Palmetto GBA has prepared this packet for Ohio and West Virginia Medicare Part B 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 Palmetto GBA OH/WV EDI Technical Support Team at (866) 308-5438.
Please allow a processing time of approximately two weeks. Remember - Palmetto GBA cannot process incomplete applications or agreements.
To access the Ohio & West Virginia Part B EDI Enrollment Packet or individual forms, select the PDF link located at the bottom of this posting.
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EDI Form
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Form's PDF Name
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| Complete EDI Enrollment Packet |
EDI_Enroll_OHWVB_Pack.pdf |
| EDI Enrollment Agreement |
EDI_Enroll_OHWVB_Agree.pdf |
| EDI Application Form |
EDI_Enroll_OHWVB_Appl.pdf |
| Software Order Form |
EDI_Enroll_OHWVB_Software.pdf |
Please Note: The OH/WV Part B Electronic Funds Transfer (EFT) Registration Form is not included in the EDI Enrollment packet. The EFT Registration Form (PDF, 122 KB) is posted separately and must be mailed to Provider Enrollment.
The PDF copy of these forms is interactive. From your Adobe Reader, you can click on the form fields to type information directly onto the form. These forms also contain field tips to assist you. To see the tips, place your cursor over a field and wait for the pop up containing the field tip to appear. Once complete, please print, sign (if required) and mail the form to the appropriate address noted.