Instructions for Completing EDI Forms and Applications
Applications are processed within seven (7) days of the date we receive them. Please allow two (2) business days after the date of your approval letter before you begin submitting your claims electronically. This will allow for our internal processes to complete.
Please read and follow instructions carefully. Applications that do not comply with these guidelines will be rejected and returned.
- Access the EDI Forms or applications by clicking on the appropriate link below. You must have Adobe 8 or later installed on your system to complete these applications. Verify that a “Bar Code” appears on the fax cover sheet. Complete the application by typing your information online, directly into the application. Cahaba GBA cannot accept handwritten information on an application. If you are resubmitting an application that has been returned, you must complete and fax a new application. All fields outlined in red are required and must be completed before you will be able to print the application. Once completed, print the application, obtain an authorized signature, and fax it to Cahaba GBA EDI Help Desk. EDI Forms or Applications must be faxed to the number provided in the top right corner of the first page of the application. Pages must be faxed in the order printed. Use only the cover page provided with the application and make sure it is the first page faxed. Send only one application per fax. If an e-mail address is provided on the application, it will be used to send notifications when the application status changes. If you are completing the EDI Help Desk’s “Part A System Access Application” to request FISS access for new employees you must provide a four digit PIN for each person. This PIN must be different for each person requested. If you are resubmitting an application that has been returned, you must complete and fax a new application. New billing services and clearing houses must complete the EDI Help Desk’s “Part A Billing Service Application”. A provider’s “Part A Application” is also required. The provider’s application must be in front of the billing service/clearing house application and sent in the same fax. Billing Services and clearing houses must complete the EDI’s “Part A Billing Services Application” to update company information. New vendors will need to fax at least one provider’s “Part A Application” along with the EDI Help Desk’s “Part A Vendor Application.” The provider’s application must be in front of the vendor’s application and sent in the same fax. Vendors must complete the EDI “Part A Vendor Application” to update company information. New network service vendors need to complete the “Part A Network Services Vendor”
application to include an authorized signature. The name, address, and tax ID provided must match the legal name, street address, and tax ID we have associated with the PTAN and NPI in our system. If submitting multiple PTANs, the name and address on the application must match the first PTAN/NPI combination. Provider Contact Name, E-mail address, and phone number must be a contact person who works for the provider and not a billing service, clearing house, or software vendor. Providers must include the street address we have on file for the facility listed on the Part A Application. A PO Box is not acceptable and will cause your application to be returned. Contact Provider Enrollment at (877) 567-7271 if you have questions regarding your facility’s street address. If you must attach a separate sheet to list all of the PTANs or users, this should be placed after the last page of the application. Applications must be faxed within 90 days of the date of the signature. If you have any questions, contact the EDI Help Desk at (866) 582-3253 or via e-mail at PartAEDIServices@cahabagba.com
ATTENTION MAC USERS:
For some Mac computers the bar code on the first page of the Part A Application, Part A Billing Service Application, the Part A Vendor Application, the Part A System Access Application, and the Part A Services System Access Recertification may not appear. If this is the case you will need to access the forms and complete them on another, Windows-based computer where the bar code will appear.
ATTENTION GOOGLE CHROME USERS:
If you are using the Google Chrome Internet Browser the bar code on the first page may not appear. In this case you would need to complete the application using Internet Explorer.
Click the link to the appropriate EDI Form or application below to begin entering the data. You must have Adobe 8 or later installed on your system to complete these applications.
- Part A Application – For providers who need to be set up for electronic claims filing or who are changing vendors, billing services, or clearing houses.
- Part A Billing Service Application – For new billing services or clearing houses or those that need to change their information in our system.
- Part A Vendor Application – For new direct software vendors, or for vendors that need to update their information in our system and on the Approved Vendor List.
- Part A Network Service Vendor – For new Network Service Vendors (NSVs).
- Part A System Access Application – To request access to the Fiscal Intermediary Shared System (FISS) for Direct Data Entry (DDE).