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  Tuesday, May 21, 2024
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Registration Forms

In order to submit ANSI X12N electronic transactions to Georgia Medicaid/PeachCare for Kids®, the appropriate enrollment forms must be completed:

  1. EDI Trading Partner Agreement - All new electronic submitters are required to complete the Georgia Medicaid Electronic Data Interchange (EDI) Trading Partner Agreement form to enroll into EDI Services. Those submitters that are using an already enrolled billing agent, clearinghouse, or software vendor do not need to enroll separately since the clearinghouse, billing agency, or software vendor is already enrolled to transmit electronically. Only one trading partner ID is assigned per submitter location. If multiple submitter IDs are needed for the same address location, please attach a letter to the Trading Partner Agreement explaining the need for the additional trading partner ID. Providers must use the secure Web Portal to delegate access to their clearinghouse, billing agent, or software vendor to allow EDI files to be downloaded on their behalf. Information on how to delegate access is found in the Web Portal User Account Management Guide on the Provider Information >> Provider Manuals page.
  2. Gainwell Technologies EDI Submitter Update Form- If you are already enrolled to transmit or receive electronically and would like to make a change to your EDI trading partner ID profile or provider ID (ERA Only) profile, please complete the corresponding Gainwell Technologies EDI Submitter Update Form indicating the changes you wish to make. The following changes can be made: Trading Partner Name, Contact Information, Address, Status (Active or Inactive), Transmission Method, and Transaction Types. Trading partners cannot change their trading partner ID. This ID can simply be deactivated using the EDI Submitter Update form and a new EDI Trading Partner Agreement for enrollment must be submitted once the original trading partner ID has been deactivated.
  3. SFTP Setup Request Form- This form is only required when transmitting using the Secure File Transfer Protocol (SFTP). This form must be signed by an authorized agent and is necessary to transmit to and from the Georgia Medicaid server. Failure to submit this form will cause your enrollment to be delayed, and/or returned to you as incomplete. For more information on SFTP access, please review the SFTP Setup and Data Transfer Requirements manual on the EDI >> Companion Guides and Manuals page.

Attention Payees Receiving ERAs.
Important: Providers enrolled for Electronic Remittance Advices (ERAs) must activate their Payee Provider Web Portal PINs that they received in the mail.

ERAs are generated using the PAYEE Provider ID; therefore, if you wish to delegate these 835 ERAs so that your clearinghouse/software vendor/billing agent can access these on your behalf, you must provide them access to your file downloads.

Contact your clearinghouse/software vendor/billing agent to get the email address and username that you should grant access to, then follow the instructions in the "Web Portal User Account Management Guide" found on the Provider Manuals page. Refer to section 3.2 titled, "Providers or Trading Partners Delegating Access to a Billing Agent or Trading Partner Account" for detailed instructions.

You will need to grant the "Trade Files Download" role for a user to have access to your 835 ERA file.
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Registration Forms (4 rows returned) List

Registration Forms (4 rows returned)

 TitleFile TypeSize (KB)Release Date 
Disclosure of Ownership and Control Interest Statement - Trading Partners OnlyPDF630.809/01/2022 
Gainwell EDI Submitter Update FormPDF168.411/29/2022 
Gainwell EDI Trading Partner Enrollment AgreementPDF226.211/29/2022 
Gainwell SFTP Access Request FormPDF414.111/23/2020 
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