CMS-855B is to be used by Clinics/group practices and certain other suppliers — Complete this application if you are an organization/group that plans to bill Medicare and you are:
• A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, portable x-ray suppliers).
• A hospital or other medical practice or clinic that may bill for Medicare Part A services but will also bill for Medicare Part B practitioner services or provide purchased laboratory tests to other entities that bill Medicare Part B.
• Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor’s jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another Medicare fee-for-service contractor).
• Currently enrolled in Medicare and need to make changes to your enrollment data (e.g., you have added or changed a practice location).
The following suppliers must complete this application to initiate the enrollment process:
• Ambulance Service Supplier
• Ambulatory Surgical Center
• Clinic/Group Practice
• Independent Clinical Laboratory
• Independent Diagnostic Testing Facility (IDTF)
• Intensive Cardiac Rehabilitation Supplier
• Mammography Center
• Mass Immunization (Roster Biller Only)
• Part B Drug Vendor
• Portable X-ray Supplier
• Radiation Therapy Center
• Pharmacy
Note: Are you a supplier looking for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) enrollment? Please visit CGS Medicare external link, the DMEPOS Medicare Administrative Contractor (MAC) for Florida, Puerto Rico, and the U.S. Virgin Islands.
CMS-855 applications
When to complete a new CMS-855
Q: When do I need to complete a new CMS-855?
A. You need to complete a new CMS-855 when:
• An individual or entity is requesting initial enrollment into the Medicare program.
• Changes are being submitted to update enrollment information and the individual or entity does not have a completed enrollment application (CMS-855) on file.
• An individual or entity is submitting a request for Electronic Funds Transfer (EFT) and an enrollment application is not on file.
Access the Provider Enrollment Application Assistance Tool for more help in determining the appropriate enrollment form for submission.
How to complete a CMS-855 form
Q: How do I complete a CMS-855 form? How can I be sure that I have everything I need?
A: Medicare enrollment applications/forms (CMS-855A, CMS-855B, CMS-855I, and CMS-855R) must be completed with accurate information and include all supporting documentation.
First Coast Service Options Inc. (First Coast) offers several online resources to assist you during the provider enrollment process including:
• CMS-855 tutorials
• Institutional providers: CMS-855A flash file
• Clinics/group practices and certain other suppliers: CMS-855B flash file
• Physicians and non-physician practitioners: CMS-855I flash file
• Reassignment of benefits: CMS-855R flash file
• Provider enrollment tips, terms, and specialty codes:
• Tips to expedite your Medicare enrollment process
• Commonly used provider enrollment terms and their definitions
• Medicare provider/supplier specialty codes
Access the Provider Enrollment Application Assistance Tool for more help in determining the appropriate enrollment form and documentation for submission.
Determining the provider’s legal name
Q: What is the provider’s legal business name that should appear on CMS-855 Medicare enrollment applications?
A: A provider’s legal business name is the name that is registered with the Internal Revenue Service (IRS) and should appear on IRS documents, such as the CP-575, that contains a provider’s employee identification number (EIN) or tax identification number (TIN).
The provider’s legal business name with the IRS should identically match (including any or no punctuation) the business name registered with the National Plan & Provider Enumeration System (NPPES), which issues the national provider identifier (NPI). This is the information that will be loaded into the Provider Enrollment, Chain and Ownership System (PECOS). PECOS and NPPES must match exactly.
To validate that the legal business name the IRS has for you matches the business name registered with NPPES by visiting the NPPES website external link or contacting them at 1-800-465-3203 or 1-800-692-2326 for TTY services.
Certification statement of the CMS-855
Q: Who should sign the certification statement of the CMS-855 provider enrollment application?
A: The following shows the information for the various applications:
CMS-855A and CMS-855B
For initial enrollment and revalidation, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization’s status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized officials. However, each authorized official must be listed in section 6 of the CMS-855. Anyone listed as a “Contracted Managing Employee” in section 6 of the CMS-855 cannot be an authorized official.
CMS-855C
For initial enrollment, updating information and voluntarily withdrawing your registration, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization’s status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
CMS-855I
The only person who may sign the CMS-855I is the individual practitioner, including solely-owned entities listed in section 4A. This applies to initial enrollments, changes of information, reactivations, etc. An individual practitioner may not delegate authority to any other person to sign the CMS-855I on his/her behalf.
CMS-855POH
For physician-owned hospitals complying with the annual reporting requirement, the certification statement must be signed and dated (preferably in blue ink) by an authorized or delegated official. An authorized or delegated official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization’s status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The official’s signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized or delegated officials. However, each official must be previously reported and approved on the CMS-855A at the time the physician-owned hospital was enrolled or when a CMS-855A was submitted to report a change in the authorized or delegated official.
CMS-855R
For initial reassignment, both the individual and the group’s authorized or delegated official must sign section 6. If either signature is missing, First Coast Service Options Inc. (First Coast) will return the application.
If terminating a reassignment, either party may sign section 6; both signatures are not required. If no signatures are present, First Coast will return the application.
The authorized or delegated official who signs section 6 must be currently on file with First Coast.
All CMS-855 applications
If the application is not signed and dated appropriately, the application will be returned. The application will need to be corrected and resubmitted. Any application resubmission must contain a brand new certification statement page containing a signature and date. The provider cannot simply add a signature to the original certification statement submitted.
Access the Provider Enrollment Application Assistance Tool for more help in determining the appropriate enrollment form for submission.
Delegating authority to sign CMS-855B applications
Q: May an authorized official delegate their authority to sign CMS-855B applications?
A. An authorized official of an organization may delegate authority to make changes to enrollment information and to add physicians/practitioners. The organization must complete the section 16 of the CMS-855B and an authorized official must sign the certification statement. The delegated official must be an individual with an “ownership or control interest” in or be a W-2 managing employee of the supplier. The delegated official must be reported in Section 6.
An individual physician or practitioner cannot delegate authority and must sign the certification statement of the CMS-855I.
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Sole proprietor versus a sole owner
Q: What are the differences in completing Section 4 of a CMS-855I application for a sole proprietor versus a sole owner?
A: Sole Proprietorship – Section 4F of the CMS-855I is completed with the employer identification number (EIN). The instructions in this section state, “if you are a sole proprietor and you want Medicare payments to be reported under your EIN, list it below.” Only one national provider identifier (NPI) number is needed for the provider. Sole proprietors do not complete section 4A.
Sole Ownership – Section 4A of the CMS-855I is completed with the tax identification number (TIN). If anything is listed in section 4A, a separate NPI number must be obtained for the group number that will be assigned and listed in section 4A. The individual’s NPI number and information must be listed in section 4C.
CMS recently made available a document that will assist physicians and non-physician practitioners in completing the CMS-855I form titled Medicare Provider Enrollment of Individuals (Physicians and Non-Physician Practitioners) external pdf file. Scenarios 2a, 2b, 3 & 4 are very helpful in determining if you are a sole proprietor or sole owner.
Section 4 of the CMS-855R
Q: What information should be in Section 4 of the CMS-855R form?
A. The following information is required:
Initial Reassignment
Section 4A on page 6 is signed and dated by the person reassigning their benefits. Section 4B is signed and dated by the group’s authorized official or delegated official. If either signature is missing, First Coast Service Options Inc. (First Coast) will request this information as part of the development process.
Terminating Reassignments
If the individual terminates a reassignment, the individual signs and dates section 4A.
If the organization terminates a reassignment, the group’s authorized official or delegated official signs and dates Section 4B.
For terminations, both signatures are not required. However, if no signatures are present, First Coast will request this information as part of the development process.
Applicable to all CMS-855R applications
The authorized or delegated official who signs section 4B must be currently on file with First Coast. All signatures must be original, preferably in blue ink. Faxed, stamped, or photocopied signatures cannot be accepted.
If the application is not signed and dated appropriately, First Coast will send a developmenMiscellaneous forms and documentation.
Miscellaneous forms and documentation
CMS-460
Q: What is the purpose of the Medicare Participating Physician or Supplier Agreement (CMS-460)?
A: New physicians, practitioners, and suppliers may submit the CMS-460 form external pdf file at the time of their enrollment. Participants agree to accept assignment for all covered services provided to Medicare patients.
In addition, the CMS-460 may also be used for existing providers during the annual participation open enrollment. The annual physician and supplier participation period begins January 1 of each year, and runs through December 31. The annual participation enrollment is scheduled to begin on November 15 of each year. (Note: The dates listed for release of the participation enrollment/fee disclosure material are subject to publication of the annual Final Rule.)
During the annual enrollment period, for First Coast Service Options Inc. (First Coast), the MAC for jurisdiction N (JN), which includes Florida, Puerto Rico, and the U.S. Virgin Islands, submit your completed CMS-460 form (or disenrollment request) to:
Provider Enrollment
P.O. Box 3409
Mechanicsburg, PA 17055-1849
