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Electronic Data Interchange Enrollment Forms

Important Enrollment Information

Please allow 10 business days before contacting Electronic Data Interchange (EDI) Services for a status of electronic billing forms sent for processing.
Avoid submitting a duplicate request, and inquire about the status of your submitted form by using the Form Status and Verification Inquiry Tool.
Effective March 2, 2018, EDI Services will return all enrollment forms received that contain a form revision date older than R11-17.
Effective for forms received on or after September 1, 2016, Novitas Solutions EDI will require that the Authorized Official or Delegated Official as listed on the CMS-855 sign the EDI enrollment form (8292JH), and other EDI provider forms.

Novitasphere Portal

Get instant access to the world of online Medicare transactions with Novitasphere!

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Novitasphere is a FREE, secure internet portal for Part A and B customers to use to easily connect directly to Novitas Solutions. Novitasphere provides quick access to beneficiary eligibility, claim submission, claim corrections (Part B), electronic remittance advice, and many other time saving features. To learn more and enroll for Novitasphere, visit the Novitasphere Center.

EDI Enrollment Forms

To connect to Novitas Solutions via Secure File Transfer Protocol (SFTP) directly or by billing service or clearinghouse, please review the EDI Enrollment forms below.

Prior to enrolling for electronic billing, please carefully review the Technical Requirements for electronic billing and the General Tips for Completing EDI Enrollment Forms.

This form should be completed by providers using SFTP or a billing service/clearinghouse to submit claims and/or retrieve reports.
This form should only be completed by a vendor, billing service, or clearinghouse.
Providers who use an in-house software and will be requesting multiple submitter IDs, please complete this form to have your software added to our database.
Complete this form to update information we have on file to mail you EDI-related documents.

Top Ten 8292JH Form Return Reasons - Updated February 2018

Reason for Return

How to Avoid A Return

Invalid signature/printed name. The Authorized Official or Delegated Official as listed on the CMS-855 is required to sign.

The Authorized Official or Delegated Official as listed on the CMS-855 is required to sign. If you are unsure who your authorized or delegated official(s) on file are, this information can be verified in the Provider Enrollment Chain and Ownership System (PECOS).

Missing/Incorrect name of provider, group or supplier

Ensure the provider name on the EDI forms matches the provider name that Novitas Solutions has on file. This is the name used when completing the CMS-855 form and enrolling with the Medicare program.

Missing/Incorrect PTAN

Your PTAN is assigned to you by Provider Enrollment upon completion of the CMS-855 form. Ensure the PTAN is reported in the required field. The PTAN is the same as your Provider Identification Number (PIN) that you used for billing prior to being required to report a National Provider Identifier (NPI). You may also know this as your legacy identifier or Medicare provider number.

Note: Effective July 2, 2013 - If the PTAN reported on the Enrollment form is the only incorrect information, the form will be reviewed based on the NPI and Name of Provider, Group or Supplier listed. If only one PTAN is linked to that valid NPI, the form will be processed.

Missing/Incorrect NPI

The NPI is a unique identification number for covered health care providers. The NPI is a 10-digit number. Ensure that the NPI is reported in the required field in addition to your PTAN, and that it is correct.

Rendering PTAN/NPI given

EDI Enrollment is based on the group PTAN.  Once the group PTAN is set up, the associated rendering PTANs are considered enrolled.  It is not necessary to enroll group members.

Not a Novitas Solutions, Inc provider

Customers must be enrolled as a provider with Novitas Solutions, Inc prior to submitting your EDI Enrollment form. Please note, Novitas Solutions does not handle enrollment for all provider types. Please confirm who your correct MAC is prior to submitting your form.

Customer requested to maintain existing Electronic Remittance Advice (ERA) setup, but is not currently receiving ERA.

Effective December 4, 2017, ERA is a requirement for EDI Enrollment.  Please complete the Electronic Remittance Advice block with your preference for receiving ERA.

Block G is incomplete

Please review Block G to indicate your preference for maintaining existing submitter/receiver ID setups.

Missing date of signature

Ensure that the signature section is completed in its entirety, including the date the form was signed.

Incomplete EDI Enrollment Form

Pages 1 and 3 of the EDI Enrollment form are required for processing. Please ensure you submit both pages to EDI.

Hypertext Transfer Protocol Secure (HTTPS) Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules (CORE)-Compliant Connection for EDI

Click here for information on the HTTPS CAQH CORE-Compliant Connection for EDI.

If you need assistance, please contact an EDI Analyst.

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Last modified:  02/26/2018