Part A Provider Enrollment Interactive Help Tool
If you choose to complete paper forms to enroll in Medicare for the first time, or make changes to your existing enrollment information, use this tool to.
- Help you complete the CMS Medicare enrollment application
- Identify the supporting documentation required to complete the enrollment process
- Receive a barcoded application coversheet that will help CGS process your application in a timely manner
Instructions: Answer the question(s) below. The tool will identify the appropriate form(s) to complete and the supporting documents required with the application submission
1. Are you currently enrolled as a Part A provider with CGS Administrators LLC?
2. Are you adding a practice location?
3. Have you paid the fee requirement as prescribed by CMS?
4. Complete form CMS 855A as identified below:
This tool is for those providers with an active PECOS enrollment wanting to add, change, or delete information. Complete only the identified section(s) of the CMS 855A application that are changing.
CMS 855A | Section | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 2 | 2B1 | 3 | 4 | 5 | 6 | 8 | 12 | 13 | 14 | 15 | |
Identifying Information Ex: Legal Name Change, Doing Business As Name info, License or Correspondence) | X | X | X | X | X | X | ||||||
Adverse Legal Actions/Convictions | X | X | X | X | X | |||||||
Practice Location Information, Payment Address & Medical Record Storage Information | X | X | X | X | X | X | ||||||
Ownership Interest and/or Managing Control Information | X | X | X | X | X | X | X | |||||
Chain Home Office Information | X | X | X | X | X | X | ||||||
Billing Agency Information | X | X | X | X | X | X | ||||||
Special Requirements for Home Health Agencies | X | X | X | X | X | X | ||||||
Authorized/Delegated Official | X | X | X | X | X | X |
5. Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:
Mailing Address - Jurisdiction 15
CGS Administrators LLC – J15 MAC
Part A Provider Enrollment
P.O. Box 20004
Nashville, TN 37202
Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
CGS Administrators LLC – J15 MAC
26 Century Blvd STE ST610
Nashville, TN 37214-3685
Be sure to:
- Complete all required information, including any boxes to indicate "not applicable".
- Provide information required for Electronic Fund Transfer.
- Sign your application in BLUE ink.
- Date your application.
- Submit copies of all appropriate licenses, agreements and tax documents.
Important Information:
- Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.
- Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.
- Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.
4. Complete form CMS 855A as identified below:
This tool is for those providers with an active PECOS enrollment wanting to add, change, or delete information. Complete only the identified section(s) of the CMS 855A application that are changing.
CMS 855A | Section | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 2 | 2B1 | 3 | 4 | 5 | 6 | 8 | 12 | 13 | 14 | 15 | |
Identifying Information Ex: Legal Name Change, Doing Business As Name info, License or Correspondence) | X | X | X | X | X | X | ||||||
Adverse Legal Actions/Convictions | X | X | X | X | X | |||||||
Practice Location Information, Payment Address & Medical Record Storage Information | X | X | X | X | X | X | ||||||
Ownership Interest and/or Managing Control Information | X | X | X | X | X | X | X | |||||
Chain Home Office Information | X | X | X | X | X | X | ||||||
Billing Agency Information | X | X | X | X | X | X | ||||||
Special Requirements for Home Health Agencies | X | X | X | X | X | X | ||||||
Authorized/Delegated Official | X | X | X | X | X | X |
5. Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:
Mailing Address - Jurisdiction 15
CGS Administrators LLC – J15 MAC
Part A Provider Enrollment
P.O. Box 20004
Nashville, TN 37202
Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
CGS Administrators LLC – J15 MAC
26 Century Blvd STE ST610
Nashville, TN 37214-3685
Be sure to:
- Complete all required information, including any boxes to indicate "not applicable".
- Provide information required for Electronic Fund Transfer.
- Sign your application in BLUE ink.
- Date your application.
- Submit copies of all appropriate licenses, agreements and tax documents.
Important Information:
- Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.
- Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.
- Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.
3. Complete form CMS 855A as identified below:
This tool is for those providers with an active PECOS Enrollment wanting to add, change, or delete information. Complete only the identified section(s) of the CMS 855A application that are changing.
CMS 855A | Section | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 2 | 2B1 | 3 | 4 | 5 | 6 | 8 | 12 | 13 | 14 | 15 | |
Identifying Information Ex: Legal Name Change, Doing Business As Name info, License or Correspondence) | X | X | X | X | X | X | ||||||
Adverse Legal Actions/Convictions | X | X | X | X | X | |||||||
Practice Location Information, Payment Address & Medical Record Storage Information | X | X | X | X | X | X | ||||||
Ownership Interest and/or Managing Control Information | X | X | X | X | X | X | X | |||||
Chain Home Office Information | X | X | X | X | X | X | ||||||
Billing Agency Information | X | X | X | X | X | X | ||||||
Special Requirements for Home Health Agencies | X | X | X | X | X | X | ||||||
Authorized/Delegated Official | X | X | X | X | X | X |
4. Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:
Mailing Address - Jurisdiction 15
CGS Administrators LLC – J15 MAC
Part A Provider Enrollment
P.O. Box 20004
Nashville, TN 37202
Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
CGS Administrators LLC – J15 MAC
26 Century Blvd STE ST610
Nashville, TN 37214-3685
Be sure to:
- Complete all required information, including any boxes to indicate "not applicable".
- Provide information required for Electronic Fund Transfer.
- Sign your application in BLUE ink.
- Date your application.
- Submit copies of all appropriate licenses, agreements and tax documents.
Important Information:
- Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.
- Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.
- Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.
2. Have you paid the fee requirement as prescribed by CMS?
3. Complete form 855A sections 1-8, 13, 15 16 (Optional), and 17 (Reference)
- CMS 855A form
- Refer to the chart below regarding Sections 5 and 6
Type of Organization Section 5 and/or 6 Officer Director Managing Employee Authorized Official Delegated Official 5% or > Direct Owner 5% or > Indirect Owner General Partner Limited Partner Sole Proprietorship A N/A N/A N/A N/A N/A A A* M* General Partnership M M A N/A M M A A* M* Limited Partnership M M A A M M A A* M* Corporation A M N/A N/A A A A A* M* Limited Liability Company A M N/A N/A M M A A* M* Non-Profit Organization M M N/A N/A A A A A* M* Government Owned Entity A N/A N/A N/A M M A A* M* A = Applicable & required to include
M = May be applicable; required to include if applicable to your organization
N/A = Not applicable*The individual(s) signing section 15 and/or section 16 must be listed as an authorized official or delegated official in Section 6.
- Section 15 (Certification Statement) of the 855A must be signed and dated by the 'authorized official' for initial enrollment. Faxed, photocopied, or stamped signatures will not be accepted.
4. Include the following documents:
- License, certifications and registrations required by Medicare or State Law
- Federal, State, and/or local (city/county) business licenses, certifications and/or registrations required to operate a health facility
- Written confirmation from the IRS confirming your Tax Identification Number with the Legal Business Name (e.g. IRS CP575) provided in Section 2. Please ensure your legal business name is listed on the application and identified with NPPES exactly as it is with the IRS.
- Copy of IRS Determination Letter, if provider is registered with the IRS as non-profit
- Copy of an attestation for government entities and tribal organizations (if applicable)
- Organization Structure Diagram/Flowchart identifying all entities listed in Section 5 (if Section 5A-Ownership and/or Managing Control–Organizations is applicable). For Skilled Nursing Facilities, include all entities and individuals that have less than a 5% direct or indirect ownership interest.
- Copy of HRSA Notice of Grant Award (Federally Qualified Health Center only)
5. Electronic Funds Transfer (EFT)
- EFT CMS 588 form
- A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter.
- Please ensure your legal business name is listed on the EFT agreement and bank documentation exactly as it is with the IRS.
4. Complete form 855A sections 1-8, 13, 15 16 (Optional), and 17 (Reference)
- CMS 855A form
- Refer to the chart below regarding Sections 5 and 6
Type of Organization Section 5 and/or 6 Officer Director Managing Employee Authorized Official Delegated Official 5% or > Direct Owner 5% or > Indirect Owner General Partner Limited Partner Sole Proprietorship A N/A N/A N/A N/A N/A A A* M* General Partnership M M A N/A M M A A* M* Limited Partnership M M A A M M A A* M* Corporation A M N/A N/A A A A A* M* Limited Liability Company A M N/A N/A M M A A* M* Non-Profit Organization M M N/A N/A A A A A* M* Government Owned Entity A N/A N/A N/A M M A A* M* A = Applicable & required to include
M = May be applicable; required to include if applicable to your organization
N/A = Not applicable*The individual(s) signing section 15 and/or section 16 must be listed as an authorized official or delegated official in Section 6.
- Section 15 (Certification Statement) of the 855A must be signed and dated by the 'authorized official' for initial enrollment. Faxed, photocopied, or stamped signatures will not be accepted.
5. Include the following documents:
- License, certifications and registrations required by Medicare or State Law
- Federal, State, and/or local (city/county) business licenses, certifications and/or registrations required to operate a health facility
- Written confirmation from the IRS confirming your Tax Identification Number with the Legal Business Name (e.g. IRS CP575) provided in Section 2. Please ensure your legal business name is listed on the application and identified with NPPES exactly as it is with the IRS.
- Copy of IRS Determination Letter, if provider is registered with the IRS as non-profit
- Copy of an attestation for government entities and tribal organizations (if applicable)
- Organization Structure Diagram/Flowchart identifying all entities listed in Section 5 (if Section 5A-Ownership and/or Managing Control–Organizations is applicable). For Skilled Nursing Facilities, include all entities and individuals that have less than a 5% direct or indirect ownership interest.
- Copy of HRSA Notice of Grant Award (Federally Qualified Health Center only)
6. Electronic Funds Transfer (EFT)
- EFT CMS 588 form
- A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter.
- Please ensure your legal business name is listed on the EFT agreement and bank documentation exactly as it is with the IRS.