Cms 855R Form PDF Details

The CMS-855R form is used by individual healthcare practitioners to reassign their Medicare Part B billing rights to an eligible organization. When you file the cms 855r form, the organization can bill Medicare directly for services you provide. The cms 855r form applies to physicians, nurse practitioners, physician assistants, and other Medicare-enrolled practitioners who join a group practice or change their billing arrangement.

Who Needs to File the CMS-855R Form

File the cms 855r form if you are in one of these situations. You are newly joining a group practice and want that practice to bill Medicare for your services. You are changing the organization that currently receives your Medicare payments. You want to end an existing billing reassignment entirely. In each case, a new cms 855r form submission is required.

Both the practitioner and the receiving organization must be enrolled in Medicare before or at the time of the cms 855r form submission. If either party is not yet enrolled, the Medicare Administrative Contractor (MAC) will reject the application. Active enrollment for both parties is a firm requirement.

Key Sections of the CMS-855R Form

The cms 855r form is eight pages and contains several important sections. Section 1 asks why you are filing. You choose one option: Add, Change, or Remove a reassignment. Section 2 captures your personal and professional details. Enter your full legal name, National Provider Identifier (NPI), Social Security Number, and home address. Your information must match your current Medicare enrollment records exactly. Section 3 asks for the receiving organization's name, NPI, and Tax Identification Number (TIN). Section 4 requires effective dates and signatures from both parties. An unsigned cms 855r form will be returned without processing.

How to Submit the CMS-855R Form

You have two ways to submit the cms 855r form to Medicare. The first option is through PECOS, the online Provider Enrollment, Chain, and Ownership System. Log in with your I&A credentials and navigate to the reassignment section. Online submission is faster and allows you to track your application status. The second option is paper submission. Mail the completed cms 855r form to your local MAC. CMS lists all MAC mailing addresses on their website. Your MAC is determined by the state where you practice.

Processing Time for the CMS-855R Form

MACs typically process the cms 855r form within 60 days. Online submissions through PECOS are usually faster than paper forms. You will receive a written approval notice with the effective date of the reassignment. Do not change your billing arrangement until you receive this confirmation. Keep billing under your current method during the review period.

Common Mistakes When Filing the CMS-855R Form

Missing NPI numbers or incorrect NPIs are the top reason the cms 855r form gets rejected. Always verify NPI numbers at the NPPES NPI Registry before you submit. Incomplete signatures are another common problem. Both you and an authorized official of the receiving organization must sign before submission. Using an old version of the cms 855r form is also a frequent error. Download the current version directly from the CMS website or use a fillable pdf version. The form revision date appears at the bottom of each page.

Frequently Asked Questions About the CMS-855R Form

Can I reassign my Medicare benefits to more than one organization at a time?

No. The cms 855r form only allows reassignment to one organization at a time. To change the receiving organization, file a new cms 855r form to remove the current reassignment and add the new one.

How long does a reassignment stay active?

Your Medicare reassignment stays active until you file a new cms 855r form to end it. There is no automatic expiration date. You must actively terminate the reassignment when you leave a practice or change employers.

What if my MAC requests additional documentation?

Respond as quickly as possible to any MAC documentation requests. Common requests include copies of your professional license or documentation of your employment relationship with the organization. Delays in responding can slow down processing of your application.

QuestionAnswer
Form NameCms 855R Form
Form Length26 pages
Fillable?Yes
Fillable fields513
Avg. time to fill out2 min
Other namescms 855r provider enrollment form, cms 855r enrollment application, cms 855r medicare enrollment, 855r provider enrollment form

How to Fill Out Form CMS-855I

Form CMS-855I at a glance

What it is: CMS-855I is the Medicare Enrollment Application for Physicians and Non-Physician Practitioners.

Where and when to file: 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 CMS.gov/Medicare/Provider-Enrollment-and-Certification.

All physicians, as well as all eligible professionals as defined in section 1848(k)(3)(B) of the Social Security Act must complete this application to enroll in the Medicare program and receive a Medicare billing number (OMB No. 0938-1355, 05/26).

Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change to their enrollment information (including adding or terminating a reassignment of benefits) using either the Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or the paper CMS-855I enrollment application.

All reassignment actions should now be reported via the CMS-855I. The CMS-855R (Reassignment of Medicare Benefits) form has been discontinued.

What to bring and attach to Form CMS-855I

Completed Form CMS-588, Electronic Funds Transfer Authorization Agreement. Include a voided check or bank letter.

If you currently receive payments electronically and are not making a change to your banking information, the CMS-588 is not required.

Physicians and non-physician practitioners who are reassigning all of their payments to a group/clinic or other health care organization are not required to submit the CMS-588.

Completed Form CMS-460, Medicare Participating Physician or Supplier Agreement. The CMS-460 must be submitted for all initial enrollments or reactivations only if you want to be a Participating Practitioner in Medicare.

Attach all required supporting documentation.

A filled-in Form CMS-855I example: Dr. Sample fills in Section 2A

Form CMS-855I example filled out, example: Dr. Sample fills in Section 2A
Dr. Jane Ann Sample enrolls in Medicare with a paper CMS-855I. The form asks for her Social Security Number, date of birth and NPI in Section 2A. The picture shows Section 2A, and none of its entries is real.

How to fill out Form CMS-855I, box by box

Section 1A: you are a new enrollee, reporting a change or terminating

Check one box and complete the sections of this application as indicated.

If you are a new enrollee in Medicare, complete all applicable sections.

If you are reporting a change to your Medicare enrollment information (includes establishing or terminating a reassignment), go to section 1B below.

If you are voluntarily terminating your Medicare enrollment: Sections 1A, 2A, 13 (optional), and 15.

Section 1B: what information is changing

Check all that apply and complete the required sections. When reporting ANY information, sections 1, 2A, 3 and 15 MUST always be completed in addition to the information that is changing within the required section.

Section 2A: provider's Name, Date of Birth and Social Security Number

The provider's Name, Date of Birth, and Social Security Number must match his/her social security record.

Section 2D: Correspondence Mailing Address

Your Correspondence Mailing Address cannot be a billing agent or agency's address or a medical management company address.

Section 4B: Practice Location Information

You do not need to complete this section if you are reassigning 100% of your Medicare benefits.

Complete this section for each of your practice locations where you render services to Medicare beneficiaries, including any distant site(s) where you render telehealth services.

All reported practice location addresses must be a specific street address as recorded by the United States Postal Service. Your practice location must be the physical location where you render services to Medicare beneficiaries. Your practice location address cannot be a Post Office (P.O.) Box.

Only report those practice locations that are within the jurisdiction of the designated MAC to which you will be submitting this application. If you have to report practice locations outside the jurisdiction of the designated MAC to which you are submitting this application you must submit a separate CMS-855I Enrollment Application to the MAC that has jurisdiction for those locations.

Section 15: certification statement and signature

As an individual practitioner, you are the only person who can sign this application. The authority to sign the application on your behalf may not be delegated to any other person (CMS-855I 05/23, Section 15, 23).

You MUST sign and date the certification statement in order to be enrolled in the Medicare program.

In order to process this application it MUST be signed and dated.

More rules for Form CMS-855I

This form must be typed. It may not be handwritten.

All information on this form is required with the exception of those fields specifically marked as “optional.” Any field marked as optional is not required to be completed nor does it need to be updated or reported as a “change of information” as required in 42 C.F.R. section 424.516.

Keep a copy of your completed Medicare enrollment package for your own records.

If your situation is different

When establishing or terminating a reassignment, or making changes to reassignment information

When establishing a new reassignment, Section 15B must be signed by the individual practitioner and Section 15C must be signed by a delegated/authorized official of the organization/group. If the reassignment is to an individual, that person must sign Section 15C.

When terminating a reassignment or making changes to reassignment information, either the organization/group must sign Section 15C or the individual practitioner must sign Section 15B.

Common questions about Form CMS-855I

Is there a deadline?

If the MAC requests 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) and (2).

Where do I file it?

Send this completed application with original signatures and all required documentation to your designated MAC.

Is there a penalty?

18 U.S.C. 1035 authorizes criminal penalties against individuals in any matter involving a health care benefit program who knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact. The individual shall be fined or imprisoned up to 5 years or both.

When is this form not the right one?

If you are a sole owner and intend to add an Authorized/Delegated Official to your Medicare enrollment, do not complete the CMS-855I application; rather, use the CMS-855B application.

Sources

[1] Form CMS-855I (05/23), Medicare Enrollment Application, Physicians and Non-Physician Practitioners, Centers for Medicare & Medicaid Services (the Official source link on this page).

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