JJ Part B EDI Online Enrollment Forms

Published 03/13/2023

Palmetto GBA now offers Electronic Data Interchange (EDI) online enrollment in lieu of use of the following PDF packet. If you utilize the online enrollment, you will not need to download and submit the forms found in the packet.

Palmetto GBA has prepared this packet and our online forms for Part A, Part B & HHH submitters of electronic claims. The packet 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 877-567-7271.

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

The PDF version of the Part A, Part B & HHH EDI Enrollment packet 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.

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.

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