DMERC EDI ENROLLMENT PACKET

Transcription

1 MEDICARE Part A Intermediary Part B Carrier DME Regional Carrier DMERC EDI ENROLLMENT PACKET Attention: Please Read Before Completing Paperwork There are two addresses for the submission of paperwork. Whether or not you are sending a check (or money order) determines to which address you should send all your paperwork. If you are sending a check or money order, send all paperwork to: Electronic Data Interchange Medicare Finance, AG-215 PO Box Columbia, SC If you are not sending money at this time, send all paperwork to: Medicare DMERC EDI, AG-420 PO Box Columbia, SC IMPORTANT NOTE: Orders containing a check or money order will not be processed if sent to the incorrect address! Thank you for your interest in Electronic Media Claims! Government Programs Electronic Data Interchange (EDI) Operations, AG-420 Post Office Box ? Columbia, South Carolina? A CMS Contracted Intermediary and Carrier

2 MEDICARE Part A Intermediary Part B Carrier DME Regional Carrier USING ELECTRONIC DATA INTERCHANGE SERVICES has prepared this packet for Region C s submitters of electronic claims. It contains forms and explanations for each of the services offered by our Electronic Data Interchange (EDI) department. For further information regarding any of this material, please call the EDI Technology Support Center toll-free at If you are a supplier waiting for a number from the National Supplier Clearinghouse (NSC), please wait! You must be assigned your supplier number before completing any of the paperwork below. Call the NSC at (803) to apply for this ten-digit number that identifies providers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). You will find forms in the following order in your packet; explanations of each are provided below. Please allow a processing time of approximately 6 to 8 weeks from the date you mail the form. Remember cannot process incomplete applications or agreements! Please fill in all appropriate blanks and make all checks payable to. Please allow the full 8 weeks before calling to check on your paperwork status. 1. Submitter ID Application Form 2. Electronic Data Interchange (EDI) Enrollment Agreement 3. Software Order Form 4. AT&T Global Network Services Order Form & Statement of Understanding for Charges 5. Claims Status Inquiry (CSI) Addenda # s 1 & 2 6. Electronic Remittance Notices (ERNs) Addenda # s 1 & 2 7. GPNet Communications Gateway 1. SUBMITTER ID APPLICATION FORM A Submitter ID number is a unique, nine-digit number that identifies electronic submitters. If another DMERC has already assigned a submitter number to your company, you should still complete this form. We will not assign another Submitter ID number, but will provide you with the passwords and logons you need to connect to our system. If you use a billing service to submit your claims, do not complete this form. Billing services, not their customers, need electronic submitter numbers. The Application Form provides three options for Telecommunications (Modem Submission). Direct Dial Asynchronous. CONNECT:Direct (Network Data Mover, NDM), available for file transmission and report retrieval. Submitters selecting NDM as their mode of communication can find specifications in the GPNet Communications Manual. This manual is available by visiting the Web site at File Transfer Protocol (FTP) is a direct dial up connection for file transmission. Additional information and specifications can be found in the GPNet Communications Manual. This manual is available by visiting the Web site at Begin testing once you have software and a Submitter ID number. You must submit a minimum of 20 claims (they do not have to be real or current claims) and you must score 95% or better to get certified for live claims production. Do not notify before you test just start! DMERC Enrollment Letter (Page 1 of 5) October 2003

3 Test cycles run once a day, Monday through Saturday, at 8:00 p.m. EST. Error reports are available one business day after each cycle. Submitters should retrieve their reports, correct any errors, and re-submit the claims until a single file of 20 claims is 95% error free. Once that occurs, an EDI representative will notify you within 24 hours when to begin submitting production claims. Production cycles run once a day, Monday through Friday, at 7:00 p.m. EST. Edit reports are available the following morning. These reports are critical to your daily operations; they indicate whether a claim was accepted into s system for processing. If the claim was rejected, correct any errors and resubmit it. If it was accepted, the Claim Control Number (CCN) on the edit report is its permanent identification in our system. 2. EDI ENROLLMENT AGREEMENT Every supplier who submits electronic claims to, whether directly or through a billing service/clearinghouse, must complete this agreement. Please indicate your NSC supplier number so the contract may be logged correctly. If you are a corporation whose branch offices have individual supplier numbers, please list those numbers on the attached addendum for corporate offices or complete this addendum online at Billing services should not complete the EDI Enrollment Agreement unless they are a DMEPOS supplier as well as a billing agency. The term provider on the EDI Enrollment Agreement refers to the supplier of the DMEPOS service. While provider is a generic term used in Medicare Part A and Part B, the term supplier is more commonly used in DMERC. EDI cannot process any of the enclosed forms for a supplier without a completed EDI Enrollment Agreement on file. Faxes of signatures and copies of signatures are not acceptable each EDI Enrollment Agreement must include an original signature. 3. SOFTWARE ORDER FORM offers PC-ACE Pro32, a claims-entry software that allows suppliers to enter their claims and certificates of medical necessity. Pro32 does not integrate into office systems such as accounts receivable, inventory or billing. Use the software order form, which includes explanations of available software, to enroll in CSI and ERNs, and to order software from. Minimum system requirements for Pro32 include: Pentium 133 MHz processor (Pentium II-350 for larger claim volume) 64 MB system memory (128 MB recommended) CD-ROM drive SVGA monitor resolution (800 x 600)* Windows 95, 98, 2000, Me, XP or NT 4.0 operating system Adobe Acrobat Reader Version 4.0 or later (for overlaid claim printing) This free software can be downloaded from the Adobe website ( 4. AT&T ORDER FORM FOR DIAL ACCESS TO PALMETTO GBA AT&T Global Network Services is the AT&T data network that uses leased data lines. Its advantages are cleaner, more trouble-free communications because dedicated data lines are used instead of ordinary phone lines. There is a $3.00 per month account fee plus line charges. The trade-off for the monthly fee is lower line charges, less than $6.00 per prime-time hour. All suppliers ordering Passport must complete the AT&T Global Network Services Order Form for Dial Access to and the Statement of Understanding for Charges forms and return it with the Software Order Form. DMERC Enrollment Letter (Page 2 of 5) October 2003

4 5. CLAIMS STATUS INQUIRY (CSI) CSI is an on-line transaction enabling electronic submitters to access a six-month history of their pending and resolved claims. It displays data for both assigned and non-assigned claims; however, CSI displays only minimal pending information and no payment amounts for non-assigned claims. CSI forms, including Addenda, are available to complete on-line at Just follow these links: Providers Electronic Data Interchange (EDI), EDI Enrollment, DMERC and finally DMERC Online CSI and ERN Enrollment Form. CSI allows you to view the total dollar amount pending on the payment floor, the dates and amounts of your last three payments, and claims which have been crossed over to secondary insurers. You can also query beneficiary eligibility information. offers Passport software to perform CSI. All you need is a PC with Windows 95 or higher and a modem to take advantage of this feature. Your software vendor may also offer CSI capabilities; suggests that you check with your vendor before ordering software. In order to have CSI and/or ERN access, you must be submitting claims electronically for the provider and/or supplier. EDI Operations will verify claims submission and provider and/or supplier authorization. If you wish to enroll for CSI without ordering software, simply check the appropriate box on the Software Order Form. The daily on-line option allows you to dial our system 22 hours per day, six day a week. places the weekly report for retrieval in your electronic mailbox. It is a summary of the same information found on the on-line inquiry. Weekly reports are not available to submitters who use software. They must choose the daily on-line option. Some software vendors specifically write scripts to produce the weekly report. Other applicable CSI forms are: a. CSI Addendum #1 for Billing Services and Clearinghouses. This form should be completed and signed by suppliers who authorize billing services/clearinghouses to perform CSI for them. The name and electronic submitter number of the billing service are the only two pieces of information on this form that do not relate to the supplier s company. This form is available to complete online. b. CSI Addendum #2 for Corporate Offices. This form is for suppliers only. Corporate offices that have branches with individual NSC supplier numbers should complete this addendum; it gives you CSI access for satellite offices. This form is available to complete online. 6. ELECTRONIC REMITTANCE NOTICES (ERNS) ERNs, downloaded from your electronic mailbox, duplicate the information contained on paper remittances. ERN forms, including addenda, are available to complete online at Just follow these links: Providers Electronic Data Interchange (EDI), EDI Enrollment, DMERC and finally DMERC Online CSI and ERN Enrollment Form. In order to have CSI and/or ERN access, you must be submitting claims electronically for the provider and/or supplier. EDI Operations will verify claims submission and provider and/or supplier authorization. To utilize ERNs, submitters need to contact their vendor. If you wish to enroll for ERNs, simply mark the appropriate box on the Software Order Form. Other applicable forms for ERNs are: a. ERN Addendum #1 for Corporate Offices. This form is for suppliers only. Corporate offices that have branches with individual NSC supplier numbers should complete this addendum. It allows you to retrieve ERNs for satellite offices. This form is available to complete online. DMERC Enrollment Letter (Page 3 of 5) October 2003

5 b. ERN Addendum #2 for Billing Services and Clearinghouses. This form should be completed and signed by suppliers who authorize billing services/clearinghouses to retrieve ERNs for them. The name and electronic submitter number of the billing service are the only two pieces of information on this form that do not relate to the supplier s company. This form is available to complete online. 7. GPNET COMMUNICATIONS GATEWAY GPNet is the new HIPAA-compliant EDI gateway used by. The GPNet communication platform supports asynchronous telecommunications up to 56K bps. It will support numerous asynchronous telecommunication protocols, including Kermit, Xmodem (Check Sum), Ymodem (Batch) and Zmodem. Most off-the-shelf communication software will support one or all of these protocols. You may select any of the protocols indicated; however, Zmodem is recommended based on its speed and reliability. The asynchronous user s modem should be compatible with 56K, V bps or V bps. In addition, we encourage the use of PKZIP compatible compression software. GPNet is defaulted to send uncompressed files; therefore, if you wish to receive all of your files in a compressed format, contact the Technology Support Center for maintenance to the database. Note: In addition to modem file transfers, GPNet also supports file transfers via File Transfer Protocol (FTP) and CONNECT:Direct (also known as Network Data Mover or NDM). The GPNet platform is available 24 hours a day, seven days a week. The real time editing system is down from 11:30 p.m. to 5:00 a.m. EST. If the editing system is not available, you may still upload a file to GPNet. As soon as the editing system resumes processing, files in GPNet will be edited. The response files will be built and loaded into your mailbox for retrieval at your convenience within 24 hours. Response files, which indicate your Medicare edits, are available in either a file format or a report format. GPNet defaults to the report format. If you wish to receive the response file in the file format, contact the Technology Support Center at The following asynchronous communication packages are currently successfully transmitting to GPNet: ProComm Plus; Release 2.03 (DOS) ProComm Plus; Release 2.11 (Windows) Crosstalk; Release 2.2 (Windows) QuickLink2; Release (Windows) PC Anywhere; Release 5.0 (DOS) The settings you should verify are: Terminal Emulation - VT100 Parity - NONE PC Anywhere; Release 2.0 (Windows) Term; Release 6.1, 6.2, and 6.3 Mlink; Release 6.07 HyperTerminal; Windows 95, 98, and NT Data Bits 8 Stop Bits - 1 For Zmodem, ensure that both sender and receiver crash recovery is OFF or set to OVERWRITE. When downloading a file, this setting will determine whether Zmodem overwrites an existing file of the same name. Since the response file name will be repeated, we recommend that the downloaded files be renamed or moved to another directory immediately to avoid losing or overwriting a file. Notice To Billing Services If you will be submitting claims for more than one supplier and you do not have a financial relationship with those suppliers (other than a billing relationship), you will be classified as a billing service. Each supplier must complete an EDI Enrollment Agreement. Also, if you will be performing Claim Status Inquiry or Electronic Remittance Notice functions for the supplier, an Addendum to CSI and ERN for Billing Services must be DMERC Enrollment Letter (Page 4 of 5) October 2003

6 completed and mailed to. In order to have CSI and/or ERN access, you must be submitting claims electronically for the provider and/or supplier. EDI Operations will verify claims submission and provider and/or supplier authorization. Faxes of signatures or copies of signatures are not acceptable. The following form is available, and can be completed, online at DMERC Online CSI and ERN Enrollment Form Change of Ownership, Address or Phone Number When you have a change of ownership, you must notify by calling the Technology Support Center toll-free at If the change of ownership results in different supplier numbers(s), please inform the Technology Support Center when you call. You must also notify when you have a change of address or phone number. Please send this information to us on your company letterhead and include your Submitter ID and Supplier Number, if applicable, to: Medicare DMERC EDI, AG-420 PO Box Columbia, SC DMERC Enrollment Letter (Page 5 of 5) October 2003

7 SUBMITTER ID APPLICATION FORM Company Name: Contact: Mailing Address: Phone Number: Fax #: Address: NSC Supplier #: Submitter ID #: (if assigned by another DMERC) Status(es): Supplier Billing Service Clearinghouse Software Vendor Software Vendor if other than : Software Vendor Security ID: (provided by vendor) Telecommunications (Modem Submission) Communications Protocol GPNet Palmetto Direct-Dial Asynchronous Dial-Up FTP CONNECT:Direct (NDM) Submit completed form to: Medicare DMERC EDI, AG-420 PO Box Columbia, SC DMERC Submitter ID Application Form October 2003

8 ELECTRONIC DATA INTERCHANGE (EDI) ENROLLMENT AGREEMENT The provider agrees to the following provisions for submitting Medicare claims electronically to CMS or to CMS s contractors. A. The Provider Agrees: 1. That it will be responsible for all Medicare claims submitted to CMS by itself, its employees, or its agents. 2. 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. 3. That it will submit claims only on behalf of those Medicare beneficiaries who have given their written authorization to do so, and to certify that required beneficiary signatures, or legally authorized signatures on behalf of beneficiaries, are on file. 4. That it will ensure that every electronic entry can be readily associated and identified with an original source document. Each source document must reflect the following information: Beneficiary s name Beneficiary s health insurance claim number Date(s) of service Diagnosis/nature of illness Procedure/service performed 5. That the Secretary of Health and Human Services and 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 authorization and 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. 6. 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. 7. That it will submit claims that are accurate, complete, and truthful. 8. That it will retain all original source documentation and medical records pertaining to any such particular Medicare claim for a period of at least 6 years, 3 months after the bill is paid. Electronic Data Interchange Enrollment Agreement (Page 1 of 3) October 2003

9 9. That it will affix the CMS-assigned unique identifier number of the provider on each claim electronically transmitted to the contractor. 10. That the CMS-assigned unique identifier number constitutes the provider s legal electronic signature and constitutes an assurance by the provider that services were performed as billed. 11. That it will use sufficient security procedures to ensure that all transmissions of documents are authorized and protect all beneficiary-specific data from improper access. 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 it will establish and maintain procedures and controls so that information concerning Medicare beneficiaries, or any information obtained from CMS or its contractors, shall not be used by agents, officers, or employees of the billing service except as provided by the contractor (in accordance with 1106(a) of the Act). 14. That it will research and correct claim discrepancies. 15. That it will notify the contractor or CMS within 2 business days if any transmitted data are received in an unintelligible or garbled form. B. The Centers for Medicare & Medicaid Services 1. Transmit to the provider an acknowledgment of claim receipt. 2. Affix the intermediary/carrier 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 s 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, indirectly, or by agreement. 6. Notify the provider within 2 business days if any transmitted data are received in an unintelligible or garbled form. Electronic Data Interchange Enrollment Agreement (Page 2 of 3) October 2003

10 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 are submitted to CMS or the contractor. Either party may terminate this arrangement by giving the other party (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/Supplier Name: Address: Phone Number: City/State/Zip: By (Print Name): Authorized Signature: Title: Date: Medicare Provider/Supplier Number: Complete and mail this form with original signature to: Medicare DMERC EDI, AG-420 PO Box Columbia, SC Electronic Data Interchange Enrollment Agreement (Page 3 of 3) October 2003

11 ADDENDUM TO EDI ENROLLMENT AGREEMENT FOR CORPORATE OFFICES The following supplier numbers are covered under our attached Electronic Data Interchange (EDI) Enrollment Agreement and are assigned to satellite locations of our corporate office. Provider Name By: (Print Name And Title) Address Authorized Signature City/State/Zip Date Supplier Numbers of Satellite Locations Submit completed form to: Medicare DMERC EDI, AG-420 PO Box Columbia, SC DMERC EDI Addendum for Corporate Offices October 2003

12 PALMETTO GBA SOFTWARE INFORMATION 1. Claims Entry Software PC-ACE Pro32: Pro32 is s Windows-based claims entry software. You can enter claims and CMNs in Pro32. This software will not integrate into accounts receivable, inventory or other office programs. The $25.00 charge represents the initial annual fee for Pro32. There is an ongoing $25.00 annual distribution fee for Pro32. System Requirements: See the PC-ACE Pro32 section of this packet for a complete listing of requirements. Not for installation on a network! 2. Claims Status Inquiry Passport software is used to perform Claim Status Inquiry (CSI) functions. This software cannot be used to transfer files to. In order to have CSI and/or ERN access, you must be submitting claims electronically for the provider and/or supplier. EDI Operations will verify claims submission and provider and/or supplier authorization. Passport is the only communications software that can be used to access CSI. System Requirements: IBM or compatible PC w/floppy disk drive; 1.5 MB of hard disk space w/ 512K memory; Windows 95 or higher; Hayes or compatible fax/data modem w/at least 2400, 9600 or 14.4 BPS. Not for installation under a DOS Shell, or on a network! a. Passport: Passport software lets you access the Claim Status Inquiry functions. You must complete the AT&T Order Form for Dial Access to Applications when you order Passport. b. Vendor Software Activation: Please check with your software vendor to determine if their software is capable of performing CSI functions. 3. Electronic Remittance Notices In order to have CSI and/or ERN access, you must be submitting claims electronically for the provider and/or supplier. EDI Operations will verify claims submission and provider and/or supplier authorization. Please check with your software vendor to determine if your software is capable of performing ERN functions. ERN ANSI Version: X A1 DMERC Software Order Form Instructions October 2003

13 PALMETTO GBA EDI SOFTWARE ORDER FORM Computer Operating System (Must Complete): Company Name: Contact: Mailing Address: Submitter ID #: Phone #: (If already assigned) NSC Supplier #: Fax #: Address: Software vendor if other than : Software Vendor Security ID: (provided by vendor) THE ORDER WILL NOT BE PROCESSED UNLESS THE SECTION ABOVE IS COMPLETED. To order software from, please check appropriate box(es) and add totals. 1. Claims Entry Software Cost Total PC-ACE Pro32 (available on CD only) $ Claims Status Inquiry (CSI) Passport $30.00 Vendor Software Activation N/A 3. Electronic Remittance Notices (ERNs) Vendor Software Activation ANSI 4010A1 N/A Grand Total Please make check or money order (if applicable) payable to and mail one of the two following addresses. Software Purchases (Payment Required): EDI Operations Medicare Finance, AG-215 PO Box Columbia, SC Vendor Software Activation Only (No Cost Incurred): Medicare DMERC EDI, AG-420 PO Box Columbia, SC DMERC Software Order Form October 2003

14 AT&T GLOBAL NETWORK SERVICES CHARGES $3.00 per month for access to the network. (This amount is charged whether you access the network or not.) $5.66 per hour of prime-time usage. (8:00 a.m. to 8:00 p.m. EST) $2.83 per hour of non prime-time usage. (8:00 p.m. to 8:00 a.m. EST) $7.75 additional per hour when using the national 800 number. This $7.75 per hour is added to the $5.66 or $2.83 per hour depending on what time you are communicating. The national 800 number is used when a local least cost number is not available. Time is billed by the minute. Bills are received from AT&T Global Network Services. AT&T Global Network Services Charges October 2003

15 AT&T Global Network Services Order Form for Dial Access to Palmetto Government Benefits Administrators (GBA) Applications By completing this form and returning it to AT&T, you will be provided a User Identification on the AT&T Global Network with which you can access applications. Each month AT&T will send you an invoice on behalf of for the charges incurred by this User Identification during the preceding month. You may send payment for these charges directly to AT&T on s behalf. Please complete the following information: Name Street Address Street Address City State Zip Code County Inside City Limits? (Y or N) (Area Code) Phone Number If you are tax exempt, mark this box and attach a copy of your certificate. (Your exemption will not be processed without a copy of the certificate). Completed by: Signature Date Title For AT&T Use Only

16 STATEMENT OF UNDERSTANDING FOR CHARGES I, the undersigned, understand that I will receive a User ID for each copy of software that is ordered. I also understand that for each User ID I order (whether or not it is used), there is a charge of $3.00 per month in addition to usage charges. Each User ID will be invoiced separately by AT&T Global Network Services at the beginning of each month. All stubs must be returned with the payment to AT&T Global Network Services. Authorized Signature Company Name Date Statement of Understanding for Charges October 2003

17 ADDENDUM TO CSI ENROLLMENT FORM FOR CORPORATE HEADQUARTERS (This form may be completed online at The companies listed on the reverse side of this addendum are branches/satellites of our corporate headquarters that will in turn be performing Claims Status Inquiry for them. I am authorized to endorse this addendum on behalf of my company, and acknowledge that it is my responsibility to notify in writing if I wish to make revisions to this authorization. NSC Supplier Number Submitter Number Corporate HQ Entity Name Name /Title (please print) Address Signature Date City/State/Zip Phone Submit completed form to: Medicare DMERC EDI, AG-420 PO Box Columbia, SC DMERC CSI Addendum for Corporate Headquarters (Page 1 of 2) October 2003

18 Supplier locations for which corporate headquarters will be performing CSI: Supplier # Business Name and Location DMERC CSI Addendum for Corporate Headquarters (Page 2 of 2) October 2003

19 ADDENDUM TO CSI ENROLLMENT FORM FOR BILLING SERVICES AND CLEARINGHOUSES (This form may be completed online at I hereby authorize to perform any and all functions of Claim Status BILLING SVC./CLEARINGHOUSE Inquiry (CSI) on my behalf. I understand that CSI allows access to information on both pending and processed DMEPOS claims. I am authorized to endorse this addendum on behalf of my company, and acknowledge that it is my responsibility to notify Palmetto EDI in writing if I wish to revoke this authorization. NSC Supplier Number Submitter Number (Billing Svc/Clearinghouse) Company Name Name /Title (Please Print) Address Signature Date City/State/Zip Phone Submit completed form to: Medicare DMERC EDI, AG-420 PO Box Columbia, SC DMERC CSI Addendum for Billing Services and Clearinghouses October 2003

20 ADDENDUM TO ERN ENROLLMENT FORM FOR CORPORATE HEADQUARTERS (This form may be completed online at The companies listed on the reverse side of this addendum are branches/satellites of our corporate headquarters that will be receiving Electronic Remittance Notices (ERNs) for them. I am authorized to endorse this addendum on behalf of my company, and I acknowledge that it is my responsibility to notify Palmetto EDI in writing if I wish to make revisions to this authorization. NSC Supplier Number Submitter Number Corporate HQ Name Name /Title (please print) Address Signature Date City/State/Zip Phone Submit completed form to: Medicare DMERC EDI, AG-420 PO Box Columbia, SC DMERC ERN Addendum for Corporate Headquarters (Page 1 of 2) October 2003

21 Our corporate headquarters will be receiving ERNs for these satellite offices: NSC Supplier # Business Name and Location DMERC ERN Addendum for Corporate Headquarters (Page 2 of 2) October 2003

22 ADDENDUM TO ERN ENROLLMENT FORM FOR BILLING SERVICES AND CLEARINGHOUSES (This form may be completed online at I hereby authorize to receive Electronic Remittance Notices (ERNs) BILLING SVC./CLEARINGHOUSE on my behalf. I understand that ERNs contain payment information concerning my processed DMEPOS claims. I am authorized to endorse this addendum on behalf of my company, and I acknowledge that it is my responsibility to notify Palmetto EDI in writing if I wish to revoke this authorization. NSC Supplier Number Submitter Number (Billing Svc/Clearinghouse) Company Name Name /Title (please print) Address Signature Date City/State/Zip Phone Submit completed form to: Medicare DMERC EDI, AG-420 PO Box Columbia, SC DMERC ERN Addendum for Billing Services and Clearinghouses October 2003