CMS-855 Applications and Required Documentation

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  1. Where are the Medicare provider enrollment applications located?
  2. Which enrollment application form(s) should I complete?
  3. May provider enrollment applications be submitted electronically?
  4. How can I request help in completing my enrollment application, or if I have other questions regarding provider enrollment?
  5. Where should completed applications and other provider enrollment documents be sent?
  6. What are the most common reasons why enrollment applications are considered incomplete and need to be returned or developed, causing delays in processing?
  7. What is required to document the legal business names and employer identification numbers (EINs) reported on the CMS-855 enrollment forms?
  8. What is required to document the credentials of non-physician practitioners?

  1. Where are the Medicare provider enrollment applications located?

    The current, 2011 versions of the CMS-855 provider enrollment applications are available for download (external link) from the Centers for Medicare & Medicaid Services (CMS) website. The PDF forms must be printed and must be completed manually. The electronic versions of the forms can be completed online. They must then be printed, signed, dated, and submitted with all required supporting documentation, including the CMS-588 for electronic funds transfer (EFT), if applicable.

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  2. Which enrollment application form(s) should I complete?

    • CMS-855B: This form is used by groups and organizations that are enrolling in Medicare for the first time in a given state, or that are reporting a change to previously reported enrollment information. (Individuals who are the sole owner of a professional corporation, professional association, or limited liability company and who bill through that entity may complete just the CMS 855I and are not required to complete the CMS 855B.)
    • CMS-855I:This form is used by individual physicians and practitioners who are enrolling in Medicare for the first time in a given state or who are reporting changes to previously reported enrollment information. This includes individuals who are unincorporated sole proprietors, reporting their income to the Internal Revenue Service with either their Social Security Number (SSN) or their employer identification number (EIN). It also includes individuals who are the sole owner of a professional corporation, professional association, or limited liability company and who will bill Medicare through that business entity.
    • CMS-855O: This form is used by individual physicians/practitioners who are enrolling for the sole purpose of ordering and referring items and/or services for Medicare beneficiaries and who will not be submitting claims to the Medicare program for their own services, e.g., Department of Veterans Affairs and Public Health Service providers. Please refer to "Medicare Enrollment of Ordering/Referring Providers" on the Enrollment page for information on this type of enrollment.
    • CMS-855R: This form is used by individual physicians/practitioners who are reassigning Medicare benefits to an enrolled group, organization, or individual or who are making a change to a previously established reassignment. (Physician assistants do not complete the CMS-855R; they complete only the CMS-855I.)

      These Medicare provider enrollment forms can be downloaded from the CMS website at http://www.cms.gov/CMSForms/CMSForms(external link). The current forms are dated (07/11) in the lower left corner. Previous versions of the forms are no longer accepted.
    Note: Only one reason may be checked for submittal of an application. Separate applications must be submitted, for example, to report a new enrollment and a change of information to an established record, such as a voluntary termination. Termination of a reassignment of benefits may be reported only on Form CMS-855R. Termination of one reassignment and the addition of a new reassignment must be reported on separate CMS-855R forms.

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  3. May provider enrollment applications be submitted electronically?

    Providers may submit their applications electronically via Internet-Based PECOSExternal Link.

    The provider completes and reviews the application on-line and then submits it electronically. The original signed and dated certification statement and all required supporting documentation must be mailed to the WPS Medicare Provider Enrollment Department at the appropriate address in 5) below within 15 days of submitting the application. Internet-based applications may also be signed electronically; required supporting documentation, however, would still need to be mailed to the WPS Provider Enrollment Department.

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  4. How can I request help in completing my enrollment application, or if I have other questions regarding provider enrollment?

    Please review the application and its instructions. If you still have questions after reviewing the application instructions or for other questions regarding the enrollment process, call our Provider Enrollment Department at (866) 503-7664 and a provider enrollment analyst will assist you. For other questions, unrelated to the Medicare provider enrollment process, please contact the appropriate area. Contact information for all WPS Medicare areas is available by selecting the Contact Us link in the upper right corner of the web page.

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  5. Where should completed applications and other provider enrollment documents be sent?

    Completed applications and other required documents, including Certification Statements for Internet-based PECOS applications, should be sent to the following addresses:

    Priority Mailing Address
    Wisconsin Physicians Service
    Medicare Provider Enrollment
    1707 W. Broadway
    Madison, WI 53713-1834
     
    Wisconsin Physicians Service
    Medicare Provider Enrollment
    P.O. Box 8248
    Madison, WI 53708-8248


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  6. 6. What are the most common reasons why enrollment applications are considered incomplete and need to be returned or developed, causing delays in processing?

    Refer to "Return and Development of CMS-855 Enrollment Applications" for the most common reasons for return and development of enrollment applications.

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  7. What is required to document the legal business names and employer identification numbers (EINs) reported on the CMS-855 enrollment forms?

    CMS-855I: Individuals who are enrolling as the sole owner of a professional corporation, professional association, or limited liability company in Section 4A or as a sole proprietor reporting an EIN in Section 4F must include a copy of Form CP-575 or other Internal Revenue Service (IRS) document verifying the legal business name to which the EIN is assigned. Note that this document must be from the Internal Revenue Service. It cannot be a W9 or other form completed by the applicant or other person. If the applicant reports a billing agency in Section 8, a copy of the billing agency's CP-575 or other IRS document is also required.

    CMS-855B: Group practices and organizations must include a copy of Form CP-575, or other IRS document verifying the legal business name and EIN for the applicant, organizations reported in Section 5, and the billing agency reported in Section 8, if applicable.

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  8. What is required to document the credentials of non-physician practitioners?

    Non-physician practitioners are required to submit copies of documents that establish that they meet Medicare's eligibility criteria for their specialty. These include a copy of the license issued by the state licensing board; a copy of their diploma; a copy of their academic transcript if the diploma does not state the field in which the degree was granted; a copy of the certificate issued by the appropriate national certifying organization, if applicable; and, for clinical social workers, documentation of two years of post-degree supervised clinical experience-the name and address of the facility, the name of the supervisor, and the specific dates of the supervised clinical experience.

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Page Last Updated: Monday, 21-May-2012 16:09:51 CDT