Palmetto GBA has prepared this packet for Part A, Part B & HHH 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 Provider Contact Center toll-free at 855-696-0705 (JM) or 877-567-7271 (JJ).

Palmetto GBA has subcontracted with National Government Services (NGS) to continue EDI support of the Virginia and West Virginia Part A workload. Please contact the NGS Help Desk at 855-696-0705 for EDI support.

Please allow a processing time of approximately three weeks. Remember that Palmetto GBA cannot process incomplete applications or agreements.

This packet contains the following forms in this order along with instructions on how to complete each form:

 EDI FormsAccess this form by selecting this PDF link located on the bottom of this page
 EDI Enrollment Packet  EDI_Enroll_AB_Pack.pdf
 EDI Application Form  EDI_Enroll_AB_App.pdf
 EDI Enrollment (Agreement) Form  EDI_Enroll_AB_Agree.pdf 
 EDI Provider Authorization Form  EDI_Enroll_AB_ProvAuth.pdf
 DDE Enrollment Form  EDI_Enroll_AB_DDE.pdf

We've created an EDI Enrollment Instructions Guide to help you determine which form you need to complete 

Please Note: The Electronic Funds Transfer (EFT) form is not included in this EDI Enrollment packet. The EFT Enrollment Packet is posted separately and must be mailed to Provider Enrollment.

The PDF copy of these forms is interactive. From your Adobe Reader, you can type directly into the form fields on the form. Please click on the form fields to complete the form. Once complete, please retain a copy for your records and fax or email to the appropriate fax number or email address.

To access the Part A, Part B & HHH EDI Enrollment Packet, select the link below.

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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