I Am a Provider and “I Want to Allow a 3rd Party Billing Service to Bill for Me Using the Part A FISS DDE System”
This selection will prompt you to complete the Letter of Authorization Form.
This option is for providers who wish to allow third party billing service to submit their claims using the Part A FISS DDE system.
Step 1. Billing Information
Enter the name of the billing service that will be authorized on behalf of the Provider/Facility.
Step 2. Provider Information
Complete the following fields as it applies to the provider of services:
Provider/Facility Name - Enter the name EXACTLY as it was approved in section 2 of the CMS-855/PECOS enrollment application.
Provider/Facility Address- Enter the physical or corporate address EXACTLY as approved in section 4 of the CMS-855/PECOS enrollment application.
Contact First and Last Name - Enter the name of the contact within the provider’s office that will be the authorized contact for any logon IDs requested.
Title - Enter the title of the contact person within the provider’s office.
Email Address - Enter the email address of the authorized contact for the provider/facility.
Telephone Number - Enter the provider/facility telephone number to their office.
Step 3. PTAN/NPI Information
If there is one PTAN/NPI complete the following fields as it applies to the provider of services in the PTAN/NPI Information section:
Primary PTAN - Enter the provider/facility primary PTAN.
Primary NPI - Enter the provider/facility primary NPI.
Provider/Facility Name - Enter the name EXACTLY as it was approved in section 2 of the CMS-855/PECOS enrollment application.
Provider/Facility Address - Enter the physical or corporate address EXACTLY as approved in section 4 of the CMS-855/PECOS enrollment application.
If this is the same information entered in the “Provider Information” section check the box at the top of this section “Address is same as listed above”.
If the provider/facility office location is not the same as their corporate or primary location enter the provider/facility’s secondary location address EXACTLY as approved in section 4 of the CMS-855/PECOS Enrollment Application.
If there’s multiple PTAN/NPI numbers to include, then select “I have multiple PTAN/NPIs” tab.
You can enter up to 100 PTAN/NPI combinations.
They must all be for the same Medicare Contractor Code.
They must all have the same Authorized or Delegated official.
You must download and complete the supplied template.
Once completed you must upload the template.
Step 4. Offshore Provider Information
Select “Yes” or “No” to indicate whether you or your organization uses one or more business entities that work outside the United States or US Territories to access the NGSConnex Provider Portal.
If “Yes” is selected complete the additional questions/information:
Step 5. Letter of Authorization Information
Review the letter of Authorization information.
Step 6. Instructions
Review the additional instructions to familiarize yourself what the billing service must know and follow.
Step 7. Signature Instruction
Review the signature instructions and requirements.
Step 8. Authorized Signature
Review the Terms and Conditions and check the box “I agree to the terms and conditions above”.
Be sure to note the requirements for who may sign the documents. Signature must be an EXACT match as approved in section 5/6 of the CMS-855/PECOS Enrollment Application.
Next, scroll down and complete the “signature name” and “title” fields and click the “Submit” button.
Once completed, the EDI Enrollment Complete screen will display.
This screen will provide the information regarding your Letter of Authorization. You will also have the option to print the packet, finish and exit, or start a new packet. With printing, you are able to print to PDF which will allow you to save a copy of the packet or select the appropriate printer to obtain a paper copy.
