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Note: Email will be the primary method of communication.

List all Medicare Provider Transaction and Access Numbers (PTANs) and National Provider Identifiers (NPIs) (if additional room is needed, please attach a list of PTANs and NPIs)

 

Provider Name

 

PTAN

 

NPI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide a list of individuals requiring access (full name including middle initial is required before an ID can be assigned). NOTE: We cannot accept a “generic” name for DDE User IDs. The person(s) whose name is given will be assigned a DDE User ID and that person(s) will be responsible for all activities in the system under that DDE User ID. Any changes related to the assigned DDE User ID should be communicated to Palmetto GBA by contacting the Technology Support Center toll-free at 855-696-0705.

Action Requested :

 

Requesting New ID – User has never had a DDE ID from Palmetto GBA or another contractor

 

 

Delete Existing ID

 

 

 

Delete PTAN(s) from Existing ID

 

 

Add PTAN(s) to Existing ID

 

 

 

Reinstate/Reactivate Existing ID and add PTAN(s)

 

 

 

 

 

 

 

 

 

 

 

 

First Name

 

MI

 

Last Name

 

Existing ID/PIN

 

Email

 

 

 

 

 

 

 

 

 

 

Submit completed DDE Online Inquiry Services Form via mail or fax to:

Mailing address:

Fax number:

Palmetto GBA

EDI Part A: 803-699-2429

J11 EDI Operations, AG-420

EDI Part B: 803-699-2430

PO Box 100145

 

Columbia SC 29202-3145

 

Note: Please retain a copy of this form for your records.

DDE Enrollment Form

This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services (CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.

Palmetto GBA

Jurisdiction 11 EDI Enrollment Packet

DDE Enrollment Form

Action Requested :

 

Requesting New ID – User has never had a DDE ID from Palmetto GBA or another contractor

 

 

Delete Existing ID

 

 

 

Delete PTAN(s) from Existing ID

 

 

Add PTAN(s) to Existing ID

 

 

 

Reinstate/Reactivate Existing ID and add PTAN(s)

 

 

 

 

 

 

 

 

 

 

 

 

First Name

 

MI

 

Last Name

 

Existing ID/PIN

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Action Requested :

 

Requesting New ID – User has never had a DDE ID from Palmetto GBA or another contractor

 

 

Delete Existing ID

 

 

 

Delete PTAN(s) from Existing ID

 

 

Add PTAN(s) to Existing ID

 

 

 

Reinstate/Reactivate Existing ID and add PTAN(s)

 

 

 

 

 

 

 

 

 

 

 

 

First Name

 

MI

 

Last Name

 

Existing ID/PIN

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Action Requested :

 

Requesting New ID – User has never had a DDE ID from Palmetto GBA or another contractor

 

 

Delete Existing ID

 

 

 

Delete PTAN(s) from Existing ID

 

 

Add PTAN(s) to Existing ID

 

 

 

Reinstate/Reactivate Existing ID and add PTAN(s)

 

 

 

 

 

 

 

 

 

 

 

 

First Name

 

MI

 

Last Name

 

Existing ID/PIN

 

Email

 

 

 

 

 

 

 

 

 

 

Action Requested :

 

Requesting New ID – User has never had a DDE ID from Palmetto GBA or another contractor

 

 

Delete Existing ID

 

 

 

Delete PTAN(s) from Existing ID

 

 

Add PTAN(s) to Existing ID

 

 

 

Reinstate/Reactivate Existing ID and add PTAN(s)

 

 

 

 

 

 

 

 

 

 

 

 

First Name

 

MI

 

Last Name

 

Existing ID/PIN

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Action Requested :

 

Requesting New ID – User has never had a DDE ID from Palmetto GBA or another contractor

 

 

Delete Existing ID

 

 

 

Delete PTAN(s) from Existing ID

 

 

Add PTAN(s) to Existing ID

 

 

 

Reinstate/Reactivate Existing ID and add PTAN(s)

 

 

 

 

 

 

 

 

 

 

 

 

First Name

 

MI

 

Last Name

 

Existing ID/PIN

 

Email

 

 

 

 

 

 

 

 

 

 

Submit completed DDE Online Inquiry Services Form via mail or fax to:

Mailing address:

Fax number:

Palmetto GBA

EDI Part A: 803-699-2429

J11 EDI Operations, AG-420

EDI Part B: 803-699-2430

PO Box 100145

 

Columbia SC 29202-3145

 

Note: Please retain a copy of this form for your records.

DDE Enrollment Form

This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services (CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.

Palmetto GBA

Jurisdiction 11 EDI Enrollment Packet

J11 EDI Application Form Instructions

The purpose of the J11 EDI Application Form is to enroll providers, software vendors, clearinghouses and billing services as electronic submitters and recipients of electronic claims data. It is important that instructions are followed and that all required information is completed. Incomplete forms will be returned to the applicant, thus delaying processing.

Please retain a copy of this completed form for your records.

You must submit a completed EDI Application Form when submitting additional EDI forms.

The field descriptions listed below will aid in completing the form properly. There are two (2) pages to the application form. The first page is required and the second page should be used only if additional providers need to be listed.

 

Form Field Name

 

Instructions for Field Completion

 

Line of Business

 

Indicate the line of business and state for which you will be transmitting. Select

 

Information

 

all that apply to this request.

 

Action Requested:

 

Indicate the action to be taken on the application form.

 

Add Provider(s)

 

• If you need to add additional providers to an existing submitter ID, check Add

 

Change/Update

 

Provider(s).

 

Submitter

• If you request to change or update information about the Submitter, check

 

Information

 

Change/Update Submitter Information and be sure to include your current

 

Delete

 

 

 

Submitter ID.

 

 

 

 

Apply for New

• If you request to delete a provider(s), check Delete and be sure to include your

 

Submitter ID

 

submitter ID.

 

Apply for New

 

 

• If you are a new applicant, check Apply for New Submitter ID.

 

Receiver ID

 

 

• If you are a new applicant, check Apply for New Receiver ID (This option is

 

 

 

 

 

 

available for North Carolina Part A and Virginia Part B only).

 

Submitter ID

 

The submitter ID is used by the submitter to communicate with Palmetto GBA

 

 

 

electronically. For new applicants, this field should be left blank, as Palmetto

 

 

 

GBA will assign this ID if requested. For changes or additions, enter the

 

 

 

Submitter ID to which the change/additions should be applied.

 

Date

 

Please enter the date the application is completed.

 

Receiver ID

 

This option is available for North Carolina Part A and Virginia Part B

 

 

 

only. The receiver ID is used by the remittance receiver to download

 

 

 

remittance advices/notices via Palmetto GBA electronically. For new

 

 

 

applicants, this field should be left blank, as Palmetto GBA will assign this ID

 

 

 

if requested. For changes or additions, enter the Receiver ID to which the

 

 

 

change/additions should be applied.

 

Submitter Name

 

Enter the name of the entity (provider, software vendor, billing service or

 

 

 

clearinghouse) that will actually be communicating electronically with

 

 

 

Palmetto GBA.

 

Owner Name(s)

 

Enter the name of the individual(s) who owns the entity listed above.

 

Type of Submitter

 

Check the appropriate box.

 

EDI Contact Person

 

The name of the submitter’s primary EDI contact. This is the person Palmetto

 

 

 

GBA will contact if there are questions regarding the application or future

 

 

 

questions about their communications.

 

Phone

 

The area code and phone number of the Contact Person listed.

 

Fax

 

The fax number for this location.

 

Address

 

The mailing address of the submitter.

 

City, State, ZIP

 

The city, state and ZIP Code of the submitter.

EDI Application Form

This information is intended as reference to be used in addition to information from the Centers for Medicare & Medicaid Services (CMS). Use or disclosure of the data contained on this page is subject to restriction by Palmetto GBA.

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