Palmetto GBA Medicare Electronic Data Interchange (EDI) is pleased to offer an online Direct Data Entry (DDE) enrollment form for Jurisdiction M North Carolina Part A, South Carolina Part A and HHH; as well as Jurisdiction J Alabama Part A, Georgia Part A and Tennessee Part A. DDE allows you to:

  • Submit UB-04 claims
  • Correct, adjust, and cancel claims
  • Perform inquiries such as beneficiary eligibility, claims history, revenue codes, diagnosis codes, etc.
  • View certain online reports

Note: Providers must have an EDI Enrollment Agreement (PDF, 506KB) on file before a request is submitted by the provider or on behalf of a provider by a Clearinghouse or Billing Service.

To complete the DDE ID Online Request Form, please follow these instructions:

 Form Field Name

 Instructions for Field Completion
Company Name Enter the name of the entity (provider, software vendor, billing service or clearinghouse) that will actually be communicating electronically with Palmetto GBA.
Contact Name Enter 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.
Mailing Address Line 1 Enter the mailing address of the submitter.
Mailing Address Line 2 Enter additional mailing address of the submitter.
City, State & Zip Enter the city, state and zip code of the submitter.
Phone Enter the area code and phone number of the contact person listed above.
Fax Enter the fax number for this location.
Email Address Enter the email address of the contact person listed. Note: This will be the primary method of communication.
Submitter ID #

Enter the Submitter ID used by the submitter to communicate with Palmetto GBA electronically. If a site wishes for Online Inquiry Access and does not have a submitter ID, please enter five Xs (XXXXX) in the field.

Note: If a site has been issued a Submitter ID, it must accompany the request or the request will be denied.

Line of Business Indicate the line of business for which you are requesting access. Please select only one line of business.
This form is being completed by: Select the type of entity submitting this request.
Provider/Contact Name for DDE ID (Contacts are responsible for the DDE ID assigned):
Existing ID Enter any existing Online Inquiry Services ID for the individual on the request. If an ID is available from another or the current carrier, please list this ID for Palmetto GBA access to be added. Note: Requests may be prolonged if an individual does not provide an existing ID but has obtained an ID from another or the current carrier.
First Name Enter the first name of the individual that needs access or the existing user's first name. Generic names will not be accepted on these requests.
Last Name Enter the last name of the individual that needs access or the existing user's last name. Generic names will not be accepted on these requests.
Action Requested:
Requesting New ID
Delete Existing ID
Delete PTAN(s) from Existing ID
Add PTAN(s) to Existing ID
Reinstate/Reactivate Existing ID

Select only one request for the individuals listed below:

  • Requesting New ID - Check this box if you are requesting an ID for an individual who has never had a DDE ID established for them by either Palmetto GBA or another Medicare contractor.
  • Delete Existing ID - Check this box to delete the DDE ID assigned to the individual.
  • Delete PTAN(s) from Existing ID - Check this box to remove the 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 Reinstated/Reactivated ID.
Comments Include any additional information needed for the request. This field cannot be used for multiple providers, deletion of IDs, name changes or any other type of request that must be submitted via proper documentation to Palmetto GBA EDI Operations.

Record your Tracking Number after each submission. If you do not receive a Tracking Number after clicking Submit, you may click the Back button on your Internet browser to enter corrected information in all fields. You can check the processing status of your EDI request by entering your Tracking number onto the EDI Enrollment Status Online Request Form.

View the DDE ID Online Request Form.

Contact Palmetto GBA JJ Part A Medicare

Provider Contact Center: 877-567-7271

Email JJ Part A

Contact a specific JJ Part A department


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