Helpful Provider Enrollment Tips

CMS 855I Physicians and Non-Physician Practitioners

CMS 588 Electronic Funds Transfer

CMS 855B Clinics/Group Practices and Certain other Suppliers

License and Certification Websites

Provider Enrollment Change of Information Notification

Medicare Provider Applications and Reminders

1. Types of Applications
   • CMS-855B Clinics/Group Practices and Certain Other Suppliers
   • CMS-855I Physicians and Non-Physician Practitioners
   • CMS-855R Reassignment of Medicare Benefits


2. Application Availability
   • CMS Web site*


3. Processing Timeliness Guidelines
   • Initial Enrollment Applications
     • - 80% in 60 days
     • - 90% in 120 days
     • - 99% in 180 days
   • Changes of Information
     • - 80% in 45 days
     • - 90% in 60 days
     • - 99% in 90 days
   • Reassignment of Benefits
     • - 80% in 45 days
     • - 90% in 60 days
     • - 99% in 90 days


4. Reasons for Delay or Rejection
   • Providers complete discontinued applications (current version is 04/06)
   • Signatures and dates missing
   • Application is incomplete
   • Supporting documents missing
   • Incorrect application submitted
   • Failure to submit all applications necessary to process application request
   • Submit CMS 855R for a Physician Assistant (Physician Assistants should only complete a CMS 855I)
   • All requested information is not submitted or is not submitted within the required timeframe

Reminders

1. A sole proprietor who incorporates (and who is the sole owner of that business) only needs to complete the CMS 855I form. In the past, such suppliers had to complete the CMS 855B, CMS 855I and CMS 855R. However, the person will still need to report information about the practice, such as the legal business name and adverse legal history.
2. When applying for an Individual using the physician's social security number or using their own TAX ID number under their name, the CMS 855I must be completed.
3. When applying for an Individual using another entities TAX ID number, you must complete the CMS 855I and CMS 855R.
4. When applying for a Group Rendering number you must complete the CMS 855R. However, if the physician applying for a group rendering number does not have an existing Medicare Provider Identification Number (PIN) in the state they will be rendering services, the CMS 855I must also be completed.

Checklist

• Complete and submit the most current application
• Remember to sign and date all required areas
• Include the authorized and delegated official information
• Supervising physician information must be included in Section 2 of the CMS 855 I when applicable.
• The following income reporting forms must be submitted:
  • W-2 Employee
  • 1099 Contracted Physician
  • 1065K1 Partnership
• Effective Date (date first saw Medicare patients)
• Legal Business Name
• When changing or adding information complete section 1 of the application. Check all boxes that apply and complete all sections of the application where boxes have been checked.
• If additional information is requested by the carrier, a newly signed Certification Statement must be submitted.
• Include all mandatory attachments
  • Copy(s) of all professional school degrees or certificates, or evidence of qualifying course work.
  • Copy(s) of all Federal, State, and/or local (city/county) business licenses, certifications and/or registrations specifically required to operate as a health care facility.
  • CP 575 pre-printed Federal Tax Form
  • CMS 588 - Authorization Agreement or Electronic Funds Transfer
  • NPI notification from NPPES.

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