Provider Enrollment Interactive Help Tool — Physical Therapist
1. At the end of the tax year, does the owner of the entity file two separate tax returns (one for the business and one for the owner)?
2. Does the owner own 100% of the business assets?
Yes No
3. Is the owner a provider of a service?
Yes No
Physical Therapist as Sole Owner:
- Complete form 855I (sections 1, 2A, 2B, 2C, 2D, 2E, 2H, 2K, 3, 4 (check boxes to indicate reassignment, Sole Proprietor or both), 4(A)1, 4B, 4C, 6, 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.
- CMS 855I Form
- Complete the following forms:
- 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 (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.
- Electronic Funds Transfer form (EFT CMS 588 Form
- Include the following additional documentation:
- Copy of state Physical Therapy license
- CP575 or other pre-printed IRS documentation that identifies the Legal Business Name and Tax Identification Number of the entity.
- 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
- 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, Suite NT600
Nashville, TN 37214
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.
4. Does your group currently have a Medicare Part B enrollment in either Ohio or Kentucky?
Yes No
5. Are you modifying existing information?
Yes No
6. Complete form CMS 855B as identified below:
Change of Information (COI)
This tool is for those Suppliers with an Active Pecos Enrollment wanting to Add, Change or Delete Information:
Complete only the identified section(s) of the CMS 855B application that are changing:
| Section | Attachment | |||||||||||||||||||||
| 1 | 2A | 2A1 | 2B | 2F | 3 | 4 | 4A | 5 | 6 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 1 | 2 | 3 | ||
| Voluntarily terminating Medicare Enrollment | X | X | X* | X | ||||||||||||||||||
| Business Identifying Information - Ex: Legal Name Change, Doing Business As Name, License or Correspondence | X | X | X | X** | X | X* | X | |||||||||||||||
| Adverse Legal Actions/Convictions | X | X | X | X** | X | X* | X | |||||||||||||||
| Medical Specialty Information | X | X | X | X | X | X** | X | X* | X | |||||||||||||
| Supplier Specific Information | X | X | *** | X | X | X** | X | X* | X | |||||||||||||
| Physician Assistant Employment Terminations | X | X | X | X | X** | X* | X | |||||||||||||||
| Private Practice Business Information | X | X | X | X | X** | X | X* | X | ||||||||||||||
| Change of Ownership (Hospital, Hospital Departments, 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 (Organizations) |
X | X | X | X | X** | X* | X | |||||||||||||||
| Ownership Interest and/or Managing Control Information (Individuals) |
X | X | X | X+** | X* | X | ||||||||||||||||
| Managing Employee Information | X | X | X | X+** | X | X* | X | |||||||||||||||
| Address Information | X | X | # | X | X** | X | X* | X | ||||||||||||||
| Billing Agency / Agent Information | X | X | X | X** | X | X* | X | |||||||||||||||
| Authorized Official(s)/Delegated Official(s) | 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 | |||||||||||||||
| Opioid Treatment Programs (OTPs) Only | X | X | X | X** | X* | X | X | |||||||||||||||
* Optional
** For the signer if that authorized or delegated official has not been established for this supplier.
*** 2A2-2A4, 2B-2F (as applicable)
# 2A3, 2A4, 4A, 4B, 4C and/or 4E as applicable
7. 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, Suite NT600
Nashville, TN 37214
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.
6. Please contact our Part B Customer Service at 1-866-276-9558 for additional assistance.
5. Complete form 855B section 1-6, 8, 12, 13 and 15
- CMS 855B form
- Section 15 (Certification Statement) of the 855B must be signed and dated by the person being recognized as the Authorized Official. Faxed, photocopied, or stamped signatures will not be accepted.
- If enrolling as a Federally Qualified Health Center or Rural Health Clinic, please identify this within the "Other HealthCare Facility" field in Section 4A.
6. Include the following documents:
- 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.
- IRS documentation (e.g., CP575, quarterly tax coupon confirming the tax identification number and legal business name of the enrollee.
- EFT CMS 588 form
- A copy of a voided pre-printed check or a bank verification letter signed by a bank official.
- Refer back to the main menu to complete the necessary forms for any group members.
7. Submitting Claims Electronically - Electronic Data Interchange (EDI)
- There are many advantages to submitting claims electronically. In most cases, submitting electronically is required due to ASCA (Administrative Simplification Compliance Act).
- 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. To access the Enrollment Forms go EDI Enrollment Form
8. 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, Suite NT600
Nashville, TN 37214
Be sure to:
- Complete all required information, including any boxes to indicate "not applicable."
- Note because you are a new enrollee the Change, Add, Delete boxes do not apply to you.
- 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.
- 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 signs and dates the appropriate section(s) prior to submission.
3. Does your group currently have a Medicare Part B enrollment in either Ohio or Kentucky?
Yes No
4. Are you modifying existing information?
Yes No
5. Complete form CMS 855B as identified below:
Change of Information (COI)
This tool is for those Suppliers with an Active Pecos Enrollment wanting to Add, Change or Delete Information:
Complete only the identified section(s) of the CMS 855B application that are changing:
| Section | Attachment | |||||||||||||||||||||
| 1 | 2A | 2A1 | 2B | 2F | 3 | 4 | 4A | 5 | 6 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 1 | 2 | 3 | ||
| Voluntarily terminating Medicare Enrollment | X | X | X* | X | ||||||||||||||||||
| Business Identifying Information - Ex: Legal Name Change, Doing Business As Name, License or Correspondence | X | X | X | X** | X | X* | X | |||||||||||||||
| Adverse Legal Actions/Convictions | X | X | X | X** | X | X* | X | |||||||||||||||
| Medical Specialty Information | X | X | X | X | X | X** | X | X* | X | |||||||||||||
| Supplier Specific Information | X | X | *** | X | X | X** | X | X* | X | |||||||||||||
| Physician Assistant Employment Terminations | X | X | X | X | X** | X* | X | |||||||||||||||
| Private Practice Business Information | X | X | X | X | X** | X | X* | X | ||||||||||||||
| Change of Ownership (Hospital, Hospital Departments, 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 (Organizations) |
X | X | X | X | X** | X* | X | |||||||||||||||
| Ownership Interest and/or Managing Control Information (Individuals) |
X | X | X | X+** | X* | X | ||||||||||||||||
| Managing Employee Information | X | X | X | X+** | X | X* | X | |||||||||||||||
| Address Information | X | X | # | X | X** | X | X* | X | ||||||||||||||
| Billing Agency / Agent Information | X | X | X | X** | X | X* | X | |||||||||||||||
| Authorized Official(s)/Delegated Official(s) | 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 | |||||||||||||||
| Opioid Treatment Programs (OTPs) Only | X | X | X | X** | X* | X | X | |||||||||||||||
* Optional
** For the signer if that authorized or delegated official has not been established for this supplier.
*** 2A2-2A4, 2B-2F (as applicable)
# 2A3, 2A4, 4A, 4B, 4C and/or 4E as applicable
6. 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, Suite NT600
Nashville, TN 37214
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.
5. Please contact our Part B Customer Service at 1-866-276-9558 for additional assistance.
- Complete form 855B section 1-6, 8, 12, 13 and 15
- CMS 855B form
- Section 15 (Certification Statement) of the 855B must be signed and dated by the person being recognized as the Authorized Official. Faxed, photocopied, or stamped signatures will not be accepted.
- If enrolling as a Federally Qualified Health Center or Rural Health Clinic, please identify this within the "Other HealthCare Facility" field in Section 4A.
- CMS 855B
- Include the following documents:
- 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.
- IRS documentation (e.g., CP575, quarterly tax coupon confirming the tax identification number and legal business name of the enrollee.
- EFT CMS 588 form
- A copy of a voided pre-printed check or a bank verification letter signed by a bank official.
- Refer back to the main menu to complete the necessary forms for any group members.
- Participation Agreement (optional) CMS 460
- Submitting Claims Electronically - Electronic Data Interchange (EDI)
- There are many advantages to submitting claims electronically. In most cases, submitting electronically is required due to ASCA (Administrative Simplification Compliance Act).
- 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. To access the Enrollment Forms go 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, Suite NT600
Nashville, TN 37214
Be sure to:
- Complete all required information, including any boxes to indicate "not applicable."
- Note because you are a new enrollee the Change, Add, Delete boxes do not apply to you.
- 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.
- 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 signs and dates the appropriate section(s) prior to submission.
Physical Therapist as Sole Proprietor:
- Complete form 855I (sections 1, 2A, 2B, 2C, 2D, 2E, 2H, 2K, 3, 4 (check boxes to indicate reassignment, Sole Proprietor or both), 4B, 4C, 13, 15)
- CMS 855I Form
Note: If the provider is billing under a Tax Identification Number, section 4A(3) should be completed also)
- Section 15 (Certification Statement) of the 855I must be signed and dated by the provider. Faxed, photocopied, or stamped signatures will not be accepted.
- CMS 855I Form
- 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:
- Copy of state Physical Therapy license
- If the provider is billing under a Tax Identification Number, a CP575 or other pre-printed IRS documentation that identifies the Legal Business Name and Tax Identification Number of the entity must be submitted.
Note: A Disregarded Entity will not receive a CP575 form from the IRS confirming their Legal Business Name and Tax Identification Number; therefore CGS may accept other approved government documentation listing Legal Business Name and Tax Identification Number.
- 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
- 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, Suite NT600
Nashville, TN 37214
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.
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