Provider Enrollment Interactive Help Tool — Independent Clinical Laboratory
1. Does your organization currently have a Medicare Part B enrollment in either Ohio or Kentucky?
2. Are you adding a practice location?
Yes No
3. Have you paid the fee requirement as prescribed by CMS?
Yes No
4. Complete form CMS 855B as identified below:
Change of Information (COI)
This tool is for those Suppliers with an Active Pecos Enrollment wanting to Add, Change or Delete Information:
Complete only the identified section(s) of the CMS 855B application that are changing:
Section | Attachment | |||||||||||||||||||||
1 | 2A | 2A1 | 2B | 2F | 3 | 4 | 4A | 5 | 6 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 1 | 2 | 3 | ||
Voluntarily terminating Medicare Enrollment | X | X | X* | X | ||||||||||||||||||
Business Identifying Information - Ex: Legal Name Change, Doing Business As Name, License or Correspondence | X | X | X | X** | X | X* | X | |||||||||||||||
Adverse Legal Actions/Convictions | X | X | X | X** | X | X* | X | |||||||||||||||
Medical Specialty Information | X | X | X | X | X | X** | X | X* | X | |||||||||||||
Supplier Specific Information | X | X | *** | X | X | X** | X | X* | X | |||||||||||||
Physician Assistant Employment Terminations | X | X | X | X | X** | X* | X | |||||||||||||||
Private Practice Business Information | X | X | X | X | X** | X | X* | X | ||||||||||||||
Change of Ownership (Hospital, Hospital Departments, Portable X-Ray Suppliers & Ambulatory Surgical Centers Only) |
Complete all sections and provide a copy of the sales agreement. | |||||||||||||||||||||
Ownership Interest and/or Managing Control Information (Organizations) |
X | X | X | X | X** | X* | X | |||||||||||||||
Ownership Interest and/or Managing Control Information (Individuals) |
X | X | X | X+** | X* | X | ||||||||||||||||
Managing Employee Information | X | X | X | X+** | X | X* | X | |||||||||||||||
Address Information | X | X | # | X | X** | X | X* | X | ||||||||||||||
Billing Agency / Agent Information | X | X | X | X** | X | X* | X | |||||||||||||||
Authorized Official(s)/Delegated Official(s) | X | X | X | X** | X | X | ||||||||||||||||
Ambulance Service Suppliers Only | X | X | X | X** | X* | X | X | |||||||||||||||
Independent Diagnostic Testing Facilities (IDTF) Only | X | X | X | X** | X* | X | X | |||||||||||||||
Opioid Treatment Programs (OTPs) Only | X | X | X | X** | X* | X | X |
* Optional
** For the signer if that authorized or delegated official has not been established for this supplier.
*** 2A2-2A4, 2B-2F (as applicable)
# 2A3, 2A4, 4A, 4B, 4C and/or 4E as applicable
5. Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:
Mailing Address – Jurisdiction 15
CGS Administrators LLC
J15 Part B Provider Enrollment
P.O. Box 20017
Nashville, TN 37202
Overnight, UPS, Fed Ex address:
CGS Administrators LLC
J15 Part B Provider Enrollment
26 Century Blvd STE ST610
Nashville, TN 37214-3685
Be sure to:
- Complete all required information, including any boxes to indicate "not applicable".
- Include the date you first saw or will see Medicare Patients on Section 4A (Practice Location Information)
- Provide information required for Electronic Fund Transfer.
- Ensure the application is signed; either with an original or digital signature.
- 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. Pay Application fee
https://pecos.CMS.hhs.gov/pecos/feePaymentWelcome.do
5. Complete form CMS 855B as identified below:
Change of Information (COI)
This tool is for those Suppliers with an Active Pecos Enrollment wanting to Add, Change or Delete Information:
Complete only the identified section(s) of the CMS 855B application that are changing:
Section | Attachment | |||||||||||||||||||||
1 | 2A | 2A1 | 2B | 2F | 3 | 4 | 4A | 5 | 6 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 1 | 2 | 3 | ||
Voluntarily terminating Medicare Enrollment | X | X | X* | X | ||||||||||||||||||
Business Identifying Information - Ex: Legal Name Change, Doing Business As Name, License or Correspondence | X | X | X | X** | X | X* | X | |||||||||||||||
Adverse Legal Actions/Convictions | X | X | X | X** | X | X* | X | |||||||||||||||
Medical Specialty Information | X | X | X | X | X | X** | X | X* | X | |||||||||||||
Supplier Specific Information | X | X | *** | X | X | X** | X | X* | X | |||||||||||||
Physician Assistant Employment Terminations | X | X | X | X | X** | X* | X | |||||||||||||||
Private Practice Business Information | X | X | X | X | X** | X | X* | X | ||||||||||||||
Change of Ownership (Hospital, Hospital Departments, Portable X-Ray Suppliers & Ambulatory Surgical Centers Only) |
Complete all sections and provide a copy of the sales agreement. | |||||||||||||||||||||
Ownership Interest and/or Managing Control Information (Organizations) |
X | X | X | X | X** | X* | X | |||||||||||||||
Ownership Interest and/or Managing Control Information (Individuals) |
X | X | X | X+** | X* | X | ||||||||||||||||
Managing Employee Information | X | X | X | X+** | X | X* | X | |||||||||||||||
Address Information | X | X | # | X | X** | X | X* | X | ||||||||||||||
Billing Agency / Agent Information | X | X | X | X** | X | X* | X | |||||||||||||||
Authorized Official(s)/Delegated Official(s) | X | X | X | X** | X | X | ||||||||||||||||
Ambulance Service Suppliers Only | X | X | X | X** | X* | X | X | |||||||||||||||
Independent Diagnostic Testing Facilities (IDTF) Only | X | X | X | X** | X* | X | X | |||||||||||||||
Opioid Treatment Programs (OTPs) Only | X | X | X | X** | X* | X | X |
* Optional
** For the signer if that authorized or delegated official has not been established for this supplier.
*** 2A2-2A4, 2B-2F (as applicable)
# 2A3, 2A4, 4A, 4B, 4C and/or 4E as applicable
6. Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:
Mailing Address – Jurisdiction 15
CGS Administrators LLC
J15 Part B Provider Enrollment
P.O. Box 20017
Nashville, TN 37202
Overnight, UPS, Fed Ex address:
CGS Administrators LLC
J15 Part B Provider Enrollment
26 Century Blvd STE ST610
Nashville, TN 37214-3685
Be sure to:
- Complete all required information, including any boxes to indicate "not applicable".
- Include the date you first saw or will see Medicare Patients on Section 4A (Practice Location Information)
- Provide information required for Electronic Fund Transfer.
- Ensure the application is signed; either with an original or digital signature.
- 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 855B as identified below:
Change of Information (COI)
This tool is for those Suppliers with an Active Pecos Enrollment wanting to Add, Change or Delete Information:
Complete only the identified section(s) of the CMS 855B application that are changing:
Section | Attachment | |||||||||||||||||||||
1 | 2A | 2A1 | 2B | 2F | 3 | 4 | 4A | 5 | 6 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 1 | 2 | 3 | ||
Voluntarily terminating Medicare Enrollment | X | X | X* | X | ||||||||||||||||||
Business Identifying Information - Ex: Legal Name Change, Doing Business As Name, License or Correspondence | X | X | X | X** | X | X* | X | |||||||||||||||
Adverse Legal Actions/Convictions | X | X | X | X** | X | X* | X | |||||||||||||||
Medical Specialty Information | X | X | X | X | X | X** | X | X* | X | |||||||||||||
Supplier Specific Information | X | X | *** | X | X | X** | X | X* | X | |||||||||||||
Physician Assistant Employment Terminations | X | X | X | X | X** | X* | X | |||||||||||||||
Private Practice Business Information | X | X | X | X | X** | X | X* | X | ||||||||||||||
Change of Ownership (Hospital, Hospital Departments, Portable X-Ray Suppliers & Ambulatory Surgical Centers Only) |
Complete all sections and provide a copy of the sales agreement. | |||||||||||||||||||||
Ownership Interest and/or Managing Control Information (Organizations) |
X | X | X | X | X** | X* | X | |||||||||||||||
Ownership Interest and/or Managing Control Information (Individuals) |
X | X | X | X+** | X* | X | ||||||||||||||||
Managing Employee Information | X | X | X | X+** | X | X* | X | |||||||||||||||
Address Information | X | X | # | X | X** | X | X* | X | ||||||||||||||
Billing Agency / Agent Information | X | X | X | X** | X | X* | X | |||||||||||||||
Authorized Official(s)/Delegated Official(s) | X | X | X | X** | X | X | ||||||||||||||||
Ambulance Service Suppliers Only | X | X | X | X** | X* | X | X | |||||||||||||||
Independent Diagnostic Testing Facilities (IDTF) Only | X | X | X | X** | X* | X | X | |||||||||||||||
Opioid Treatment Programs (OTPs) Only | X | X | X | X** | X* | X | X |
* Optional
** For the signer if that authorized or delegated official has not been established for this supplier.
*** 2A2-2A4, 2B-2F (as applicable)
# 2A3, 2A4, 4A, 4B, 4C and/or 4E as applicable
4. Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:
Mailing Address – Jurisdiction 15
CGS Administrators LLC
J15 Part B Provider Enrollment
P.O. Box 20017
Nashville, TN 37202
Overnight, UPS, Fed Ex address:
CGS Administrators LLC
J15 Part B Provider Enrollment
26 Century Blvd STE ST610
Nashville, TN 37214-3685
Be sure to:
- Complete all required information, including any boxes to indicate "not applicable".
- Include the date you first saw or will see Medicare Patients on Section 4A (Practice Location Information)
- Provide information required for Electronic Fund Transfer.
- Ensure the application is signed; either with an original or digital signature.
- 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?
Yes No
3. Complete form 855B section 1-6, 8, 12, 13 and 15
- CMS 855B 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 must be listed as an authorized official or delegated official in Section 6.
- Section 15 (Certification Statement) of the 855B 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:
- 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). Include all entities and individuals that have any Mortgage / Security Interests (also report them in Section 5/6).
- Federal, State, and/or local (city/county) business licenses, certifications and/or registrations required to operate a health facility
- CLIA certificate (mandatory)
- Participation Agreement (optional) CMS 460 form
Note: The provider has from the approval of its initial enrollment, 90 days to submit a participation agreement. The participation effective date is based on the receipt date of the agreement.
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.
3. Pay application fee
4. Complete form 855B section 1-6, 8, 12, 13 and 15
- CMS 855B 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 must be listed as an authorized official or delegated official in Section 6.
- Section 15 (Certification Statement) of the 855B 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:
- 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). Include all entities and individuals that have any Mortgage / Security Interests (also report them in Section 5/6).
- Federal, State, and/or local (city/county) business licenses, certifications and/or registrations required to operate a health facility
- CLIA certificate (mandatory)
- Participation Agreement (optional) CMS 460 form
Note: The provider has from the approval of its initial enrollment, 90 days to submit a participation agreement. The participation effective date is based on the receipt date of the agreement.
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.