Enrolling in the Medicare Program
Physicians, non-physician practitioners, and other health care suppliers must enroll in the Medicare program to be eligible to receive Medicare payments for covered services provided to Medicare beneficiaries.
The Medicare enrollment application is used to collect information and to secure the necessary documentation to ensure the physician; non physician and other health care suppliers are qualified and eligible to enroll in the Medicare program. CMS has developed three enrollment application forms to enroll or change Medicare enrollment information. As of receipt date of January 1, 2009, NHIC can only accept the (02/08) version of the 855 forms
They are:
• Medicare Enrollment Application for Physician and Non Physician Practitioners (Form CMS- 855I). This application is used by individual physicians or non-physicians practitioners to initiate the Medicare enrollment process or to change their Medicare enrollment information.
• Medicare Enrollment Application for Clinics/Group Practices and Certain Other Suppliers (Form CMS-855B). This application is used by group practices or other organizations to initiate the Medicare enrollment process or to change their Medicare enrollment process or to change their Medicare enrollment information.
• Medicare Enrollment Application for Reassignment of Medicare Benefits (Form CMS-855R). This application is used to initiate a reassignment of a right to bill the Medicare program and receive payment.
The following forms are routinely submitted with an enrollment application:
• Authorization Agreement for Electronic Funds Transfer (Form CMS 588)
• Medicare Participating Physician or Supplier Agreement (Form CMS 460)
The Provider Enrollment, Chain and Ownership System (PECOS) is now a CMS web based program. You may now enroll and update enrollment information on line. Only the signature certification page for the 855I or 855B needs to be mailed into the contractor. Other forms required will print from inside the
program. You may also choose to use a delegate for this if you use a credentialing department. Go to http://www.cms.hhs.gov/MedicareProviderSupEnroll/ for further information on how to use PECOS on line.
program. You may also choose to use a delegate for this if you use a credentialing department. Go to http://www.cms.hhs.gov/MedicareProviderSupEnroll/ for further information on how to use PECOS on line.
Important Medicare forms are:
• Application for Health Care Providers that will Bill Medicare Fiscal Intermediaries (CMS 855A)
• Application for Health Care Providers that will Bill Medicare Carriers (CMS 855B)
• Application for Individual Health Care Practitioners (CMS 855I)
• Application for Individual Reassignment of Benefits (CMS 855R)
• Application for DMEPOS Suppliers (CMS 855S) [Note: DMERCS must notify the National Supplier Clearinghouse (NSC) of all address changes.]
The CMS Website also furnishes a comprehensive user guide with detailed instructions on how to download these applications. Providers and suppliers can complete a form on their computer, save it as a file, and print the completed form for final signature and submission. Providers and suppliers cannot submit these forms electronically at this time.
The CMS 855 is the required form for provider and supplier enrollment in the Medicare program. The forms are used for applying for a Medicare provider number, changing information in an existing Medicare enrollment record, and reassigning Medicare benefits. To change information, providers and suppliers should complete only the first section of the form and those sections that reflect the changes, additions, or deletions.
With the change to the new Form CMS 855, the 1/98 Form HCFA 855C (Change of Information Request) became obsolete. All change requests must be submitted on the appropriate Form CMS 855 with a signed and dated certification statement. Applications for Iowa, Kansas, Missouri, and Nebraska should be sent to the provider enrollment unit for each state:
Nebraska
WPS Medicare – Provider Enrollment
P.O. Box 8248
Madison, WI 53708
Iowa
WPS Medicare -Provider Enrollment
P.O. Box 8248
Madison, WI 53708
Kansas
WPS Medicare -Provider Enrollment
P.O. Box 8248
Madison, WI 53708
Missouri
WPS Medicare -Provider Enrollment
P.O. Box 8248
Madison, WI 53708
• Application for Health Care Providers that will Bill Medicare Fiscal Intermediaries (CMS 855A)
• Application for Health Care Providers that will Bill Medicare Carriers (CMS 855B)
• Application for Individual Health Care Practitioners (CMS 855I)
• Application for Individual Reassignment of Benefits (CMS 855R)
• Application for DMEPOS Suppliers (CMS 855S) [Note: DMERCS must notify the National Supplier Clearinghouse (NSC) of all address changes.]
The CMS Website also furnishes a comprehensive user guide with detailed instructions on how to download these applications. Providers and suppliers can complete a form on their computer, save it as a file, and print the completed form for final signature and submission. Providers and suppliers cannot submit these forms electronically at this time.
The CMS 855 is the required form for provider and supplier enrollment in the Medicare program. The forms are used for applying for a Medicare provider number, changing information in an existing Medicare enrollment record, and reassigning Medicare benefits. To change information, providers and suppliers should complete only the first section of the form and those sections that reflect the changes, additions, or deletions.
With the change to the new Form CMS 855, the 1/98 Form HCFA 855C (Change of Information Request) became obsolete. All change requests must be submitted on the appropriate Form CMS 855 with a signed and dated certification statement. Applications for Iowa, Kansas, Missouri, and Nebraska should be sent to the provider enrollment unit for each state:
Nebraska
WPS Medicare – Provider Enrollment
P.O. Box 8248
Madison, WI 53708
Iowa
WPS Medicare -Provider Enrollment
P.O. Box 8248
Madison, WI 53708
Kansas
WPS Medicare -Provider Enrollment
P.O. Box 8248
Madison, WI 53708
Missouri
WPS Medicare -Provider Enrollment
P.O. Box 8248
Madison, WI 53708
