TriWest VACCN Regions 4 & 5 Palmetto GBA
Please follow the Enrollment Instructions below to become an electronic submitter to Palmetto GBA for your TriWest Region 4 & 5 claims. This is only for claims that need to be sent to Payer ID TWVACCN. For TriCare West claim submissions, which is Payer ID 99726 please review the instructions found on this page instead: http://www.claimshuttle.com/tricare-west-palmetto-gba
The following documents are required enrollment documents that must be completed, signed and returned to the PGBA office prior to initiation of electronic claims submission or inquiry. You must either call them at 1-800-259-0264 option 1 or email them to request they send you these forms: PGBA.EDI@PGBA.com
1. PGBA, LLC VACCN Electronic Trading Partner Agreement
2. PGBA, LLC EDIG Trading Partner Enrollment Form
( Billing Services please contact Palmetto directly for the forms and instructions on how to complete them. )
PGBA, LLC VACCN Electronic Trading Partner Agreement
Please leave the Agreement Number line blank
Enter today’s date, your Business/Practice or Provider name in the first paragraph, and your address (You are the Trading Partner)
Please complete section 9.1 on page 13 with your information (This tells PGBA who they should send notices to)
Complete the Trading Partner section on the left side of page 16
Complete Exhibit A
Enter your information in the Trading Partner section
Please enter the information for 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.
If you are a provider using a Billing Service, please enter the Billing Services information in the Billing Service Information section
On Exhibit A Page 2 Please Write in under Means of Electronic Access " Secure FTP" and write in "Will use AXIOM Systems Inc's IP and Certificate"
PGBA, LLC EDIG Trading Partner Enrollment Form
Enter today’s date
New applicants, please select “New Trading Partner ID”
Complete the Trading Partner Name field with your Business/Practice or Provider name
Leave the Trading Partner ID line blank and fill in your Tax ID in the Tax ID line
For Type of Business select either Institutional or Professional
If you are a Billing Service, please choose Billing Service
Please make sure you also call them to see if there are any additional forms you or your providers need to complete
For Line of Business, please choose “VA CCN”
Enter today’s date for the start date and leave the end date blank
Compression: choose PKZIP
Protocol: choose Secure FTP ( on the left in the blank area write in "will use AXIOM Systems Inc's IP and Certificate" )
Complete your address and contact information.
For Transactions, choose:
ASC X12N 835 for Electronic Remits (EOB's)
ASC X12N 837I for Institutional, or
ASC X12N 837P for Professional
For every transaction checked, provide an average number of transactions submitted weekly
For Vendor’s information Please enter the information for 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.
Complete the Customers Information section with your information
Submitting your Forms
It is recommended that you keep a copy of all the forms you will be submitting for your records. Email the enrollment forms to the following email address:
It is very important that you complete and return the entire enrollment packet as described above. Incomplete documents will not be processed and will be sent back 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 to three weeks from the date of receipt.
After processing, a confirmation will be sent to you as notification to begin filing claims electronically. If neither confirmation nor a returned packet is received after three weeks, contact the PGBA, LLC EDI Technology Support Center at 1-800-259-0264 option 1 to check the status of the application.
Once you have received your Submitter ID from PGBA, LLC, please call the Claimshuttle Support Team at 602-439-2525 and set an appointment for a Mailbox setup and Test Transmission.
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.