EDI Enrollment Forms for Dental Claims

Beginning July 1, 2024, Palmetto GBA will begin receiving and processing dental claims submitted in the ANSI 837D format. You must complete and submit a Part B Dental EDI Application Form (PDF) prior to submitting Jurisdiction J and Jurisdiction M Part B dental claims in the ANSI 837D format. If you currently submit electronic claims files to Palmetto GBA and have an EDI Enrollment Agreement form on file, you do not need to resubmit a new enrollment agreement form.

Testing 837D Dental Claims

Submitter testing is required to ensure that the flow of data from the submitter to Palmetto GBA works properly. Testing also ensures the data submitted is valid and formatted correctly. New dental claim submitters are required to test prior to sending their first production dataset. New dental claim submitters are also required to have completed the Palmetto GBA enrollment process prior to testing.

Begin testing once you have software and a Submitter ID number. You must submit a minimum of five dental claims and you must score 100% to get certified for live claims production. You should submit test claim files using your Medicare provider number. Do not notify Palmetto GBA before you test – just start!

Response reports are available within 24 hours of transmission. Submitters should retrieve their reports, correct any errors, and re-submit the claims until a single file of at least 5 claims is 100% error free. You must contact the Palmetto GBA Provider Contact Center once you have successfully passed testing.

Please refer to the ANSI 837D Companion Guide (PDF) and 999 & 277CA Dental Edits Listing (PDF) for additional information.