Provider Enrollment Interactive Help Tool — Cardiac Rehab/Intensive Cardiac Rehabilitation
1. Has your ICR program been approved by CMS through the national coverage determination (NCD) process?
Yes No
2. Does the group have at least one member that will receive a Medicare Part B Provider Transaction Access Number (PTAN)?
Yes No
3. Complete form 855B section 1-6, 8, 12, 13 and 15
- CMS 855B form
- Section 2A Type of Supplier should be completed as Other: Intensive Cardiac Rehabilitation
- Section 4A Only one practice location may be listed
- 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
- Certification from CMS approved program
- 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. - Refer back to the main menu to complete the necessary forms for any group members.
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. Complete form 855B section 1-6, 8, 12, 13 and 15
- CMS 855B form
- Section 2A Type of Supplier should be completed as Other: Intensive Cardiac Rehabilitation
- Section 4A Only one practice location may be listed
- 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
- Certification from CMS approved program
- 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. - Refer back to the main menu to complete the necessary forms for any group members.
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.
Note: The above is a CMS requirement and must be attained prior to application submission.