Provider Enrollment Interactive Help Tool — Physical/Occupational Therapy
1. Does your group currently have a Medicare Part B enrollment in either Ohio or Kentucky?
Yes No
2. Are you modifying existing information?
Yes No
This tool is for those Suppliers with an Active Pecos Enrollment wanting to Add, Change or Delete Information:
3. Complete form CMS 855B as identified below:
Complete only the identified section(s) of the CMS 855B application that are changing:
Section | Attachment | ||||||||||||||||||||||||||
1 | 2 | 2B1 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 1* | 2* | |||||||||
Identifying Information Ex: Legal Name Change, Doing Business As Name info, License or Correspondence) |
X | X | X | X | X | X | X | X | |||||||||||||||||||
Adverse Legal Actions/Convictions | X | X | X | X | X | X | |||||||||||||||||||||
Practice Location Information, Payment Address & Medical Record Storage Information | X | X | X | X | X | X | X | X | |||||||||||||||||||
Change of Ownership (Hospital, 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 (Group/Organization) | X | X | X | X | X | X | X | X | |||||||||||||||||||
Billing Agency Information | X | X | X | X | X | X | X | ||||||||||||||||||||
Authorized/Delegated Official | X | 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 |
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.
Please contact our Part B Customer Service at 1-866-276-9558 for additional assistance.
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 (Reference)
- CMS 855B form
- Section 2D Questionnaire
- 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)
- License, certifications and registrations required by Medicare or State Law
- Federal, State, and/or local (city/county) business licenses, certifications and/or registrations required to operate a health facility
- 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).
- 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 (Reference)
- CMS 855B form
- Section 2D Questionnaire
- 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)
- License, certifications and registrations required by Medicare or State Law
- Federal, State, and/or local (city/county) business licenses, certifications and/or registrations required to operate a health facility
- 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).
- 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.