EDI Onboarding Forms

Please select the appropriate options to access the form(s) needed to submit your request.

* Trading Partner Type:

Action Type:

Will you submit your own data?

* Indicates required field.

Submitter/Receiver ID Application Form

OMB No. 0938-1152 - Expires: March 31, 2025
The Submitter/Receiver ID Application is used when an Organization needs to obtain a Submitter or Receiver ID in order to exchange data with the Customer Service Front End System (CSFES). This form must be completed before an ID can be issued.

Important note: The Data Exchange Mechanism is often not entered on the application and causes delays in processing. Please ensure you select the mechanism your organization uses to exchange data with the CSFES.

Operations Contact Representative

Technical Contact Representative

* Medicare Advantage Organization Contract Number(s)

The unique contract number assigned by CMS
A maxium of 7 entries are allowed. If Additional MAO Contract Numbers are needed, use the 'Additonal Medicare Advantage Contract Numbers' section at the bottom of the screen.
Data exchange with CMS can be accomplished using different tools and is dependent on a contract's capabilities and the volume of data to be exchanged. The different Data Exchange Mechanisms available are found below.

CMS SFTP and Managed File Transfer (MFT) are available to contracts with <100,000 enrollees and are supported by the Medicare Advantage Prescription Drug (MAPD) Help Desk. Connectivity to CMS Systems must be established prior to completing this form. MAPDHelp@cms.hhs.gov 1-800-927-8069.

Other available options are Connect:Direct and SFTP and are supported by The Customer Service and Support Center (CSSC). Connectivity with a CMS-approved Network Service Vendor must be established prior to completing this form. CSSCOperations@palmettogba.com 1-877-534-2772.

* Medicare Advantage Organization Data Type

* Medicare Medicaid Data Type

Receiver ID

Medicare Advantage Organizations wishing to receive Prescription Drug Event reports only be must select one of the following options and Data Exchange Mechanism types, in order to be issued a Receiver ID.

* Indicates required field.

Electronic Data Interchange (EDI) Agreement

OMB No. 0938-1152 - Expires: March 31, 2025

The eligible organization agrees to the following provisions for submitting Medicare and/or Medicaid data electronically to the Centers for Medicare & Medicaid Services (CMS) or to its contractors.

A. The Eligible Organization Agrees:

  1. That it will be responsible for all Medicare and/or Medicaid data submitted to CMS by itself, its employees, and/or its agents.
  2. That it will use adequate security procedures to ensure that all transmissions of electronic data are secure and protect all beneficiary-specific data from unauthorized access, as required by the HIPAA Security regulations (45 C.F.R. Parts 160 and 164, subparts A and C).
  3. That it will establish and maintain procedures and controls so that information concerning Medicare and/or Medicaid beneficiaries, or any information obtained from CMS or its contractor, shall not be used by the eligible organization, its employees or agents, except as provided by the contractor and in accordance with all applicable State and Federal laws.
  4. That the Secretary of Health and Human Services (HHS), his/her designee and/or contractors designated by HHS , has the right to inspect, audit and confirm information submitted by the eligible organization and shall have access at all reasonable times, to all original source documents, and medical records, when applicable, related to the eligible organization's submissions, including the beneficiary's authorization and signature.
  5. That it will affix the CMS-assigned unique identifier number of the eligible organization on each file electronically transmitted to CMS. Affixing the CMS-assigned unique identifier number constitutes the eligible organization's legal electronic signature.
  6. That it will ensure that every electronic entry can be readily associated and identified with an original source document. That it will retain all original source documentation, and medical records, when applicable, pertaining to any such particular Medicare and/or Medicaid data for a period of at least 10 years after the data is received and processed
  7. That it will research and correct discrepancies in the event that a record or file is rejected or found to be in error.
  8. That it will notify CMS or its designated contractor within 2 business days if the eligible organization receives any data from that contractor or CMS in an unintelligible or garbled form.
  9. That it will not disclose any information concerning a Medicare and/or Medicaid beneficiary to any other person or organization, except CMS and/or its contractors, without the express written permission of the beneficiary or his/her parent or legal guardian, or where required for the care and treatment of a beneficiary who is unable to provide written consent, or to bill insurance primary or supplementary to Medicare and/or Medicaid, or as required by State or Federal law.
  10. Based on best knowledge, that it will submit data that are accurate, complete, and truthful

B. The Centers for Medicare and/or Medicaid Services Agrees To:

  1. Transmit to the eligible organization an acknowledgment of receipt.
  2. Ensure that no CMS contractor may require the eligible organization to purchase any or all electronic services from the CMS contractor or from any subsidiary of the CMS contractor or from any company for which the CMS contractor has an interest.
  3. Ensure that Medicare and/or Medicaid eligible organizations have equal access to any services that CMS requires Medicare and/or Medicaid contractors to make available to eligible organizations, regardless of the electronic billing technique or service they choose.
  4. Notify the eligible organization within 2 business days if it receives any electronic data from that eligible organization in an unintelligible or garbled form.

NOTICE:

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 eligible organization. The responsibilities and obligations contained in this document will remain in effect as long as Medicare and/or Medicaid data are submitted to CMS or the contractor. CMS may suspend or revoke authorization to submit data at any time if the eligible organization fails to abide by the terms of this Agreement. Either party may terminate this arrangement by giving the other party (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.

Signature:
I am authorized to sign this document on behalf of the eligible organization, doing business as the eligible organization, and I have read and agree to the foregoing provisions and acknowledge same by signing below.
The unique contract number assigned by CMS.
In the event you have questions, please contact CSSC Operations at 1-877-534-2772 or via Email at csscoperations@palmettogba.com.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1152. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850. (Form CMS-10340 (03/2025))
* Indicates required field.

Encounter Connect:Direct Form

OMB No. 0938-1152 - Expires: March 31, 2025
The Connect:Direct Form provides the parameters Palmetto GBA has defined that Organizations will need to use when exchanging data files using the Connect:Direct software. Organizations need to complete the form and provide the unique dataset names they would like their return reports to be delivered to.

Submitter's Network Mapping Values

In order to establish bi-directional data transfers with Palmetto GBA, provide the following network mapping values.
Example: 999.999.999.999
The Network Address Translation (NAT) IP Address must be obtained
from your Network Service Vendor (NSV).
Example: 1364
The listener port is 1364 by default, however if this is changed,
it must be verified with your network team.
Example: ABCDEFGHIJ999999
The node ID must be obtained from your Connect:Direct support team.

Additional Information

If submitting data files, the Production ID is required. If the submitter's system equires login credentials to receive data files, provide the Login ID.
Example: ABC123XYZ!#$
This is the log in ID used to transmit files to Palmetto GBA.
Example: ABC1234!#$
This is the log in ID Palmetto GBA will use to
send files and/or processing reports to you,
if your system requires log in credentials for
sending files and processing reports back to your system.
This is the person that will be responsible for setting up and testing Connect:Direct connectivity.
Example: (888) 999-1234
This is the phone number for the person that will be responsible for setting up and testing Connect:Direct connectivity.
Example: email@domain.com
This is the email address of the person that will be
responsible for setting up and testing Connect:Direct connectivity.

* Dataset Names

To receive multiple data files and prevent overwriting of existing files, it is recommended that Generational Data Group (GDG) dataset names (mainframe platform only) or dataset names containing date and timestamp (any platform) are provided.
Frequency = Daily
Invalid Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
TA1 Acknowledgement Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
999A Acknowledgement Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
999R Acknowledgement Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
277CA Acknowledgement Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
MAO-001 Data Duplicates Report
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
MAO-001 Data Duplicates File
DSORG=PS,LRECL=287,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
MAO-002 Data Processing Status Report
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
MAO-002 Data Processing Status File
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
* Indicates required field.

PDE Connect:Direct Form

OMB No. 0938-1152 - Expires: March 31, 2025
The Connect:Direct Form provides the parameters Palmetto GBA has defined that Organizations will need to use when exchanging data files using the Connect:Direct software. Organizations need to complete the form and provide the unique dataset names they would like their return reports to be delivered to.

Submitter's Network Mapping Values

In order to establish bi-directional data transfers with Palmetto GBA, provide the following network mapping values.
Example: 999.999.999.999
The Network Address Translation (NAT) IP Address must be obtained
from your Network Service Vendor (NSV).
Example: 1364
The listener port is 1364 by default, however if this is changed,
it must be verified with your network team.
Example: ABCDEFGHIJ999999
The node ID must be obtained from your Connect:Direct support team.

Additional Information

If submitting data files, the Production ID is required. If the submitter's system requires login credentials to receive data files, provide the Login ID.
Example: ABC123XYZ!#$
This is the log in ID used to transmit files to Palmetto GBA.
Example: ABC1234!#$
This is the log in ID Palmetto GBA will use to
send files and/or processing reports to you,
if your system requires log in credentials for
sending files and processing reports back to your system.
This is the person that will be responsible for setting up and testing Connect:Direct connectivity.
Example: (888) 999-1234
This is the phone number for the person that will be responsible for setting up and testing Connect:Direct connectivity.
Example: email@domain.com
This is the email address of the person that will be
responsible for setting up and testing Connect:Direct connectivity.

* Dataset Names

To receive multiple data files and prevent overwriting of existing files, it is recommended that Generational Data Group (GDG) dataset names (mainframe platform only) or dataset names containing date and timestamp (any platform) are provided.
Frequency = Daily
Prescription Drug Front End System (PDFS) Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
Drug Data Processing System (DDPS)
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
DDPS Transaction Error Summary
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system

Monthly

Monthly reports are grouped by date of service year and will be distributed in one dataset unless datasets containing a variable for the year is provided.
Frequency = Monthly
DDPS 04 COV Cumulative Beneficiary Summary
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
DDPS 04 ENH Cumulative Beneficiary Summary
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
DDPS 04 OTC Cumulative Beneficiary Summary
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
P2P 40 COV Accounting
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
P2P 40 ENH Accounting
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
P2P 40 OTC Accounting
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
P2P 41 COV Receivable
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
P2P 42 COV Part-D Payment Reconciliation
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
P2P 43 COV Payable
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
Frequency = Quarterly
DDPS Potential Exclusion Warning Report
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
Frequency = Annually
Phase III
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system

Form Data


                    
* Indicates required field.

RAPS Connect:Direct Form

OMB No. 0938-1152 - Expires: March 31, 2025
The Connect:Direct Form provides the parameters Palmetto GBA has defined that Organizations will need to use when exchanging data files using the Connect:Direct software. Organizations need to complete the form and provide the unique dataset names they would like their return reports to be delivered to.

Submitter's Network Mapping Values

In order to establish bi-directional data transfers with Palmetto GBA, provide the following network mapping values.
Example: 999.999.999.999
The Network Address Translation (NAT) IP Address must be obtained
from your Network Service Vendor (NSV).
Example: 1364
The listener port is 1364 by default, however if this is changed,
it must be verified with your network team.
Example: ABCDEFGHIJ999999
The node ID must be obtained from your Connect:Direct support team.

Additional Information

If submitting data files, the Production ID is required. If the submitter's system requires login credentials to receive data files, provide the Login ID.
Example: ABC123XYZ!#$
This is the log in ID used to transmit files to Palmetto GBA.
Example: ABC1234!#$
This is the log in ID Palmetto GBA will use to
send files and/or processing reports to you,
if your system requires log in credentials for
sending files and processing reports back to your system.
This is the person that will be responsible for setting up and testing Connect:Direct connectivity.
Example: (888) 999-1234
This is the phone number for the person that will be responsible for setting up and testing Connect:Direct connectivity.
Example: email@domain.com
This is the email address of the person that will be
responsible for setting up and testing Connect:Direct connectivity.

* Dataset Names

To receive multiple data files and prevent overwriting of existing files, it is recommended that Generational Data Group (GDG) dataset names (mainframe platform only) or dataset names containing date and timestamp (any platform) are provided.
Frequency = Daily
FERAS Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
RAPS Return File
DSORG=PS,LRECL=512,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
RAPS Transaction Error Report
DSORG=PS,LRECL=133,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
RAPS Transaction Summary
DSORG=PS,LRECL=133,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
RAPS Duplicate Diagnosis Cluster
DSORG=PS,LRECL=133,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system

Monthly

Frequency = Monthly
RAPS Monthly Plan Activity
DSORG=PS,LRECL=133,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
RAPS Cumulative Plan Activity
DSORG=PS,LRECL=133,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
RAPS Monthly Error Frequency
DSORG=PS,LRECL=133,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
Frequency = Quarterly
RAPS Quarterly Error Frequency
DSORG=PS,LRECL=133,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
* Indicates required field.

MMP Connect:Direct Form

OMB No. 0938-1152 - Expires: March 31, 2025
The Connect:Direct Form provides the parameters Palmetto GBA has defined that Organizations will need to use when exchanging data files using the Connect:Direct software. Organizations need to complete the form and provide the unique dataset names they would like their return reports to be delivered to.

Submitter's Network Mapping Values

Provide the following network mapping values in order to establish bi-directional data transfers with Palmetto GBA.
Example: 999.999.999.999
The Network Address Translation (NAT) IP Address must be obtained
from your Network Service Vendor (NSV).
Example: 1364
The listener port is 1364 by default, however if this is changed,
it must be verified with your network team.
Example: ABCDEFGHIJ999999
The node ID must be obtained from your Connect:Direct support team.

Additional Information

If submitting data files, the Production ID is required. If the submitter's system requires login credentials to receive data files, provide the Login ID.
Example: ABC123XYZ!#$
This is the log in ID used to transmit files to Palmetto GBA.
Example: ABC1234!#$
This is the log in ID Palmetto GBA will use to
send files and/or processing reports to you,
if your system requires log in credentials for
sending files and processing reports back to your system.
This is the person that will be responsible for setting up and testing Connect:Direct connectivity.
Example: (888) 999-1234
This is the phone number for the person that will be responsible for setting up and testing Connect:Direct connectivity.
Example: email@domain.com
This is the email address of the person that will be
responsible for setting up and testing Connect:Direct connectivity.

* Dataset Names

To receive multiple data files and prevent overwriting of existing files, it is recommended that Generational Data Group (GDG) dataset names (mainframe platform only) or dataset names containing date and timestamp (any platform) are provided.

Prescription Drug Event

Frequency = Daily
Prescription Drug Front End System (PDFS) Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
Drug Data Processing System (DDPS)
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
DDPS Transaction Error Summary
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system

Monthly

Monthly reports are grouped by date of service year and will be distributed in one dataset unless datasets containing a variable for the year is provided.
Frequency = Monthly
DDPS 04 COV Cumulative Beneficiary Summary
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
DDPS 04 ENH Cumulative Beneficiary Summary
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
DDPS 04 OTC Cumulative Beneficiary Summary
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
P2P 40 COV Accounting
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
P2P 40 ENH Accounting
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
P2P 40 OTC Accounting
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
P2P 41 COV Receivable
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
P2P 42 COV Part-D Payment Reconciliation
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
P2P 43 COV Payable
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
Frequency = Quarterly
DDPS Potential Exclusion Warning Report
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
Frequency = Annually
Phase III
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – iif selected AS400 or Server system

Risk Adjustment

Frequency = Daily
FERAS Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
RAPS Return File
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
RAPS Transaction Error Report
DSORG=PS,LRECL=133,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
RAPS Transaction Summary
DSORG=PS,LRECL=133,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
RAPS Duplicate Diagnosis Cluster
DSORG=PS,LRECL=133,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
Frequency = Monthly
RAPS Monthly Plan Activity
DSORG=PS,LRECL=133,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
RAPS Cumulative Plan Activity
DSORG=PS,LRECL=133,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
RAPS Monthly Error Frequency
DSORG=PS,LRECL=133,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system
Frequency = Quarterly
RAPS Quarterly Error Frequency
DSORG=PS,LRECL=133,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZYYYY – where Z = an alpha character – If selected Mainframe System
Ex. format: YYYY – if selected AS400 or Server system

Medicare Encounter Data

Frequency = Daily
Invalid Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
TA1 Acknowledgement Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
999A Acknowledgement Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
999R Acknowledgement Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
277CA Acknowledgement Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
MAO-001 Data Duplicates Report
DSORG=PS,LRECL=287,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
MAO-001 Data Duplicates File
DSORG=PS,LRECL=287,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
MAO-002 Data Processing Status Report
DSORG=PS,LRECL=154,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
MAO-002 Data Processing Status File
DSORG=PS,LRECL=154,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system

Medicaid Data

Frequency = Daily
Invalid Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
TA1 Acknowledgement Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
999A Acknowledgement Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
999R Acknowledgement Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
277CA Acknowledgement Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system

Dental

Frequency = Daily
Dental Validation Report
DSORG=PS,LRECL=133,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system

NCPDP

Frequency = Daily
National Council for Prescription Drug Program (NCPDP) Response
DSORG=PS,LRECL=80,RECFM=FB
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block
DSORG – Dataset Organization
PS – Partition Sequential
LRECL – Logical Record Length
RECFM – Record Format
FB – Fixed Block Ex. format: ZCYYMMDD.ZHHMMSS – where Z = an alpha character – If Mainframe System
Ex. format: YYYYMMDDHHMMSS – if selected AS400 or Server system
* Indicates required field.

Submitter Authorization Form

OMB No. 0938-1152 - Expires: March 31, 2025
Instructions: The following information must be completed by an authorized representative of the contract. This form should not be completed by a Third Party submitter.

Please note that all required forms (i.e. EDI Agreement and Submitter Application) must be received by all entities involved in order to complete setup.

This form authorizes the following entities to submit data and receive reports on behalf of
for the following contract(s) effective
* Enter Contract Numbers
The unique contract number assigned by CMS. Format: 5 Character Alphanumeric
The unique contract number assigned by CMS. Format: 5 Character Alphanumeric
The unique contract number assigned by CMS. Format: 5 Character Alphanumeric
The unique contract number assigned by CMS. Format: 5 Character Alphanumeric
Add Row
Please provide the Third Party Submitter information authorized to submit for each Submission Type.
Sample Input - Start with 'E' Followed By 6 Alphanumeric Characters
Sample Input - Start with 'S' Followed By 6 Alphanumeric Characters
Sample Input - Start with 'S' Followed By 6 Alphanumeric Characters
Medicare-Medicaid
Sample Input - Start with 'D' Followed By 5 Alphanumeric Characters
Sample Input - Start with 'D' Followed By 5 Alphanumeric Characters
Sample Input - Start with 'D' Followed By 5 Alphanumeric Characters
Sample Input - Start with 'D' Followed By 5 Alphanumeric Characters
Sample Input - Start with 'D' Followed By 5 Alphanumeric Characters
I am authorized to complete the Submitter Authorization Form on behalf of the indicated party and agree to the instructions as outlined above.