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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
	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
	Delete Existing ID		individual who has never had a DDE ID established for them by either
	Delete PTAN(s)
	Delete PTAN(s)		Palmetto GBA or another Medicare contractor.
	from Existing ID		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
	Add PTAN(s) to		individual.
	Existing ID		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
	Existing ID		listed.
			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

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

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

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

Palmetto GBA			Jurisdiction 11 EDI Enrollment Packet

	Form Field Name		Instructions for Field Completion
	Submitter Email		The email address of the contact person listed. Note: This will be the primary
	Address		method of communication. This email address will also receive EDI
			Tracking Numbers used to monitor the processing status of your EDI
			forms.
	Claim Submission		There are four available modes of communication modes that can be used for
	Mode of		claim submission. Check only one.
	Communication		• GPNet: Asynchronous communication with the Gateway
		• Connect Direct – NDM: Network Data Mover
		• Dial-up FTP: File transfer protocol transmission via GPNet – not Internet.
			• Leased FTP: File transfer protocol transmission via the Internet or
			Network-based connection.
	Report / Electronic		Check only one mode of communication that will be used.
	Remittance Retrieval		• GPNet Asynchronous should be checked for asynchronous communication
	Mode of		with Palmetto GBA’s GPNet.
	Communication		• CONNECT:Direct (NDM) should be checked for report retrieval via
			GPNet
			• Dial-up FTP should be checked for file transfer protocol report retrieval via
			GPNet.
			• Leased FTP: File transfer protocol transmission via the Internet or
			Network-based connection.
	Report Response		Check the format in which you will receive GPNet Claims Acceptance
	Format		Responses.
	Data Compression		To receive files compressed for faster transmission, indicate which data
			compression utility you support.
	Name of Software		Indicate the name of the software vendor you are using, if applicable.
	Vendor
	Vendor ID		Include Vendor ID number if known.
	Providers For Whom Submitter Will Be Communicating Electronically:
	Provider Name		List each provider whose bills will be submitted by the submitter named above.
			(If additional providers need to be listed, indicate each one separately on the
			Multiple Providers List form.) This name must match the name submitted on
			the CMS 855 Medicare Enrollment Application.
	Tax ID		Enter the Tax Identification Number for the provider.
	Provider Email		Indicate the email address for the provider listed above. This email address will
	address		be the primary source of communications regarding approval of changes to
			their EDI options.
	Provider Number		Indicate the Medicare Provider Number for each provider listed.
	NPI		Include the National Provider Identifier (NPI).
	Enrollment Form		Indicate “Y” for Yes or “N” for No. A properly executed 3-page EDI
	Attached:		Enrollment Agreement must be attached for each provider listed. Palmetto
	Y/N		GBA will not activate a submitter ID for any provider without a properly
			executed enrollment form.
	Provider Authorization		Indicate “Y” for Yes or “N” for No. A provider authorization form is required
	Form Attached:		to authorize a clearinghouse and/or billing service as an electronic submitter
	Y/N		and recipient of electronic claims data.
	Submit Claims		Check this box if the application is for the submitter to submit claims
			electronically for this provider.
	Receive Reports		Check this box if the submitter wants to receive response reports electronically
			for the provider indicated.
	Receive Electronic		Check this box if the submitter wants to receive Electronic Remittances for the
	Remittances		provider indicated. Provider must be submitting claims electronically to receive
			Electronic Remittances.
	Online Inquiry		Check this box if the submitter currently uses or plans to use the Online Inquiry
			Services (DDE). Note: The Online Inquiry Form must be submitted if this
			option is selected. (Part A only)
			EDI Application Form

Palmetto GBA

Jurisdiction 11 EDI Enrollment Packet

Once you have completed the application form, please retain a copy for your records and mail the original to the address listed below. Your Submitter ID and software (if applicable) will be processed within 20 business days of receipt of completed forms.

Completed forms must be mailed to us at	or faxed to
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

EDI Application Form

Palmetto GBAJurisdiction 11 EDI Enrollment Packet

J11 EDI Application

Line of Business Information:

SC Part A

NC Part A

HHH

SC Part B

NC Part B

VA Part B

WV Part B

Action Requested:

Add Provider(s)

Change / Update Submitter Information

Delete

Apply for New Submitter ID

Apply for New Receiver ID (NC Part A and VA Part B Only)

Submitter ID (if available):

Date:

Receiver ID:

Submitter Name:

Owner Name:

Type of Submitter:

Software Vendor

Billing Service

Provider

Clearinghouse

EDI Contact Person:

Phone:

Fax:

Address:

City:

State:

ZIP:

Submitter Email Address:

Note: Email will be the primary method of communication.

Claim Submission

GPNet Asynchronous

Dial-up FTP

Mode of Communication:

CONNECT: Direct (NDM)

Leased FTP

Report / Electronic Remittance

GPNet Asynchronous

Dial-up FTP

Retrieval Mode of Communication:

CONNECT: Direct (NDM)

Leased FTP

Report Response Format:

File

Report

Data Compression:

Uncompressed (GPNet Default)

PKZIP

UNIX-Compress

Name of Software Vendor:

Vendor Security ID:

Providers for Whom Submitter Will Be Transmitting

Provider Name:

Tax ID:

Provider Email Address:

Provider Number:

NPI:

Enrollment Form Attached?

Yes

Provider Authorization Form Attached?

Yes

Submit Claims

Receive Reports

Receive Electronic Remittances

Online Inquiry Services

Submit completed forms via mail to

or fax to

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

Notes: Please retain a copy for your records.

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

EDI Application Form

Palmetto GBA

Jurisdiction 11 EDI Enrollment Packet

J11 EDI Application

Multiple Providers List

Date: __________________________

PROVIDERS FOR WHOM SUBMITTER WILL BE TRANSMITTING:

Provider Name:

Tax ID:

Provider Email Address:

Provider Number:

NPI:

Enrollment Form Attached?

Yes

Provider Authorization Form Attached?

Yes

Submit Claims

Receive Reports

Receive Electronic Remittances

Online Inquiry Services

Provider Name:

Tax ID:

Provider Email Address:

Provider Number:

NPI:

Enrollment Form Attached?

Yes

Provider Authorization Form Attached?

Yes

Submit Claims

Receive Reports

Receive Electronic Remittances

Online Inquiry Services

Provider Name:

Tax ID:

Provider Email Address:

Provider Number:

NPI:

Enrollment Form Attached?

Yes

Provider Authorization Form Attached?

Yes

Submit Claims

Receive Reports

Receive Electronic Remittances

Online Inquiry Services

Provider Name:

Tax ID:

Provider Email Address:

Provider Number:

NPI:

Enrollment Form Attached?

Yes

Provider Authorization Form Attached?

Yes

Submit Claims

Receive Reports

Receive Electronic Remittances

Online Inquiry Services

Submit completed form to:	Palmetto GBA
	J11 EDI Operations, AG-420
	PO Box 100145
	Columbia SC 29202-3145

Notes: Please retain a copy for your records.

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

EDI Application Form

Question	Answer
Form Name	J11 Form
Form Length	9 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 15 sec
Other names	j11 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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