EDI Providers must notify Palmetto GBA if you begin to use or discontinue using a clearinghouse or billing agent to submit or receive EDI transactions (claim submission, report retrieval, electronic remittance retrieval, etc.). For your convenience, we have developed the Ohio & West Virginia Part B EDI Provider Change Form to help you communicate changes with your electronic vendor, clearinghouse or billing agent to conduct electronic transactions on your behalf.
Please mail the completed form to the address noted on the bottom of the form. Please note that forms missing required information cannot be processed and will be returned. Required fields are indicated by an asterisk.
Notice to Clearinghouses and Billing Services:
Clearinghouses and Billing Services must complete an EDI Application form when notifying Palmetto GBA that your company will be submitting or retrieving electronic files (claims, remittance, claim status, etc.) for a provider who is already setup for electronic transmission. The provider must complete an EDI Provider Change Form. Please submit these two forms together to help ensure faster and accurate processing.
To view the OH / WV Part B EDI Provider Change Form, select the PDF link below.