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Enrollment - Tips for Enrolling For various reasons, Provider Enrollment often receives enrollment forms and applications that cannot be processed, thus causing unnecessary delays and frustrations. To correct the problem, we list herein some helpful tips on the correct way to submit these forms. The provider-applicant MUST respond to the Adverse Legal History question, either checking “Yes” or “No” in Sections 3 of the CMS 855I or 855B form. The Change box and Effective Date field must also be properly filled out. Five Percent (5%) or More Ownership Interest Section 5 of CMS 855B must be completed with information about any organization that has 5% or greater (direct or indirect) ownership of, any partnership interest in, and/or managing control of the supplier who wants to enroll in Medicare. Section 6 of CMS 855B must be completed with information about any individual that has 5% or greater (direct or indirect) ownership interest in, any partnership interest in, and/or managing control of the supplier who wants to enroll in Medicare. In addition, all officers, directors, and managing employees of the supplier must be reported in this section. If there is more than one individual, you must copy and complete this section. The supplier MUST have at least ONE owner and/or managing employee. Even when a provider works under a tax identification number, the social security number is necessary for the provider to receive their Unique Physician Identification Number (UPIN). This information, along with date of birth, school, graduation year, and board certification information, is used to identify that provider. Employer Identification Number (EIN) Be sure to enclose a copy of the IRS CP575, or other documentation from the IRS showing the appropriate Employer Identification Number for paying claims. This number must match the legal corporate name that is found on the IRS pre-printed labels for filing payroll or quarterly estimated earnings. Your accountant or lawyer should know this official corporate name. Participating Provider Agreement Participation agreements are a separate contract from the CMS 855 enrollment forms. They are titled "Medicare Participating Physician or Supplier Agreement." If the applicant wishes to be a participating provider ('accept assignment') with Medicare, this contract needs to be submitted simultaneously with the appropriate CMS 855, and must have original signatures. Group members do not need to submit this agreement. Group members are automatically participating providers if the group they are joining is participating. Changes in Tax Identification Number Tax identification number changes require new provider billing numbers for all entities except sole proprietors. Therefore, the entire CMS 855B and 855R or 855I must be completed. Any other type of change in information, on current provider numbers, must be reported using the appropriate CMS 855 application form. If you need applications or more information, please contact Customer Service at 877-527-6613. The most common reason for returned applications is missing signatures. All signatures must be original. Stamps or photocopies are not acceptable. Sections 15 and 16 on the CMS 855B, Section 15 on the CMS 855I and Sections 4A and 4B on the CMS 855R require signatures. The individual provider application requires the provider's signature. Organization and group applications require the signatures of all authorized representatives. Group member applications require the signature of the provider and authorized representatives. An authorized representative is the appointed official who has the authority to enroll the entity in the Medicare program as well as make changes and/or updates to the applicant's status. The representative must be an Officer, CEO or general partner.
05/24/2007 |
