Internet EDI Enrollment Packet

The Internet EDI Enrollment packet should be completed to request an Internet EDI ID necessary to transmit Claim Status Request transactions (ANSI 276) and receive Claim Status Response transactions (ANSI 277), and/or retrieve Electronic Remittances (ANSI 835), via Palmetto GBA’s public Internet. If retrieving Electronic Remittances (ANSI 835) via an Internet EDI ID is selected, all other access to retrieving Electronic Remittances for the Provider number listed will be terminated.

Palmetto GBA has separate packets for submitters who wish to submit claims to our front-end system. The Part A, Part B & HHH EDI Enrollment Packet and Railroad Medicare EDI Enrollment Packet are available for download from www.palmettogba.com/EDI under 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 print, sign (if required) and mail the form to the appropriate address noted.

To access Internet EDI Enrollment Packet, select the link below.

Contact Palmetto GBA JM Part HHH Medicare

Email HHH

Contact a specific JM HHH department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

Other Palmetto GBA Sites

Palmetto GBA Home

DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

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