Novitas Solutions Inc. administers Medicare health insurance for the Centers for Medicare & Medicaid Services (CMS) for Jurisdiction L which includes the State of Pennsylvania. If you are a provider located in Pennsylvania 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 Novitas Solutions office prior to initiation of electronic claims submission or inquiry.
 

To access these forms, please Go Here: https://www.novitas-solutions.com/edi/enrollment/forms-a-b.html

Select your Jurisdiction. Then choose "Forms" on the left hand side. Select the appropriate form under the subtitle "Electronic Data Interchange (EDI) Enrollment Forms".

1. Novitas Solutions EDI Enrollment Form (8292)
2. Novitas Solutions Vendor Agreement Form (8291) (For Billing Services Only)
3. File Transfer Protocol FTP Enrollment Form

If you have any questions regarding any of the documents in this package, please call the Novitas Solutions EDI Technology Support Center at 1-877-235-8073.

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.

Electronic Data Interchange (EDI) Enrollment Form

Section A: Select your Line of Business and State

Section B: Enter the name of the Group, Provider, Or Supplier who is applying for a Submitter ID

Section C: Enter your Practice’s demographic information

Section D: Enter the Provider’s PTAN, NPI and TIN or EIN

Section E: Billing Service/Clearinghouse Information:

• If Provider is sending and receiving via ClaimShuttle, place check mark next to Provider

• If a Billing Service is sending/receiving on behalf of the provider check, Billing Service

Check the last box in this section about your 855 form if applicable

Section F: Select the box for New Enrollment. Place a check next to Assign this provider a new electronic billing submitter ID

• Select either One Submitter ID or Separate Submitter ID’s per contract, whichever you prefer

• For name of software vendor, enter the name of the software vendor you will be using to create your claims. If you will be using SolAce, please call us for our information

Section G: Assign ERA to the new Submitter ID being requested in block F of this form

Section H: If you need to enroll for PC Ace check both boxes. If you do not, skip this section

Section I: Enter either your NPI or your TIN

Signature Section: Type your Name and Title, then Sign and Date

EDI Third Party Enrollment Form (Billing Services Only)

Section I. Enter your Company’s Name, Demographic info, and Contact information

• For Name of Software enter the name of the software or vendor that creates your 837 files you need ClaimShuttle to transfer for you. If you have paid for our SolAce billing software please call our support line for our SolAce software information

• Skip the first Box

• Check the second box if you do not wish to receive paper mail responses.

Section II. Check the box to Assign a new submitter ID.

• Select the box that says “I am a Billing Service or Clearinghouse that will be submitting claims directly to Medicare”

• Name of Vendor: Enter the name of the vendor that creates your 837 files you need ClaimShuttle to transfer for you. If you have paid for our SolAce billing software please call our support line for our Vendor information

• Choose either one submitter ID for all Part B contracts or Separate ID’s per contract

  • You would probably want Separate ID’s per contract.

• Check the box to assign a new ERA Receiver ID if you will be receiving your Provider’s ERAs.

Section III. Check these boxes:

• Create ANSI ASC X12N 837 version 5010 claim files

• Retrieve ANSI ASC X12N 835 version 5010 remittance files

• Provide the following type of connection to Novitas Solutions: Check box for SFTP 

  • You may also select DDE and PPTN. ClaimShuttle can provide you access to the DDE or PPTN screens. Please call our Sales team for pricing information

• Provide services to the following contracts: Check applicable boxes for Part A, and/or Part B

Section IV. Skip this section

Signature Section: Print your Name and Title, then Sign and Date this application

Secure File Transfer Protocol (FTP) Enrollment form (Please complete form after receiving your Submitter ID)

Section A: Enter your Business/Practice or Provider Name. Enter your Address, the name and email of the Contact person for your office as well as your phone number. Please Enter your Submitter ID

Section B: NSV Company name: ClaimShuttle, Contact Person EDI Team, Phone number: 602-439-2525

Sections C & D: Read through the terms then Print your Name, Title and Date, then Sign the application.

Submitting your Forms

It is recommended that you keep a copy of all the forms you will be submitting for your records. Mail the enrollment forms reflecting original signatures to:

Novitas Solutions, Inc.
EDI Department
P.O. Box 890011 Camp Hill, PA 17089-0011
Or Fax to: 1 (877) 439-5479

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 approximately two weeks from the date of receipt. (Remember that mailing time can take as much as five days.)

After processing, a confirmation will be mailed to you as notification to begin filing claims electronically. If neither confirmation nor a returned packet is received after two weeks, contact the Novitas Solutions EDI Technology Support Center at 1-877-235-8073

Testing

Once you have received your Submitter ID and Password from Novitas Solutions, please call the ClaimShuttle Support Team and set an appointment for a Mailbox setup and Test Transmission to Novitas Solutions.

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.