Please follow the Enrollment Instructions below to become an electronic submitter for Palmetto GBA.
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 Palmetto office prior to initiation of electronic claims submission or inquiry.
1. J11 Palmetto GBA EDI Enrollment Packet
If the link above does not work properly, please download this packet from the website by going here:
If you have any questions regarding any of the documents in this package, please phone the Palmetto EDI Technology Support Center at 1-866-749-4301
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.
J11 EDI Application
Select your Line of Business
New Applicants, please choose “Apply for New Submitter ID”
If you would like to receiver your EOBs electronically from Palmetto, please also select “Apply for New Receiver ID”
New Applicants, please leave the Submitter ID line blank.
If you are already an existing electronic submitter and you are just applying for a new Receiver ID to receive electronic EOBs from Palmetto please enter your current Submitter ID.
If you are applying for your OWN submitter ID please select “Provider”. If you are a Billing Service, please select “Billing Service”
Complete the EDI contact person section with your information
For claim submission mode of communication select Leased FTP
For Report/Electronic Remittance Retrieval Mode select Leased FTP
Report Response Format choose File
Data compression: choose PKZIP
Name of Software Vendor: Please enter the information for the software or vendor that creates your 837 files you need Claimshuttle to transfer for your. If you have paid for our SolAce billing software please call our support line for our SolAce software information.
Please complete the ‘Providers for Whom Submitter Will be Transmitting” with your Provider’s information and choose the following options:
Enrollment Form Attached: Yes
Provider Authorization Form Attached: Yes (If you are a provider billing through a Billing Service, otherwise leave blank)
Mark: Submit claims, Receive Reports, Receive Electronic Remittances
If you want to apply for a separate ID for the online FISS/DDE or PPTN service also select “Online Inquiry Services”
J11 Electronic Data Interchange Enrollment Agreement
Each provider must complete Section C. of this form and enter his/her Medicare Provider number and NPI.
Provider Authorization Form
Providers who wish to authorize a Billing Service the authority to submit claims electronically would fill out this form, if not please skip.
Select the proper Line of Business
Indicate the type of service(s) you are authorizing the Submitter (billing service) to access
Enter the Provider’s name for which the form is being completed.
Note: The name must match the name submitted on the CMS 855 Medicare Enrollment Application
Please provide the Providers Email address for all EDI notifications
List the Providers PTAN, a separate Provider Authorization form is required for each PTAN
Enter the Provider’s NPI
List the name and title of the person Palmetto will contact for questions regarding this form
Enter the demographic information of the Provider
Enter the name of the Submitter you are authorizing (billing service/clearinghouse)
The Provider must sign and date the application
Please skip the J11 Software Order Form sections
If you marked off the “Online Inquiry Services” option on the forms above, please complete the J11 Direct Date Entry Form. Otherwise, you may also skip this entire section.
Part A Providers are required to have access to the DDE System. If you need a Network Service Vendor that will provide the connection for your FISS/DDE and/or PPTN access please ask us about our ClaimShuttle service! We can have you logged in to your FISS/DDE or PPTN screens in no time!
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:
Palmetto GBA EDI
J11 EDI Operations, AG-420
PO Box 100145
Columbia SC 29202-3145
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 twenty business days from the date of receipt. (Remember that mailing time can take as much as five days.)
After processing, a confirmation will be faxed to you as notification to begin filing claims electronically. If neither confirmation nor a returned packet is received after 20 business days, contact Palmetto EDI Technology Support Center at 1-866-749-4301.
Once you have received your Submitter ID and password from Palmetto, please call the Claimshuttle Support Team and set an appointment for a Mailbox setup and Test Transmission to Palmetto.
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.