Provider Enrollment - Forms

The NHIC Provider Enrollment Unit is charged with the responsibility to accept, validate, and process Medicare provider enrollment applications within its jurisdiction. These pages will assist you in all phases of provider enrollment.

Information and Education Resources for Medicare Providers, Suppliers, and Physicians: Centers for Medicare & Medicaid (CMS) has developed information and educational resources to meet your Medicare business needs.

For assistance in completing the Provider Enrollment Forms, please refer to:

• Provider Enrollment Form Completion online course or
• Provider Enrollment Form Tool

Application Forms

To enroll in Medicare as a provider or make changes to your existing Medicare information, you must complete a CMS-855 application.

The CMS-855 Medicare enrollment applications located on the CMS forms web page can be completed on-line in a PDF fillable format or downloaded and completed by hand.

A comprehensive user guide, providing detailed instructions on how to download and complete each of the three application forms, is also available on the CMS Web site.

If a provider wants to enroll as a Participating Provider (PAR), the Participation Provider Agreement (CMS-460) must be included with the enrollment application.

At the time of initial enrollment or a change to existing provider information, an Electronic Funds Transfer Authorization Agreement (CMS-588) must also be submitted.

Form CMS 855I for Individual Health Care Practitioners CMS 855I (06/06)   All physicians, non-physician practitioners and incorporated individuals who render medical services to Medicare beneficiaries and submit claims for services rendered, must complete this application. If you are planning to provide services as part of an organization/group to which you will reassign your benefits, you must also complete and submit a CMS 855R - Application for the Reassignment of Medicare Benefits.

Form CMS 855B for Suppliers that will Bill Medicare Carriers CMS 855B (06/06)   Suppliers, organizations/groups, partnerships and corporations that will bill Medicare carriers for medical services provided to Medicare beneficiaries, must complete this application. If the supplier has individual practitioners, each member of the supplier must receive his or her own Provider Identification Number (PIN) and enroll as an individual (using the CMS 855I application). Once the individual practitioner is enrolled, he/she can enroll as a member of an organization. When joining an organization/group every member of the organization must complete a copy of the CMS 855R - Individual Reassignment of Benefits.

Form CMS 855R for Individual Reassignment of Benefits CMS 855R (0606)   This form is to be completed by the group/partnership or group member/partner when any of the situations listed below are present: An individual practitioner is currently enrolled in the Medicare program and joining a group/partnership that is currently in the Medicare program and where the individual practitioner will reassign benefits to the group/partnership. A newly enrolling group/partnership, to list all group members/partners rendering services within the group/partnership setting. NOTE: Enrolling group/partnership and all group members/partners not currently enrolled in the Medicare program must also complete the CMS 855I - Application for Individual Health Care Practitioners. A Medicare group/partnership wishing to update the status of current members/partners (e.g., deleting member/partner, assigning member/partner to a new practice location, etc.) or adding a Medicare individual practitioner to the group/partnership. NOTE: When adding an individual practitioner who is not enrolled in the Medicare program, the individual practitioner must complete the CMS 855I - Application for Individual Health Care Practitioners and enroll in the Medicare program prior to becoming a group/partnership member. An incorporated individual reassigning Medicare benefits to the corporation.

Electronic Funds Transfer Authorization Agreement   Below is a list of the most common errors found on the EFT applications. Please read and follow the application instruction carefully to avoid a delay in the processing of your application. EFT form not signed by the provider, or authorized/delegated official - please make sure that the person who signs the CMS 588 (EFT Authorization Agreement) application is the same person who signed section 15 or 16 of the CMS 855B or CMS 855I application. Information on EFT form not on Medicare file (i.e. EIN/NPI) and/or or the PIN/PTAN number is inactive – please call Customer Service, at 877-527-6613, for directions on how to complete and submit a CMS 855 application to update the provider’s Medicare file. Failure to attach an original pre-printed voided check, pre-printed deposit slip, or confirmation of account number and routing number on the bank letterhead, signed by an officer of the bank (EFT required documentation). Information on attached voided check/deposit slip is not accurate - please make sure that the bank letter, pre-printed check or deposit slip has the legal business name or name of the provider. All information must match the application. The attached bank letter does not contain both the routing number and account number. Part V - Authorization the fee-for-service contractor should be NHIC, Corp.. NOTE: EFT is required for new Medicare enrollment, or for any established provider, who is changing their existing Medicare file and has not reassigned all his benefits to a group (s).

Medicare Participating Physician or Supplier Agreement   To sign a participation agreement is to agree to accept assignment for all covered services that you provide to Medicare patients. If you bill for physicians’ professional services, services and supplies provided incident to physicians’ professional services, outpatient physical and occupational therapy services, diagnostic tests, or radiology services, your Medicare fee schedule amounts are 5 percent higher if you participate. Also, providers receive direct and timely reimbursement from Medicare.

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Choosing a Form

Individual Practitioners

All solo providers, who are not incorporated, must complete the CMS 855I even if they previously had a group member or individual number in the state. New providers should attach a copy of their license and medical diploma. Individuals working under a tax identification number must include a copy of the entity's IRS Form CP575.

Providers Applying as a Group

Whenever two or more providers work under the same tax identification number, they must form a group. The group number is like an umbrella the group members' numbers fall under. To create a group, complete the CMS 855B.

Attach a copy of the applicant's IRS Form CP575, and make sure the authorized official signs Section 15, the certification statement. Include a minimum of one group member's application with this group application.

To enroll a group member, complete the CMS 855R. If the provider has not previously had a Medicare provider number within the jurisdiction of NHIC, they must also complete the CMS 855I. Include copy of the member's state license and medical diploma.

Incorporated Providers - Using a Fictitious Name

Incorporated providers must complete additional CMS application forms. If you are not currently enrolled with NHIC, the first application, the CMS 855I, will be used to establish you with the Medicare program. Secondly, the CMS 855B is completed in order to enroll your business. Additionally, the CMS 855R is completed in order to reassign benefits payable to you as an individual practitioner to your business, which will be submitting claims for the services rendered.

In addition, any other practitioners who render services for your business, and who will be reassigning their benefits to the business, must also complete a CMS 855R.

Incorporated Individual Providers - Using First and Last Name

Incorporated individuals using their fist and last name must complete the CMS 855I application.

In addition, any other practitioners who render services for your business, and who will be reassigning their benefits to the business, must also complete a CMS 855R.

Provider Benefits Reassignment

Every provider or entity that wants to receive benefits that have been reassigned to them must be enrolled in the Medicare program. For example, if a hospital wants to receive benefits reassigned by a contracting physician, the hospital must be enrolled in Medicare Part B.  The hospital must therefore complete CMS 855B. Each member of the group who is NOT a current Medicare provider will complete CMS 855I; but those who are already established Medicare providers will only complete CMS 855R.

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Provider Enrollment Mailing Address

Mail your completed application for Northern or Southern California to:

Provider Enrollment
P.O. Box 2812
Chico, CA 95927-2812

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02/14/2008