Provider Enrollment Interactive Help Tool — Certified Nurse Midwife
1. Does the enrollee have an active Medicare Provider Transaction Access Number (PTAN) within CGS's jurisdiction?
Yes No
APPLICATION NOT NEEDED AS PROVIDER CAN ORDER/REFER AND STILL REMAIN A RENDERING PROVIDER.
2. Are you enrolling within CGS's jurisdiction for the sole purpose of ordering/referring Medicare beneficiaries?
Yes No
Certified Nurse Midwife:
- Complete form 855O (sections 1, 2, 3, 4b, 5, 6, 8)
- CMS 855O Form
- Section 8 (Certification Statement) of the 855O must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.
- Include the following documents:
- Copy of state Certified Nurse Midwife license
- 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.
Please contact our Part B Customer Service at 1-866-276-9558 for additional assistance.