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July 31, 2018

Sole Owner Submitting Paper CMS 855I Application

What defines a Sole Owner?  A sole owner is (1) the sole owner of a professional corporation, professional association, or limited liability company, and (2) will bill Medicare through this business entity.)  Claims payments are received directly by the business using its tax identification number (TIN) for all services provided by the owning practitioner and/or other employees through a reassignment of benefits.

As you complete the CMS 855I paper application, please consider accessing the Provider Enrollment Interactive Help Tool as well as the information below as a guide to lesson errors that may delay the processing of your enrollment application.  This article will only address initially enrolling, reactivating or revalidating enrollment scenarios.

CMS 855I section

Tips when completing

Section 1A

If you are initially enrolling, reactivating or revalidating, ensure your individual (Type 1) NPI is listed at the top of the page where it speaks of reassignments.

Section 2A

This section must identify your full name, birth information, social security number, Medical/Professional school and graduation year, DEA Number (if applicable), your medical license and certification information.

Section 2B

This section should the address and phone number where CGS can contact you directly once you are enrolled.  Please be aware that correspondence from CGS will sent to sent to this address (i.e. revocation letters, deactivation letters, revalidation correspondence, etc.).  It cannot be the address of a billing agency, management services organization, chain home office, or the provider’s representative (e.g., attorney, financial advisor).

Section 2C

This section should be completed if you are currently in a residency or fellowship program.

Section 2D

A primary specialty must be identified in Section 2D.  You may only designate 1 primary physician specialty, but may identify more than one secondary physician specialty.  Only 1 non physician specialty may be identified.

If you are a psychologist, physical or occupational therapist, nurse practitioner or clinical nurse specialist, don’t forget to complete the section specific to you specialty following Section 2D.

Section 3

This section must be answered yes or no.  The following actions should be reported, answered yes or no.  The following actions should be reported, if applicable:

  • Felony and Misdemeanor conviction(s) within 10 years
  • Current or Past Suspension(s)/Revocation(s) of a medical license
  • Current or Past Suspension(s) Revocation(s) of an accreditation
  • Current or Past Suspension(s) or Exclusion(s) imposed by the U.S. Department of Health and Human Service’s Office of Inspector General (OIG)
  • Current or Past Debarment(s) from participation in any Federal Executive Branch procurement or non-procurement program
  • Medicaid exclusion(s), revocation(s) or termination(s) of any billing number
  • Any other Current or Past Federal Sanction(s)

Send any documentation to support these actions.

Section 4A

Complete this section with information related to your business entity.  The legal business name must be listed as it’s on file with the Internal Revenue Service (IRS).  Identify the tax identification number, Medicare Number (PTAN) if issued, NPI (Type 2) Incorporation information (if applicable), and type of organization structure and how you are registered with the IRS.  You must also identify if you are an Indian Health Facility supplier.   

Regarding the Final Adverse Legal Action History, this section must be completed the same as section 3, only the actions are applicable to the business entity.

Section 4C

Complete this section for each of your practice locations where you render services to Medicare beneficiaries.

Provide the practice location name, street address, telephone number, Medicare ID Number (PTAN) for the business if assigned, NPI (Type 2), the date you first saw a Medicare patient this this location, type of practice location and the CLIA/FDA if applicable.

Section 4D

List the city/town, State, and ZIP code for all locations where health care services are rendered in patients’ homes.

Section 4E

Medicare will issue payments via electronic funds transfer (EFT). Since payment will be made by EFT, the “Special Payments” address will indicate where all other payment information (e.g., remittance notices, special payments) are sent.  

You must check the applicable box to indicate where the special payments address is the same as the practice location listed in Section 4C.  If it differs, the address must be provided.

Section 4G

If the patients’ medical records are stored at a location other than the location shown in Section 4C, complete this section with the name and address of the storage location. This includes both current and former patients’ records.

Section 4H

If you only render services in patients’ homes (house calls), you may supply your home address in this section if you do not have an office. In Section 4H, explain that this address is for administrative purposes only and that all services are rendered in patients’ homes.

Section 6

This section must be completed for all managing employees, either under contractor or through some other arrangement, regardless of whether the employee is a W2 employee of the provider.  The sole owner can identify themselves if operating their own business.

Section 8

If you have a company or individual that you contract with to prepare and submit your claims, identify them in Section 8.

Section 13

List the person(s) we can contact if we have questions regarding your current enrollment application.

Section 15

This should be signed and dated by the enrolling provider.

Supporting Documents
  • Copy of state Medical license
  • Copy of certification (if applicable)
  • Degree for non physician practitioners
  • CP575 or other pre-printed IRS documentation that identifies the Legal Business Name and Tax Identification Number of the entity.
  • Electronic Funds Transfer form (EFT CMS 588 FormExternal PDF)
    Note: A copy of a voided pre-printed check OR bank letter verifying the information on the EFT form)
  • Participation Agreement (optional) CMS 460External PDF 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.

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