Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 5
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54SECTION 1: BASIC INFORMATION
NEW ENROLLEES
If you are:
• Enrolling with a particular fee-for-service contractor for the first time.
• Undergoing a change of ownership where the new owner will not be accepting assignment of the
Medicare assets and liabilities of the seller/former owner.
ENROLLED MEDICARE PROVIDERS
The following actions apply to Medicare providers already enrolled in the program:
Reactivation
To reactivate your Medicare billing privileges, submit this enrollment application. In addition, you
must be able to submit a valid claim and meet all current requirements for your provider type before
reactivation can occur.
Voluntary Termination
A provider should voluntarily terminate its Medicare enrollment when:
• It will no longer be rendering services to Medicare patients,
• It is planning to cease (or has ceased) operations,
• There has been an acquisition/merger and the new owner will not be using the identification number of
the entity it has acquired,
• There has been a consolidation and the identification numbers of the consolidating providers will no
longer be used, or
• There has been a change of ownership and the new owner will not be accepting assignment of the
Medicare assets and liabilities of the seller/former owner, meaning that the number of the seller/former
owner will no longer be used.
A voluntary identification number termination cannot be used to circumvent any corrective action
NOTE:
plan or any pending/ongoing investigation, nor can it be used to avoid a period of reasonable assurance,
where a provider must operate for a certain period without recurrence of the deficiencies that were the
basis for the termination. The provider will not be reinstated until the completion of the reasonable
assurance period.
Change of Ownership (CHOW)
A CHOW typically occurs when a Medicare provider has been purchased (or leased) by another
organization. The CHOW results in the transfer of the old owner’s Medicare Identification Number and
provider agreement (including any outstanding Medicare debt of the old owner) to the new owner. The
regulatory citation for CHOWs can be found at 42 C.F.R. 489.18. If the purchaser (or lessee) elects not
to accept a transfer of the provider agreement, then the old agreement should be terminated and the
purchaser or lessee is considered a new applicant.
CMS-855A (07/11)
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