Section 2A -Supplier Identification Information

Section 2A is required for all CMS 855 initial enrollment, revalidation, or change of information applications. This section must include:

• Legal Business Name (LBN) must be listed as it is reported to the Internal Revenue Service (IRS).
• Tax Identification Number (TIN)
• National Provider Identifier (NPI)

Section 2B-Type of Supplier

Section 2B is required for all CMS 855 initial enrollment or revalidation applications. Check the appropriate box to identify the type of supplier you are enrolling as with Medicare.

Section 6 – Ownership Interest and/or Managing Control Information

Sections 6A and 6B are required to be completed for all individuals that currently have any ownership interest or managing control of the Provider/Supplier on all initial enrollment or revalidation applications. An established provider/supplier must complete Section 6 of a change of information application to report any updates to ownership interest or managing control.

• If an individual is serving as more than one role, please be sure to identify all applicable roles in this section:
  • 5 Percent or Greater Direct/Indirect Owner
  • Authorized Official
  • Delegated Official
  • Partner
  • Director/Officer
  • Contracted Managing Employee
  • Managing Employee (W-2)
• All Provider/Suppliers are required to list at least one Managing Employee.
• All Provider/Suppliers are required to list at least one Authorized Official.
• If (and only if) the supplier is a corporation (whether for-profit or non-profit), all officers and directors of the supplier must be listed.
• Enter the effective date the individual acquired ownership and/or managing control. Furnish both dates if applicable.
• Final Adverse Legal Action History must be reported for all individuals listed (Section 6B).

If you are revalidating your enrollment, Section 6 is required to be completed for all applicable individuals, regardless if there are any changes.

Section 6A/B: Authorized Official

Complete sections 6A and 6B of the CMS 855B Application for the individual(s) identified as the authorized official(s).

• A supplier MUST have at least ONE Authorized Official.
• An Authorized Official is defined as an appointed official (for example, chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization's status in the Medicare program, and to commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
• All Authorized Officials must identify one other relationship of 5% or greater direct/indirect owner, Partner or Director/Officer.
• A contracted managing employee does not qualify as an authorized/delegated official.

Application Fee

An Application Fee is required for institutional providers when:

• Initially enrolling in the Medicare Program
• Revalidating their Medicare enrollment; or
• Adding a new Medicare practice location.

CMS has defined an "institutional provider" to mean any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A, CMS-855B (except physician and non-physician practitioner organizations), or CMS-855S or associated Internet-based PECOS enrollment application.

Section 2D – Correspondence Mailing Address

The address where correspondence will be sent is required for initial enrollment and revalidation applications or if the information is changing.

• Cannot be a billing agent or agency's address.
• Cannot be a medical management company address.

Section 2H – Eligible Professional or Other Non-Physician Specialty Type

Section 2H of the CMS 855I application captures the practitioner's non physician's specialty. This section is required for initial enrollment and revalidation applications.

• Designate only one non physician specialty.
• If you have multiple non-physician specialty types, you must complete and submit a separate CMS-855I application for each non-physician specialty type.
• Complete additional specialty sections as directed on the application.

A practitioner must meet all federal and state requirements for the type of specialty checked.

Section 3C – Adverse Legal History

Section 3C of the CMS 855I Application is required regardless if there is an adverse action to report. This is required for all initial enrollment, change of information or revalidation applications. Documentation to support the action must be submitted.

The following actions are required to be reported:

• Felony and Misdemeanor conviction(s) within 10 years
• Current or Past Suspension(s)/Revocation(s) of a medical license
• Current or Past Suspension(s) Revocation(s) of an accreditation
• Current or Past Suspension(s) or Exclusion(s) imposed by the U.S. Department of Health and Human Service's Office of Inspector General (OIG)
• Current or Past Debarment(s) from participation in any Federal Executive Branch procurement or non-procurement program
• Medicaid exclusion(s), revocation(s) or termination(s) of any billing number
• Any other Current or Past Federal Sanction(s)

Section 4F – Individual Reassignment/Affiliation Information

Practitioners who want to reassign their benefits must complete Section 4F with the eligible individual's or entity's name, Medicare Identification Number (PTAN) and NPI. This is required for initial enrollment, reactivation and revalidation.

In addition, the CMS-855R Reassignment of Benefits application must be submitted with the CMS-855I application.

Section 15: Certification Statement

Section 15 is required for all CMS 855I applications.

• Only the individual practitioner may sign this application.
• The authority to sign the application on the practitioner's behalf may not be delegated to any other person.
• Ensure all fields of Section 15 are completed.
• Original Signature(s) (not stamped or copied)
• Signature must be dated
• Signature dates cannot be more than 120 days prior to the receipt date

Section 1 – Basic Information

Section 1 of the CMS 855O Application is required for all initial enrollment, change of information or termination applications.

• Complete section 1A "Reason for Submitting This Application" of the CMS 855O.
• Complete section 1B "Reason You Are Enrolling to Order and Certify or Prescribe Part D Drugs" of the CMS 855O.

Section 2A – Personal Identifying Information

Section 2A of the CMS 855O Application is required for all initial enrollment, change of information or revalidation applications.

• Complete the entire section 2A of the CMS 855I Application.
• List the provider's full name as on file with the Social Security Administration (SSA).
• Ensure the provider's social security number, date of birth and NPI are completed correctly.
• Enter the provider's medical school and year of graduation.

Section 3C – Adverse Legal History

Section 3C of the CMS 855O Application requires this section to be completed, regardless if there is an adverse action to report. This is required for all initial enrollment, change of information or revalidation applications. Documentation to support the action must be submitted.

The following actions are required to be reported:

• Felony and Misdemeanor conviction(s) within 10 years
• Current or Past Suspension(s)/Revocation(s) of a medical license
• Current or Past Suspension(s) Revocation(s) of an accreditation
• Current or Past Suspension(s) or Exclusion(s) imposed by the U.S. Department of Health and Human Service's Office of Inspector General (OIG)
• Current or Past Debarment(s) from participation in any Federal Executive Branch procurement or non-procurement program
• Medicaid exclusion(s), revocation(s) or termination(s) of any billing number
• Any other Current or Past Federal Sanction(s)

Section 8 – Certification Statement

Section 8 is required for all CMS 855O applications.

• Only the individual practitioner may sign this application.
• Ensure all fields of Section 8 are completed.
• Section 8 must include the practitioner's original dated signature.
• Stamped signatures will not be acceptable.

Unacceptable Submission

The CMS 855O application must be submitted by mail. Faxed and emailed applications cannot be accepted and will delay the processing of your application.

855I Application:

• Before you submit an 855R Reassignment of Benefits application, take a moment to verify the practitioner has an approved enrollment record in PECOS with CGS Administrators LLC.
• If the practitioner does not have an approved PECOS enrollment record, you must complete and submit the CMS 855I application along with the CMS 855R application. If the CMS 855I is not submitted, this will delay the processing of the CMS 855R.
• The CMS 855I application must be submitted by mail. Faxed and emailed applications cannot be accepted and will delay the processing of your application.
• If you are unable to determine the above, please call the J15 Contact Center at 866.276.9558, option 3. A representative can confirm the practitioner's PECOS enrollment status.

855R Application:

The CMS 855R application must be completed for any practitioner reassigning their benefits to a group/organization.

Section 3 – Individual Who is Reassigning Benefits

Section 3 of the CMS 855R must be completed for the individual practitioner who will be reassigning his/her benefits, or who will be terminating a reassignment.

• Practitioner First Name and Last Name
• Social Security Number (SSN)
• National Provider Identifier (NPI)

Section 4 – Primary Practice Location(s)

If completed, Section 4 must identify the primary and/or secondary practice location of the organization/group where the individual practitioner will render services most of the time. This practice location must be currently enrolled or enrolling in Medicare.

Section 6A and 6B – Certification Statement and Signature

Please remember when submitting the CMS 855R, Section 6 must contain the following for all signatories:

• Original Signature(s) (not stamped)
• Signature dates cannot be more than 120 days prior to the receipt date
• Signature for the Practitioner
• Signature for the Authorized/Delegated official

Please remember when submitting the CMS 855R, Section 6B must be signed and dated by an authorized/delegated Official of the Provider/Supplier. The official signing must be currently approved as an authorized or delegated official for the current group/organization enrollment record. If the official is not established, you must submit a change of information to add the individual as an authorized/delegated official for your group/organization.

Part II: Account Holder Information

The account holder's legal business name must be listed as it appears with the Internal Revenue Service (IRS) in Part II of the CMS 588 EFT Agreement. If the legal business name has changed, you must submit a change of information via the applicable CMS 855 application to update the legal business name for your organization.

Part II: Account Holder Information

Within Part II of the EFT agreement, the account holder's street address must be provided.

Part V: Authorization

Part V Authorization is required for all CMS 588 EFT forms and must meet the following for all signatories:

• Signed by the provider or an established Authorized/Delegated Official of the group
• Original Signature (not stamped or copied)
• Signature must be dated
• Signature dates cannot be more than 120 days prior to the receipt date

Supporting Documents – Voided check or account confirmation

A pre-printed voided check or written letter from the bank verifying the bank account information is required to be submitted with the CMS 588 EFT Agreement. If you are submitting a letter from the bank, the letter must identify the type of account (checking or savings) and by signed by a Bank officer/representative.

The account holder's legal business name listed on the voided check or written letter must be listed as it appears with the Internal Revenue Service (IRS).

Before submitting the EFT Agreement, take a moment to ensure the Legal Business name is written the same on all CMS documents and it matches with the IRS.

855B – Application Required

In order to bill for services and/or receive a reassignment of benefits, the supplier must be actively enrolled in the PECOS system.

• Each supplier must complete and submit the entire CMS 855B Application along with the required supporting documents.
• Currently, the supplier does not have an active enrollment record within our jurisdiction. An authorized user will need to login under their PECOS ID, select 'My Enrollments', 'New Application' and submit the Internet-Based PECOS application. To speed up the processing time, we recommend electronically signing the application.

Signature(s)

Each Authorized and/or Delegated official identified as a signor must sign the Internet Based PECOS application. Upon submission of the application, the signor can electronically sign or print, sign and date a paper CMS 855B certification statement. Paper certification statements must be uploaded via PECOS. Mailed certification statements will not be accepted.

Application Fee

An Application Fee is required for institutional providers when:

• Initially enrolling in the Medicare Program
• Revalidating their Medicare enrollment; or
• Adding a new Medicare practice location.

CMS has defined an "institutional provider" to mean any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A, CMS-855B (except physician and non-physician practitioner organizations), or CMS-855S or associated Internet-based PECOS enrollment application.

Section 6: Authorized Official

Complete sections 6 of the CMS 855B Application for the individual(s) identified as the authorized official(s).

• A supplier MUST have at least ONE Authorized Official.
• An Authorized Official is defined as an appointed official (for example, chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization's status in the Medicare program, and to commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
• All Authorized Officials must identify one other relationship of 5% or greater direct/indirect owner, Partner or Director/Officer.
• A contracted managing employee does not qualify as an authorized/delegated official.

Section 6 – Ownership Interest and/or Managing Control Information

If you are submitting an initial enrollment, change of information or revalidation application, ensure that Sections 6A and 6B are completed for:

• All persons who have a 5 percent or greater direct or indirect ownership interest in the supplier;
• If (and only if) the supplier is a corporation (whether for-profit or non-profit), all officers and directors of the supplier;
• All managing employees of the supplier;
• All individuals with a partnership interest in the supplier, regardless of the percentage of ownership the partner has; and
• All authorized and delegated officials. The officials signing sections 15 and/or 16 must also be listed in section 6.

Regarding revalidation applications, this section must be completed for all applicable individuals, regardless if there are any changes.

If an individual is serving as more than one role, please be sure to identify all applicable roles in this section.

Personal Identifying Information

• List the provider's full name as on file with the Social Security Administration (SSA).
• Indicate any Other Name and type (Former, Maiden, Professional) for the provider.
• Ensure the provider's social security number, date of birth and NPI are completed correctly.
• The provider's name on file with National Plan and Provider Enumeration System (NPPES) should appear as it is reported to the SSA.
• Enter the provider's medical school and year of graduation.

Medical Specialty

• Provider must enroll for a valid Medicare covered specialty.
• Ensure the correct physician OR non-physician specialty is selected.
• A provider must meet all federal and state requirements for the type of specialty(s) submitted.

Physician Assistant (PA) Employment

Section 2 must be completed for a Physician Assistant provider establishing or terminating an employment arrangement(s). Ensure all employer information is entered correctly:

• Group's NPI currently associated with the group/organization.
• Group's legal business name and tax identification number as currently reported to the Internal Revenue Service and PECOS.
• Group's Medicare ID (PTAN) currently affiliated with the group/organization.
• Complete all applicable effective dates.

Contact Person Information (optional)

If submitted, the Contact Person Information section must include:

• Valid First Name and Last Name for the contact person
• Complete contact address
• Valid contact phone number
• Valid email address (if applicable)

Signatures

The practitioner must sign the Internet Based PECOS application. Upon submission of the application, the practitioner can electronically sign or print, sign and date a paper CMS 855I certification statement or CMS 855R Authorization Statement. Paper certification statements must be uploaded via PECOS. Mailed certification statements will not be accepted.

CMS 855I Application

Before you submit an 855R Reassignment of Benefits application, take a moment to verify you have an approved enrollment record in PECOS with CGS Administrators LLC.

If you do not have an approved PECOS enrollment record, you must complete and submit the CMS 855I application along with the CMS 855R application. If the CMS 855I is not submitted, this will delay the processing of the CMS 855R. Here are tips to confirm your enrollment status:

If you have access to Internet Based PECOS:

• Login.
• View My Associates.
• Click View Enrollments.
• Look for your enrollment, with CGS Administrators LLC, in the applicable state and in a status of Approved.
• If you don't see an approved enrollment record, you will need to submit an 855I application, either via Internet Based PECOS by clicking on More Options to continue or submitting the paper CMS 855I application to our office.

If you don't have access to Internet Based PECOS, please call the J15 Contact Center at 866.276.9558, option 3. A representative can confirm your PECOS enrollment status.

Practitioner Signature

The practitioner must sign the Internet Based PECOS application. Upon submission of the application, the practitioner can electronically sign or print, sign and date a paper CMS 855R authorization statement. Paper certification statements must be uploaded via PECOS. Mailed certification statements will not be accepted

Authorized/Delegated Official Signature

The Authorized and/or Delegated official identified as a signor must sign the Internet Based PECOS application. Upon submission of the application, the signor can electronically sign or print, sign and date a paper CMS 855R authorization statement. Paper certification statements must be uploaded via PECOS. Mailed certification statements will not be accepted.

Please remember when submitting the CMS 855R, the authorization statement must be signed and dated by an authorized/delegated Official of the Provider/Supplier. The official signing must be currently approved as an authorized or delegated official for the current group/organization enrollment record. If the official is not established, you must submit a change of information to add the individual as an authorized/delegated official for your group/organization.

855I Application – Physician Assistant (PA) Information

A CMS 855R Application cannot be processed to enroll or terminate a Physician Assistant. A CMS 855I Application is required in order to enroll or update Physician Assistant providers.

Practice Address

If completed, the reassignment must identify the primary and/or secondary practice location of the organization/group where the individual practitioner will render services most of the time. This practice location must be currently enrolled or enrolling in Medicare.

EFT – Supporting Documentation

A pre-printed voided check or written letter from the bank verifying the bank account information is required to be submitted with the CMS 588 EFT Agreement. If you are submitting a letter from the bank, the letter must identify the type of account (checking or savings) and by signed by a Bank officer/representative.

The account holder's legal business name listed on the voided check or written letter must be listed as it appears with the Internal Revenue Service (IRS) as well as the provider's address.

Before submitting the EFT Agreement, take a moment to ensure the Legal Business name is written the same on all CMS documents and it matches with the IRS.

EFT – Provider/Supplier Name

The provider/supplier name identified within the EFT and supporting document (bank letter or voided check) must match the Physician's or Individual Practitioner's Name, or the Legal Business Name of the Provider/Supplier as it is reported to the Internal Revenue Service (IRS).

EFT – Authorization

The Authorization is required for all CMS 588 EFT Upon submission of the application, the signor can electronically sign or print, sign and date a paper CMS 588 authorization statement.

• Signed by the provider or an established Authorized/Delegated Official of the group
• Original Signature (not stamped or copied)
• Signature must be dated
• Signature dates cannot be more than 120 days prior to the receipt date