Fiscal Intermediary Shared System (FISS) Enrollment Application

Logon ID Requirements: In accordance with the CMS security policy, the FISS Logon ID (RACF ID) is not to be used by anyone other than the assigned user. Each person who utilizes FISS must have their own unique RACF ID and should not share this information with anyone, including supervisors, managers, or third party billers. Additionally, RACF IDs and passwords should not be stored in any type of script or log on feature.

If at any time you believe your RACF ID has been compromised, complete the form below to have the ID suspended immediately and also to request a new RACF ID.

Fields marked with * are required.

Please read the requirements above prior to completing this application.


When requesting access for multiple states, only one FISS application should be submitted. In this scenario, please choose only one state in the drop down menu below.
Choose a State...ArkansasColoradoDelawareLouisianaMaryland/DCMississippiNew JerseyNew MexicoOklahomaPennsylvaniaTexasWPS Legacy
Who does this RACF ID belong to?

If you have gone through a recent name change, please provide an explanation for the name update in the "Processing Details" block below.

You may receive an encrypted email when your application has been processed. The passphrase to open this email will be faxed to this number.

For "Remove Access" requests ONLY: Provide the e-mail of the person requesting the access removal.

This must be your business email address and comply with these requirements:
  • Identify your name (e.g. Jane.Doe@Hospital.org, j.doe@Hospital.org)
  • Identify your company/organization (e.g. Jane.Doe@Hospital.org)
  • CANNOT be a SHARED emailed address (e.g. Billing@Hospital.org)
  • CANNOT belong to a supervisor/manager (e.g. BillingOfficeManager@Hospital.org)
  • CANNOT be a private email address (Gmail, Yahoo, Verizon, AOL etc.)
If you cannot meet these email requirements, please provide a detailed explanation in the "Processing Details" box below. This would include email updates due to a recent name change.

Requester's Location

Is this user located outside of the United States? *
The following fields are required for an offshore user.

Is the last connection hop prior to accessing the Medicare system within the United States? This question should be answered by your technical support. *
  • All offshore connections must be encrypted.
  • Background checks must be conducted on all offshore users.
  • All offshore users must be in compliance with HIPAA security and privacy requirements.
Noncompliance will result in termination of all accounts associated with that provider/domain.
In support of any authorized audit, a network diagram may be requested.
*
Is this request for a Third-Party Biller? *
I certify that the third party organization is authorized to access data on behalf of the provider.
Do You Currently Have an active FISS RACF ID? *
Users with an existing FISS RACF ID cannot request additional IDs. If you had a RACF ID assigned to you and it is currently inactive, please list that ID in the box below. If you do not remember your RACF ID, just key the word 'Inactive'.

New Users: Enter the 4 digit numeric PIN associated with the RACF ID listed above. You will need to know this number in order to have your password reset in the future. The PIN cannot be 1234.
Existing Users: Key the PIN associated to your existing RACF ID.
How can we help you?
Select One...New User - Create a new RACF IDAdd PTAN(s) to my Existing Logon IDRemove AccessReinstate an inactive RACF IDOther Request

Enter a 4 digit numeric PIN to associate with the RACF ID being requested. You will need to know this number in order to have your password reset in the future. The PIN cannot be 1234.

Please only list active Part A Provider Transaction Access Numbers (PTANs). Requests listing National Provider Identifiers (NPIs) will be returned.
Please enter information for only one of your providers.
Please provide any specific processing details in the block below. Additional comments regarding name change/email address/etc. should also be listed in this box.

Please only list active Part A Provider Transaction Access Numbers (PTANs) that should be added to your FISS account. Requests listing National Provider Identifiers (NPIs) will be returned. Do not list PTANs that are already linked.
Please enter information for only one of your providers.
Please provide any specific processing details in the block below. Additional comments regarding name change/email address/etc. should also be listed in this box.

Please only list active Part A Provider Transaction Access Numbers (PTANs). Requests listing National Provider Identifiers (NPIs) will be returned.
Please enter information for only one of your providers.
Please provide any specific processing details in the block below. Additional comments regarding name change/email address/etc. should also be listed in this box.
What is your detailed business reason for removing this access? *

Some examples:
  • "Please remove access for John Doe, the employee has left their position."
  • "The RACF ID for John Doe has been compromised."
  • "Please remove PTAN 111111 from my access, this facility is no longer in business."

Please only list active Part A Provider Transaction Access Numbers (PTANs). Requests listing National Provider Identifiers (NPIs) will be returned.
Please enter information for only one of your providers.
Please provide any specific processing details in the block below. Additional comments regarding name change/email address/etc. should also be listed in this box.
Please provide a detailed explanation of the change you are requesting.*

Some examples:
  • "My last name has changed due to marriage."
  • "I work for a new company and require a new RACF ID."
  • "Our hospital changed ownership and I need to update my email address."
By submitting this form you are agreeing to the following:
  • I agree that I have read and completed this application in accordance to CMS Security policy.
  • I understand the responsibility to protect and maintain the confidentiality of the data.
  • I also understand that if the Medicare data obtained from the FISS is mishandled in any way, I will be held responsible in accordance with Medicare requirements.
  • I agree that Novitas Solutions can add my email address indicated above to the general email list to receive electronic notifications.
  • I understand that if I do not wish to receive email notifications, I can unsubscribe at any time on the Novitas Solutions website.
  • I agree that this unique ID will not be used by anyone other than the person to whom it is assigned and that I may be held legally responsible for any disclosure of the ID.

I have read the above agreement and attest to the truth of all information submitted herein.

IMPORTANT: BEFORE YOU CLICK SUBMIT, PLEASE PRINT THIS PAGE (YOUR COMPLETED FORM) IF YOU WOULD LIKE TO MAINTAIN A COPY FOR YOUR RECORDS!