The CMS Standard EDI Enrollment Form must be completed prior to submitting electronic media claims (EMC) to Medicare. The agreement must be executed by each provider of health care services, physician, or supplier that intends to submit EMC.

Each new EMC biller must sign the form and submit it to their local Medicare carrier or fiscal intermediary. Any existing EMC billers who have not completed the CMS Standard EDI Enrollment Form must complete and sign this form and submit it to their local Medicare carrier or fiscal intermediary also.

An organization comprising of multiple components that have been assigned Medicare provider numbers, supplier numbers, or UPINs may elect to execute a single EDI Enrollment Form on behalf of the organizational components to which these numbers have been assigned. The organization as a whole is to be held responsible for the performance of its components.

To obtain a electronic copy of the CMS Standard EDI Enrollment Form, please go to:

www.mtindia.org/freedownloads/default.cfm