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The Centers for Medicare & Medicaid Services (CMS) agrees to:
1. Transmit to the provider an acknowledgement of claim receipt.
(R11-18)
2. Affix the A/B MAC, DME MAC, CEDI or other contractor if designated by CMS number, as its electronic signature, on each remittance advice sent to
the provider.
3. Ensure that payments to providers are timely in accordance with CMS's policies.
4. Ensure that no A/B MAC, CEDI, or other contractor if designated by CMS may require the provider to purchase any or all electronic services from the
A/B MAC, CEDI or from any subsidiary of the A/B MAC, CEDI, other contractor if designated by CMS, or from any company for which the A/B
MAC, CEDI has an interest. The A/B MAC, CEDI, or other contractor if designated by CMS will make alternative means available to any electronic
biller to obtain such services.
5. Ensure that all Medicare electronic billers have equal access to any services that CMS requires Medicare A/B MACs, CEDI, or other contractor if
designated by CMS to make available to providers or their billing services, regardless of the electronic billing technique or service they choose. Equal
access will be granted to any services sold directly, indirectly, or by arrangement by the A/B MAC, CEDI, or other contractor if designated by CMS.
6. Notify the provider within 2 business days if any transmitted data are received in an unintelligible or garbled form.
NOTE: Federal law shall govern both the interpretation of this document and the appropriate jurisdiction and venue for appealing any final decision made
by CMS under this document.
This document shall become effective when signed by the provider. The responsibilities and obligations contained in this document will remain in effect as
long as Medicare claims are submitted to the A/B MAC, DME MAC, CEDI, or other contractor if designated by CMS. Novitas reserves the right
to
terminate this agreement if there is no EDI activity within a six (6) month period. You agree that Novitas will be entitled to damages, court costs and
reasonable attorney's fees if you breach this agreement. Either party may terminate this agreement by giving the other party thirty (30) days written notice of
its intent to terminate. In the event that the notice is mailed, the written notice of termination shall be deemed to have been given upon the date of
mailing,
as
established by the postmark or other appropriate evidence of transmittal.
If Providers elect to submit/receive transactions electronically using a third party such as a billing agent or a clearinghouse, the A/B MACs or CEDI must
notify these providers that they are required to have an agreement singed by that third party. The third party must agree to meet the same Medicare security
and privacy requirements that apply to the provider in regard to viewing or use of Medicare beneficiary data. (These agreements are not to be submitted to
Medicare, but are to be retained by the providers.)
ATTESTATION
Any provider who submits Medicare claims electronically to CMS or its contractors remains responsible for those claims as those
responsibilities are outlined on the EDI Enrollment. In accepting claims submitted electronically to the Medicare Program from any
billing service or through the use of a particular product which accomplishes this process, neither CMS, nor any other Medicare
contractors are attesting to the appropriateness of the methods used by the billing service/clearinghouse or to the accuracy of a particular
vendor's product used to facilitate such electronic submissions. The provider furnishing the item or service for whom payment is claimed
under the Medicare Program retains the responsibility for any claim regardless of the format it chooses to use to submit the claim.
Prior to signing this agreement, please carefully review the technical requirements for electronic billing in Chapter 3 of the Electronic Billing
Guide. New EDI submitters must connect to Novitas within 90 days of receiving the logon ID by using the Secure File Transfer Protocol
(SFTP) software provided by your Network Service Vendor.
I understand that any individual who knowingly and willfully makes or causes to be made any false claim or false statement of
false representation of a material fact in any application to the federal government for benefits or payment with respect to the Medicare
program may be subject to civil and/or criminal enforcement action which may result in fines, penalties, damages and/or imprisonment.
AUTHORIZED/DELEGATED OFFICIAL SIGNATURE REQUIREMENTS
I certify that I have been appointed an authorized individual to whom the provider has granted the legal authority to enroll it in the Medicare
Program, to make changes and/or updates to the provider's status in the Medicare Program (e.g., new practice locations, change of address,
etc.), and to commit the provider to abide by the laws, regulations, and the program instructions of Medicare. I authorize the above listed
entities to communicate electronically with Novitas Solutions on my behalf.
By signing below, the provider confirms they have read and agree to the Agreement, the Attestation, and the above signature
requirements.
*The Authorized Official signing this form must be an AUTHORIZED OR DELEGATED OFFICIAL that was listed on the
Medicare Enrollment Application (CMS-855).
WRITTEN SIGNATURE OF PERSON SUBMITTING ENROLLMENT (add after you print out the form)
DATE (add after you print out the form)
PRINTED NAME OF PERSON SUBMITTING ENROLLMENT
PRINTED TITLE OF PERSON SUBMITTING ENROLLMENT
COMPLETE FORM, PRINT, SIGN, DATE AND MAIL OR FAX ALL PAGES TO:
Novitas Solutions, Inc. - EDI, P.O. Box 3011, Mechanicsburg, PA 17055-1801
or Fax: 1 (877) 439-5479
