Provider Enrollment Interactive Help Tool — Clinical Nurse Specialist
1. Does the enrollee have an active Medicare Provider Transaction Access Number (PTAN) within CGS's jurisdiction?
Yes No
2. Is the organization/group to whom benefits are being reassigned enrolled with an active Medicare PTAN/Legacy Number within CGS' jurisdiction?
Yes No
Clinical Nurse Specialist:
- Complete form 855I sections 1, 2A, 4F, 12, 13, and 15.
- 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 37202Overnight, 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."
- Sign your application and date your application.
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.
Clinical Nurse Specialist:
- Complete form 855I sections 1, 2A, 4F, 12, 13, and 15.
- Complete form 855B sections 1-6, 8, 13, 15, and 16
- CMS 855B Form
- Section 15 (Certification Statement) of the 855B must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.
- Complete the following forms:
- Participation Agreement (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.
- Electronic Funds Transfer form (EFT CMS 588 Form)
Note: A copy of a voided pre-printed check OR bank letter verifying the information on the EFT form)
- Participation Agreement (CMS 460 Form)
- Include the following additional documentation:
- CP575 or other pre-printed IRS documentation that identifies the Legal Business Name and Tax Identification Number of the group.
- Submitting Electronic Claims Electronic Data Interchange (EDI)
- New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form
- 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 37202Overnight, 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."
- Sign your application and date your application.
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. Is the group the enrollee is reassigning benefits to enrolled with an active Medicare PTAN/Legacy number within CGS's jurisdiction?
Yes No
Clinical Nurse Specialist:
- Complete form 855I (sections 1, 2A, 2B, 2C, 2D, 2E, 2H, 2K, 3, 4F, 13, 15)
- CMS 855I Form
- Section 15 (Certification Statement) of the 855I must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.
- Include the following documents:
- Copy of state Clinical Nurse Specialist license
- Copy of Degree from an accredited educational institution (Master's Degree in Nursing/Doctor Of Nursing Practice acceptable)
- Copy of Certification by approved national body:
- American Academy of Nurse Practitioners
- American Nurses Credentialing Center
- National Certification Corporation for Obstetric, Gynecologic and Neonatal Nursing Specialties
- Pediatric Nursing Certification Board (previously named the National Certification Board of Pediatric Nurse Practitioners and Nurses)
- Oncology Nurses Certification Corporation
- AACN Certification Corporation
- National Board on Certification of Hospice and Palliative Nurses. (NBCHPN)
- 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 37202Overnight, 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."
- Sign your application and date your application.
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.
Clinical Nurse Specialist:
- Complete form 855I (sections 1, 2A, 2B, 2C, 2D, 2E, 2H, 2K, 3, 4F, 13, 15)
- CMS 855I Form
- Section 15 (Certification Statement) of the 855I must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.
- Include the following documents:
- Copy of state Clinical Nurse Specialist license
- Copy of Degree from an accredited educational institution (Master's Degree in Nursing/Doctor of Nursing Practice acceptable)
- Copy of Certification by approved national body:
- American Academy of Nurse Practitioners
- American Nurses Credentialing Center
- National Certification Corporation for Obstetric, Gynecologic and Neonatal Nursing Specialties
- Pediatric Nursing Certification Board (previously named the National Certification Board of Pediatric Nurse Practitioners and Nurses)
- Oncology Nurses Certification Corporation
- AACN Certification Corporation
- National Board on Certification of Hospice and Palliative Nurses. (NBCHPN)
- Complete form 855B sections 1-6, 8, 13, 15, and 16
- CMS 855B Form
- Section 15 (Certification Statement) of the 855B must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.
- Complete the following forms:
- Participation Agreement (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.
- Electronic Funds Transfer form (EFT CMS 588 Form)
Note: A copy of a voided pre-printed check OR bank letter verifying the information on the EFT form)
- Participation Agreement (CMS 460 Form)
- Include the following additional documentation:
- CP575 or other pre-printed IRS documentation that identifies the Legal Business Name and Tax Identification Number of the group.
- Submitting Electronic Claims Electronic Data Interchange (EDI)
- New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form
- 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 37202Overnight, 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."
- Sign your application and date your application.
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.