Network Service Agreement

The Network Service Agreement should be completed in order to submit and receive EDI transactions on behalf or providers. Network Service Vendors (NSVs) can submit or receive EDI Medicare transactions for providers who have filed and EDI Enrollment Agreement and EDI forms that authorize the NSV to conduct specified transactions on their behalf. An NSV will be in violation of CMS and HIPAA privacy and security requirements for the following actions:

  • Attempting to conduct EDI transactions for a provider that has not authorized it to perform such actions on their behalf
  • Conducts an authorized transaction for a provider who did not request the specific transaction (such as submission of a request for eligibility data when that request was not originated by the provider identified as the source of the request)

Violators may be subject to penalties established by HIPAA and could lose all access rights to Medicare contractor systems nationally.

NSVs who do not translate non-HIPAA transactions or prepare claims are not permitted to read the content of data transmitted between a provider and Medicare, beyond accessing basic fields needed to determine inbound or outbound routing.

The field descriptions listed below will aid in completing the form properly.

Form Field Names Instructions for Field Completion 
Company Name* Enter the name of the entity (NSV) that will be communicating electronically with Palmetto GBA.
Address* The mailing address of the NSV.
City, State, ZIP*  The city, state, and ZIP code of the NSV.
Phone* The area code and phone number of the entity.
Company Email* The entity’s email address.
Company Website* The entity’s website address.
Contact Name The printed name of the authorized contact.
Contact Phone Number The area code and phone number of the contact person listed.
Contact Email Address The contact person’s email address.
Signature The signature of the authorized contact.
Date The date the form was signed.

*Will be displayed on the Network Service Vendor listing on our website.

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Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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