Provider Enrollment Interactive Help Tool — Physician Assistant
1. Is the organization/group to which the practitioner is employed by enrolled with an active Medicare PTAN/Legacy Number within CGS' jurisdiction?
Yes No
Physician Assistant:
- Complete form 855I (sections 1, 2A, 2B, 2C, 2D, 2E, 2H, 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 Physician Assistant license
- Copy of National Certification
- Copy of Degree from accredited educational institution
- 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."
- Ensure the application is signed; either with an original or digital signature.
- 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.
Physician Assistant:
- Complete form 855I (sections 1, 2A, 2B, 2C, 2D, 2E, 2H, 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 Physician Assistant license
- Copy of National Certification
- Copy of degree from accredited educational institution
- 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."
- Ensure the application is signed; either with an original or digital signature.
- 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.