Payer List

Palmetto GBA administers Medicare health insurance for the Centers for Medicare and Medicaid Services (CMS) for Jurisdiction M, which includes the state of North Carolina. If you are a provider located in the state of North Carolina and need to become an electronic submitter for your Medicare A/B claims, please follow the enrollment instructions below.
 

Required Documents for those applying for new Submitter IDs

The following documents are required enrollment documents that must be completed, signed and returned to the Palmetto office prior to initiation of electronic claims submission or inquiry.

1. Palmetto GBA EDI Enrollment Packet
 

If the link above does not work properly, please download this packet from the website by going here:

https://www.palmettogba.com/

Choose one of the Jurisdiction M links under Topics choose EDI, then EDI Enrollment

If you have any questions regarding any of the documents in this package, please phone the Palmetto EDI Technology Support Center at 855-696-0705.

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

Our Vendor Information

EDI Application

• Select your Line of Business
• New Applicants, please choose “Apply for New Submitter ID”
  • If you are billing for Part A services and wish to receive your remittance advice electronically, also choose "Apply for New Receiver ID"
• New Applicants, please leave the Submitter ID and Receiver ID line blank
• Please enter today's date
• Enter your company or provider name as Submitter Name
• Please enter the name of the owner of your company
• If you are applying for your OWN Submitter ID please select “Provider”
• If you are a Billing Service, please select “Billing Service”
• Complete the EDI contact person section with your information
• Report Response Format: choose File
• Data compression: choose PKZIP
• Name of Software Vendor: AXIOM System’s Inc.
  • Vendor ID: 
    VS4148 for JM and JJ Part A
    VBJ0070 for JM and JJ Part B
    VR1158 for Railroad Medicare
• For name of Network Service Vendor please enter ClaimShuttle by Axiom Systems
• Please complete the "Providers for Whom Submitter Will be Transmitting” with your Provider’s information and choose the following options:
  • Enrollment Form Attached: Yes
  • Provider Authorization Form Attached: Yes (If you are a provider billing through a Billing Service, otherwise leave blank)
  • Mark: Submit claims, Receive Reports, Receive Electronic Remittances
  • If you want to apply for a separate ID for the online FISS/DDE service also select “Online Inquiry Services”

Electronic Data Interchange Enrollment Agreement

Each provider must complete Section C. of this form and enter his/her Medicare Provider number and NPI.

Provider Authorization Form

Providers who wish to authorize a Billing Service the authority to submit claims electronically would fill out this form, if not please skip.

• Select the proper Line of Business
• Indicate the type of service(s) you are authorizing the Submitter (billing service) to access
• Enter the Provider’s name for which the form is being completed.
• Note: The name must match the name submitted on the CMS 855 Medicare Enrollment Application
• Please enter the Providers Tax ID
• Please provide the Providers Email address for all EDI notifications
• List the Providers PTAN, a separate Provider Authorization form is required for each PTAN
• Enter the Provider’s NPI
• List the name and title of the person Palmetto will contact for questions regarding this form
• Enter the demographic information of the Provider
• Enter the name of the Submitter you are authorizing (billing service/clearinghouse)
• The Provider must sign and date the application

If you marked off the “Online Inquiry Services” option on the forms above, please complete the J11 Direct Date Entry Form. Otherwise, you may also skip this entire section. Part A Providers are required to have access to the DDE System. If you need a Network Service Vendor that will provide the connection for your FISS/DDE access please ask us about our ClaimShuttle service! We can have you logged in to your FISS/DDE screens in no time!

Submitting your Forms

It is recommended that you keep a copy of all the forms you will be submitting for your records.

Submit the enrollment forms reflecting original signatures to:

Part A Fax: 803-699-2429

Part B Fax: 803-699-2430

Part A Email: [email protected]

Part B Email: [email protected]

It is very important that you complete and return the entire enrollment packet as described above. Incomplete packets will not be processed and will be returned to the submitter.

Waiting for a Response

Once the complete provider enrollment packet has been received, the documents will be processed. Processing will take up to twenty business days from the date of receipt.

After processing, a confirmation will be faxed to you as notification to begin filing claims electronically. If neither confirmation nor a returned packet is received after 20 business days, contact Palmetto EDI Technology Support Center at 855-696-0705.

Testing

Once you have received your Submitter ID and password from Palmetto, please call the SolAce Support Team at 602-439-2525 and set an appointment for a Mailbox setup and Test Transmission to Palmetto.

Please have 25 test claims ready for testing. Test files should consist of a variety of claims that represent the type of claims you will be submitting once production status is achieved. Test claims will not be processed for payment but will be validated against production files; therefore, they must contain valid patient procedure, diagnosis, and provider information.