Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 2

Download a blank fillable Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Form Approved
OMB NO. 0938-0685
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Expires: 08/19
CENTERS FOR MEDICARE & MEDICAID SERVICES
who Should SuBMit thiS aPPliCation
Clinics and group practices can apply for enrollment in the Medicare program or make a change in their
enrollment information using either:
• The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or
• The paper enrollment application process (e.g., CMS 855B).
For additional information regarding the Medicare enrollment process, including Internet-based PECOS, go
to
Clinics and group practices who are enrolled in the Medicare program, but have not submitted the CMS
855B since 2003, are required to submit a Medicare enrollment application (i.e., Internet-based PECOS or
the CMS 855B) as an initial application when reporting a change for the first time.
The following suppliers must complete this application to initiate the enrollment process:
• Ambulance Service Supplier
• Mammography Center
• Ambulatory Surgical Center
• Mass Immunization (Roster Biller Only)
• Clinic/Group Practice
• Part B Drug Vendor
• Independent Clinical Laboratory
• Portable X-ray Supplier
• Independent Diagnostic Testing Facility (IDTF)
• Radiation Therapy Center
• Intensive Cardiac Rehabilitation Supplier
If your supplier type is not listed above, contact your designated fee-for-service contractor before you
submit this application.
Complete and submit this application if you are an organization/group that plans to bill Medicare and
you are:
•
A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics,
independent laboratories, portable x-ray suppliers).
•
A hospital or other medical practice or clinic that may bill for Medicare Part A services but will also
bill for Medicare Part B practitioner services or provide purchased laboratory tests to other entities that
bill Medicare Part B.
•
Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another
fee-for-service contractor’s jurisdiction (e.g., you have opened a practice location in a geographic
territory serviced by another Medicare fee-for-service contractor).
•
Currently enrolled in Medicare and need to make changes to your enrollment data (e.g., you have
added or changed a practice location). Changes must be reported in accordance with the timeframes
established in 42 C.F.R. § 424.516(d). (IDTF changes of information must be reported in accordance with
42 C.F.R. § 410.33.)
Billing nuMBer inforMation
The National Provider Identifier (NPI) is the standard unique health identifier for health care providers
and is assigned by the National Plan and Provider Enumeration System (NPPES). As a Medicare health
supplier, you must obtain an NPI prior to enrolling in Medicare or before submitting a change for
your existing Medicare enrollment information. Applying for an NPI is a process separate from Medicare
enrollment. As a supplier, it is your responsibility to determine if you have “subparts.” A subpart is a
component of an organization (supplier) that furnishes healthcare and is not itself a legal entity. If you do
have subparts, you must determine if they should obtain their own unique NPIs. Before you complete this
enrollment application, you need to make those determinations and obtain NPI(s) accordingly.
CMS-855B (07/11)
1

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Medical
Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Medical
Form Cms-855i - Medicare Enrollment Application - Physicians And Non-physician Practitioners Form Cms-855i - Medicare Enrollment Application - Physicians And Non-physician Practitioners Medical
Form Cms-8550 - Medicare Enrollment Application Form Cms-8550 - Medicare Enrollment Application Medical
Form Cms-855a - Medicare Enrollment Application - Institutional Providers Form Cms-855a - Medicare Enrollment Application - Institutional Providers Medical
Form Cms-46 - Medicare Participating Physician And Supplier Agreement Form Cms-46 - Medicare Participating Physician And Supplier Agreement Legal
Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Medical
Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Medical
Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Medical
Form Cms-671 - Ltc Facility Application For Medicare/medicaid Form Cms-671 - Ltc Facility Application For Medicare/medicaid Medical

Related Categories

Parent category: Medical
Download
Go
Page of 49