Cms 855B Form – Fill Out and Use This PDF

WHO SHOULD SUBMIT THIS APPLICATION

Clinics, group practices, and other suppliers must complete this application to enroll in the Medicare program and receive a Medicare billing number.

Clinics, group practices, and other suppliers can apply for enrollment in the Medicare program or make a change in their enrollment information using either:

•The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or

•The paper CMS-855B enrollment application. Be sure you are using the most current version.

For additional information regarding the Medicare enrollment process, including Internet-based PECOS and to get the current version of the CMS-855B, go to http://www.cms.gov/MedicareProviderSupEnroll.

NOTE: Applicants using this application require a Type 2 NPI. See below for more information.

NOTE: For the purposes of this application, the word “supplier” is used universally and includes any providers or suppliers who are required to complete the CMS-855B application.

Complete and submit this application if you are an organization/group or other supplier that plans to bill Medicare and you are:

•Enrolling in the Medicare program for the first time with this Medicare Administrative Contractor (MAC) under this tax identification number.

•Currently enrolled in Medicare but have a new tax identification number. If you are reporting a change to your current Medicare enrollment to your tax identification number, you must complete a new application.

•Currently enrolled in Medicare and need to enroll in another Medicare Administrative Contractor’s (MAC’s) jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another MAC).

•Revalidating your Medicare enrollment. CMS may require you to submit or update your enrollment information. The MAC will notify you when it is time for you to revalidate your enrollment information. Do not submit a revalidation application until you have been contacted by your MAC.

•Previously enrolled in Medicare and you need to reactivate your Medicare billing number to resume billing. Prior to being reactivated, you must meet all current requirements for your supplier type before reactivation may occur.

•Currently enrolled in Medicare and need to make changes to your enrollment information (e.g., you have added or changed a practice location). Changes must be reported in accordance with the timeframes established in 42 C.F.R. section 424.516. (IDTF changes of information must be reported in accordance with 42 C.F.R. section 410.33.)

•A hospital, hospital department, 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 will bill Medicare Part B.

•A certified Medicare Part B provider (i.e. Ambulatory Surgery Center, Portable X-ray Supplier) intending to report a CHOW. A CHOW typically occurs when a Medicare provider has been purchased (or leased) by another organization. The CHOW results in the transfer of the old owner’s Medicare Identification Number and provider agreement (including any outstanding Medicare debt of the old owner) to the new owner. The regulatory citation for CHOWs can be found at 42 C.F.R. 489.18. If the purchaser (or lessee) elects not to accept a transfer of the provider agreement, then the old agreement should be terminated and the purchaser or lessee is considered a new applicant and must initially enroll in Medicare.

•A medical practice, group/clinic or other supplier that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, portable x-ray suppliers).

•Terminating a Physician Assistant (PA) employer relationship.

•Terminating an employer or individual relationship with an Independent Diagnostic Testing Facility (IDTF).

•Voluntary terminating your Medicare billing privileges. A supplier should voluntarily terminate its Medicare enrollment when it:

•Will no longer be rendering services to Medicare patients, or

•Is planning to cease (or has ceased) operations.

NOTE: For the purposes of this section of this application, an entity is defined as a group/clinic, other supplier, or any organization to which you will reassign your Medicare benefits.

TIPS TO AVOID DELAYS IN YOUR ENROLLMENT

To avoid delays in the enrollment process, you should:

•Complete all required sections, as shown in section 1.

•Ensure that the legal business name shown in section 2 matches the name on the tax documents.

•Ensure that the correspondence address shown in section 2 is the supplier’s address.

•Enter your NPI(s) in the applicable section(s).

•Include the Electronic Funds Transfer (EFT) Authorization Agreement (when applicable) with your enrollment application with a voided check or bank letter.

•Sign and date section 15.

•Ensure all supporting documents are sent to your designated MAC.

•The supplier pays the required application fee (via https://pecos.cms.hhs.gov/pecos/feePaymentWelcome.do) upon initial enrollment, the addition of a new business location, revalidation and, if requested, reactivation PRIOR to completing and submitting this application to the MAC.

ADDITIONAL INFORMATION

•You may visit our website to learn more about the enrollment process via the Internet-Based Provider Enrollment Chain and Ownership System (PECOS) at: https://www.cms.gov/Medicare/Provider-Enrollment- and-Certification/MedicareProviderSupEnroll/InternetbasedPECOS.html. Also, all of the CMS-855 applications are all located on the CMS webpage: https://www.cms.gov/medicare/cms-forms/cms-forms/ cms-forms-list.html. Simply enter “855” in the “Filter On:” box on this page and only the application forms will be displayed to choose from.

•The MAC may request additional documentation to support and validate information reported on this application. You are responsible for providing this documentation within 30 days of the request per 42 C.F.R. section 424.525(a)(1).

•The information you provide on this form is protected under 5 U.S.C. section 552(b)(4) and/or (b)(6), respectively. For more information, see the last page of this application to read the Privacy Act Statement.

ACRONYMS COMMONLY USED IN THIS APPLICATION

DEFINITIONS

NOTE: For the purposes of this CMS-855B application, the following definitions apply:

•Add: You are adding additional enrollment information to your existing information (e.g. practice locations).

•Change: You are replacing existing information with new information (e.g. billing agency, managing employee) or updating existing information (e.g. change in suite #, telephone #).

•Remove: You are removing existing enrollment information.

WHERE TO MAIL YOUR APPLICATION

Send this completed application with original signatures and all required documentation to your designated MAC. The MAC that services your State is responsible for processing your enrollment application. To locate the mailing address for your designated MAC, go to www.cms.gov/MedicareProviderSupEnroll.

SECTION 2: IDENTIFYING INFORMATION

A. SUPPLIER IDENTIFICATION INFORMATION

1. BUSINESS INFORMATION

Other Name (if applicable)

Type of Other Name (if applicable). Check box indicating Type of Other Name:

Former Legal Business Name

Doing Business As Name

Other (Describe):

Business Structure information

Identify how your business is registered with the IRS. (NOTE: If your business is a Federal and/or State government supplier, indicate “Non-Profit” below. In addition, government-owned entities do not need to provide an IRS Form 501(c)(3)).

Proprietary

Non-Profit (Submit IRS Form 501(c)(3)

Disregarded Entity (Submit IRS Form 8832)

NOTE: If a checkbox identifying how the business is registered with the IRS is not completed, the supplier will be defaulted to “Proprietary.”

Identify the type of organizational structure of this supplier: (Check one)

Corporation

Limited Liability Company

Partnership

Sole Proprietor

Other (Specify):

2. LICENSE/CERTIFICATION/REGISTRATION INFORMATION

Complete the appropriate subsection(s) below for your supplier type as you will report in section 2B. If no subsection is associated with your supplier type, check the box stating the information is not applicable.

a. Active License Information

License Not Applicable

SECTION 2: IDENTIFYING INFORMATION (Continued)

b. Active Certification Information

Complete the appropriate subsection(s) below for your supplier type as you will report in section 2B. If no subsection is associated with your supplier type, check the box stating the information is not applicable. *If

you are certified by a national entity, put the word “all” in the “State Where Issued” data field.

Certification Not Applicable

Certifying Entity (Specialty Board, State, Other)

3. CORRESPONDENCE MAILING ADDRESS

This is the address where correspondence will be sent to the supplier listed in section 2A1 by your designated MAC. This address cannot be a billing agent or agency’s address or a medical management company address.

If you are reporting a change to your Correspondence Mailing Address, check the box below. This will replace any current Correspondence Mailing Address on file.

Attention (optional)

Correspondence Mailing Address Line 1 (P.O. Box or Street Name and Number)

Correspondence Mailing Address Line 2 (Suite, Room, Apt. #, etc.)

4. MEDICAL RECORD CORRESPONDENCE ADDRESS

This is the address where the medical record correspondence will be sent to the supplier listed in section 2A1 by your designated MAC. This information would be used for any medical record review requests.

Check here if your Medical Record Correspondence Address should be mailed to your Correspondence Address in section 2A3 (above) and skip this section.

If you are reporting a change to your Medical Record Correspondence Address, check the box below. This will replace any current Medical Record Correspondence Address on file.