Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 3
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54INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION
• Type or print all information so that it is legible. Do not use pencil.
• Report additional information within a section by copying and completing that section for each
additional entry.
• Attach all required supporting documentation.
• Keep a copy of your completed Medicare enrollment package for your records.
• Send the completed application with original signatures and all required documentation to your
designated Medicare fee-for-service contractor.
AVOID DELAYS IN YOUR ENROLLMENT
To avoid delays in the enrollment process, you should:
• Complete all required sections.
• 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 provider’s address.
• Enter your NPI in the applicable sections.
• Enter all applicable dates.
• Ensure that the correct person signs the application.
• Send your application and all supporting documentation to the designated fee-for-service contractor.
OBTAINING MEDICARE APPROVAL
The usual process for becoming a certified Medicare provider is as follows:
1. The applicant completes and submits a CMS-855A enrollment application and all supporting
documentation to its fee-for-service contractor.
2. The fee-for-service contractor reviews the application and makes a recommendation for approval or
denial to the State survey agency, with a copy to the CMS Regional Office.
3. The State agency or approved accreditation organization conducts a survey. Based on the survey results,
the State agency makes a recommendation for approval or denial (a certification of compliance or
noncompliance) to the CMS Regional Office. Certain provider types may elect voluntary accreditation
by a CMS-recognized accrediting organization in lieu of a State survey.
4. A CMS contractor conducts a second contractor review, as needed, to verify that a provider continues
to meet the enrollment requirements prior to granting Medicare billing privileges.
5. The CMS Regional Office makes the final decision regarding program eligibility. The CMS Regional
Office also works with the Office of Civil Rights to obtain necessary Civil Rights clearances. If
approved, the provider must typically sign a provider agreement.
CMS-855A (07/11)
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