Remittance Enrollment Guide for DMEREGIONC

Electronic Remittance Advice (ERA) Enrollment Form as required by the CMS Change Request 8223 Phase III Electronic Remittance Advice (ERA) Enrollment Operating Rules (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8223.pdf ). This form will be used by providers to enroll their DME Provider Transaction Access Number (PTAN) and National Provider Identifier (NPI) with CEDI to receive Medicare ERA files created by the DME MACs.*New Electronic Providers (Form 1 and 3 required), Existing Electronic Enrolled Providers (Form 3 only)Form 1 – Complete the Submitter Information with the following:  Submitter Status: Existing Submitter,Submitter ID:  Region A Submitter ID C08495979, Region B Submitter ID C08495979, Region C Submitter ID C08495979,Region D Submitter ID D08607230, Submitter Name: Availity LLC, Submitter Type: ClearinghouseForm 3 – Complete the Submitter and/or Receiver Information with the following:  Entity Name - Availity LLC,Operating as a - Clearinghouse, Submitter ID: Region A Submitter ID C08495979, Region B Submitter ID C08495979,Region C Submitter ID C08495979, Region D Submitter ID D08607230, Address - 740 E Campbell Road, Suite 1000, Richardson, TX 75081, Contact Name - Availity Client Services, Contact Phone Number - 800.282.4548, Contact Email – enrollments@availity.comCGS now supports DMERC Region C, but the NGS enrollment forms are still to be used.EDI_Submitter_Action_Request_Form