How to Complete the Medicare CMS855B Enrollment Application

1
How to Complete the Medicare CMS-855B Enrollment
Application

• Presented by
• Provider Outreach Education
• and
• Provider Enrollment

2
Welcome
Welcome to the Computer-Based Training (CBT)
module for Provider Enrollment. This
presentation was developed by the Provider
Outreach and Education Department along with the
Provider Enrollment Department in an attempt to
assist you with correctly completing the CMS-855B
enrollment form the first time.
3
Revised CMS-855B

• On May 1, 2006, the Centers for Medicare
  Medicaid Services
• (CMS) released and implemented a new version of
  the
• CMS-855 Medicare enrollment applications
  (versions 04/06
• and 06/06).
• The appearance and format of the enrollment
  applications
• were revised to help providers accurately
  complete the
• applications. Revisions included
• Larger font and plain language
• Tips on how to avoid delays
• Updated instructions to help you know which
  application to
• submit
• Redesigned Section 17.

4
Is this the correct form for you?

• The CMS-855B form is for the following
• Ambulance Service Supplier
• Ambulatory Surgical Center
• Clinic/Group Practice
• Competitive Acquisition Program (CAP) Part B
  Drug Vendor
• Independent Clinical Laboratory
• Independent Diagnostic Testing Facility
• Mammography Center
• Mass Immunization (Roster Biller Only)
• Portable X-ray Supplier
• Radiation Therapy Center
• Slide Preparation Facility
• Voluntary Health/Charitable Agency

5
Do You Have the CMS-855B Form?
If you do not have the form please take a few
minutes to print it. You will use it as a guide
throughout this presentation. The form is
located on the CMS Web site at www.cms.hhs.gov/
cmsforms/downloads/cms855b.pdf
6
Provider Enrollment Hotline

• If after completing the CBT you still have
  questions, contact
• the Provider Enrollment Department for your area
• Texas and Indian Health facilities
• [phone]
• Virginia
• [phone]
• DC/Delaware/Maryland
• [phone]

7
Significant Changes

• Providers are required to submit the new version
  of the
• enrollment form and additional information with
  all initial
• enrollment applications and changes of
  information .
• Required additional information includes
• The NPI Notification. (If it was not previously
  submitted with
• an application that was processed completely).
• Completed CMS-588 Form (Electronic Funds
  Transfer (EFT).
• All required documentation necessary to process
  the
• enrollment form.

8
Have You Applied for Your National Provider
Identifier (NPI)?
As a Medicare health provider, you must obtain an
NPI prior to enrolling in Medicare or before
submitting a change of existing enrollment
information. The NPI notification must be
submitted with the enrollment form. NPI was
mandated by the Health Insurance Portability and
Accountability Act. NPI is a 10-digit number
that will replace current Medicare identifiers.
The NPI will not change and will remain with the
provider regardless of job and location
changes. Effective May 23, 2007 all Medicare
claims must be submitted with only the NPI. The
Website of the NPI Enumerator is
https//nppes.cms.hhs.gov/NPPES/Welcome.do

9
Electronic Funds Transfer (EFT)
EFT is a way for Medicare to pay providers with a
money transfer from bank to bank. This eliminates
the need for a provider to wait for a check to
be mailed. CMS requires that providers filing a
CMS-855 form have EFT. The application is to be
included with your enrollment form. The EFT
form, CMS-588, is located at www.cms.hhs.gov/cms
forms/downloads/CMS588.pdf
10
Did you know you may not have to complete the
entire application?

• Not every circumstance requires the CMS-855B to
  be
• completed in it's entirety. Those include
• Voluntarily terminating Medicare enrollment
• Changing information
• identifying information
• adverse legal actions
• practice location, payment address or record
  storage
• ownership interest and/or managing control
• billing agency information
• authorized official
• delegated official.

This CBT will review each section of the CMS-855B
form.
11
Section 1A Basic Information
This section captures information about why
you are completing the application. It also
provides a list of required sections pertaining
to your reason. Find the section that applies to
you. Only one reason for application should
be checked. Changes of Medicare information must
identify any Medicare identification numbers,
NPI and complete Section 1B. Complete in blue or
black ink. NO PENCIL
v
pg. 4
12
Section 1B Basic Information
If you are reporting a change to your
Medicare enrollment information, you will need to
complete Section 1B. Check all areas that are
being changed. Read and follow each section
required for the change(s) you've selected. Secti
on 6 is also required if adding a Delegated
Official.
v
pg. 5
13
Section 1 Attachments 1 and 2
Ambulance Suppliers and Independent Diagnostic
Testing Facilities (IDTF) must complete the
appropriate sections on page six if they are
reporting changes to their Medicare
enrollment information. All other providers can
move on to Section 2.
pg. 6
14
Section 2 Identifying Information
Section 2 is the information about the provider.
It identifies the type, name, address and
information for specific suppliers. If you do not
find the type of supplier you are under section
2A, then mark "Other" and write the supplier type
on the line provided. Not all providers will need
to complete all of Section 2. American Indian
and/or Alaska Native facilities see next slide.
v
ABC Health Clinic 123456789
v
pg. 7
15
Section 2 Identifying Information
American Indian and/or Alaska Native
facilities check the "Other" boxes in Section 2B
and identify if you are tribe or IHS.
v
Tribe Name 123456789 Tribal Health Clinic
Part of Tribe or IHS
v
v
Tribe or IHS
16
Section 2B2 Identifying Information
Section 2B2 is to identify any State license or
certification information the provider
is required to have to operate as the type of
provider you are enrolling. If applicable you
must provide the license or certification
number, state where issued, effective and
expiration dates. You must check if a State
license or certification is not applicable.
Include copies of all licenses and/or
certifications.
v
v
pg. 8
17
Section 2B3 Identifying Information
Section 2B3 is the correspondence address for
the entity listed in question 2B1. This cannot
be the address of a billing agency.
123 Medical Way Suite 1A Medical City
Any ST.
12345-6789 [phone]
[phone] myname_at_clinic.com
pg. 8
18
Section 2C Identifying Information
This section is only for hospitals that need a
Medicare Part B billing number for a department
of the hospital. If this is not applicable
to you, skip to 2D.
pg. 8 and 9
19
Section 2D - Identifying Information
Section 2D is for any comments that will help
explain information in Section 2.
Indian Health clinic with no street address.
Located 1 mile east of county road 121 and
highway 40.
Section 2E - Identifying Information
Section 2E is for Physical Therapy and
Occupational Therapy groups only. Each question
must be answered with a Yes or No.
pg. 9
20
Section 2F Identifying Information
Section 2F is for free-standing Ambulatory
Surgical Centers (ASCs). Check either a Yes or No
box and complete other information if required.
Section 2G Identifying Information
This section is to report the termination
information of a Physician Assistant from your
group/clinic. You have now completed Section 2,
move to Section 3.
pg. 9 and 10
21
Section 3 Adverse Legal Actions
Complete Section 3 for all past or present
convictions, exclusions, revocations
and suspensions regardless of whether or not the
record has been expunged or an appeal is pending.
A list of reportable items is provided on page
11.
pg. 11
22
Section 3 Adverse Legal Actions
You must answer question number one. If you
answer "Yes" to question one you must complete
question two and attach all adverse
legal documentation. You have now
completed Section 3, move to Section 4.
v
pg. 12
23
Section 4 Practice Location Information
Section 4 must include information about where
the group or organization provides health
care services. Provide the specific street
address as recorded by the United States Postal
Service. Do not provide a P.O. Box. Section 4
will identify where medical records are stored,
the address for remittance notices and special
payments. Everyone will need to complete part
of Section 4.
pg. 13
24
Section 4 Practice Location Information
Section 4A requires the practice location name
which is the name used for everyday operation.
Enter the full street number, city, state and
nine-digit zip. No P.O. Box numbers. List the
telephone number for the physical location. A fax
number or email address is not necessary. America
n Indian and/or Alaska Native clinics with no
street address should list General Delivery or
Main Street as the address. Enter the first date
a Medicare patient was seen at this location.
This does not have to be the date the location
opened for business. Enter the Medicare
identification number, if issued, and the NPI for
the clinic. Select the option that best fits this
practice location. If the practice has a CLIA
and/or FDA certification enter the numbers and
attach a copy of the certification.
ABC Health Clinic
123 Medical Way Suite 1A Medical City
Any ST. 12345-6789 (123)456-789
0 [phone]
myname_at_clinic.com 01/02/2007
2468101214
v
12D345678
pg. 14
25
Section 4 Practice Location Information
Section 4B contains information about where the
group's remittance notices will be sent. This
address will also be used to send any special
Medicare payments not sent electronically. Medica
re will issue payments via electronic funds
transfer. Since payments will be made EFT, the
"special payments" address should indicate
where all other payment information should
be sent.
v
pg. 15
26
Section 4 Practice Location Information
If you store patients' medical records at a
location other than what is reported in Section
4A or 4E, complete this section. If this section
is not completed, you are indicating that all
records are stored at the practice locations
reported in Section 4A or 4E.
pg. 15 16
27
Section 4 Practice Location Information
If you provide services in patients' homes you
will need to complete Section 4D. If you provide
services to an entire state, enter the State.
You do not need to list each City/Town
separately. If you only provide services in a
City/Town, enter the City or Towns' name and the
state. The zip code is only required if you are
not servicing the entire city/town. If you do
not render services in patient's homes, skip
Section 4D.
Dallas
Texas Ft. Worth
Texas
pg. 17
28
Section 4 Practice Location Information
Section 4E is for the base of operations. This is
used for the location of where personnel are
dispatched, where mobile/portable equipment is
stored and where vehicles are parked when not
in use. Not all providers will need to complete
this section. If the address for the base
of operations is the same as Section 4A check
the indicated box.
v
pg. 18
29
Section 4 Practice Location Information
Section 4F is used when vehicles are used to
provide medical services. This does not include
ambulances. Do not report vehicles that are used
to transport medical equipment if services are
not provided in the vehicle. If there are more
than two vehicles, copy Section 4F and complete
it as many times as necessary.
pg. 18
30
Section 4 Practice Location Information
Section 4G is requesting the rendering location
of mobile or portable services. Reporting can
be by an entire state or by City/Towns. An
addition and deletion can be made on the same
application.
pg. 19
31
Section 5 Ownership Interest Organizations
Section 5 is for any organization that owns 5 or
more of the provider completing the
application. (Section 5 is not
for individuals). Organizations that have
managing control or partnership interests must
also be listed. American Indian and/or
Alaska Native organizations must list the name of
the government (i.e. Indian Health Service)
or tribal organization that will be legally and
financially responsible.
pg. 20
32
Section 5 Ownership Interest Organizations
If Section 5A does not pertain to your situation
then indicate "Not Applicable".
v
pg. 21
33
Section 5 Ownership Interest Organizations
If you check change, add or delete you must
furnish the effective date. Indicate at least
one ownership or managing control category. The
business name must be what is reported to
IRS. Submit a copy of your IRS tax document
(CP-575).
v
The Doctors Partnership ABC Health Clinic 123
Medical Way Suite 1A Medical City
Any ST. 12345-6789 246810121

pg. 21
34
Section 5 Ownership Interest Organizations
Example of American Indian and/or Alaska Native
information.
v
Tribal Name Tribal Health Clinic 123 Native
Way Indian Country Any
ST 24680-1214 369121518
pg. 21
35
Section 5 Ownership Interest Organizations
Section 5B is to report any adverse legal history
of the controlling organization. You must answer
question one. Refer to page 11 for a
description of adverse legal actions. Attach
copies of all adverse legal documentation.
v
pg. 22
36
Section 6 Ownership InterestIndividuals
Section 5 contains the information for
individuals having ownership of 5 or more of the
group. If the provider listed in Section 2 is a
corporation, list all officers and directors. Lis
t all individuals with partnership interests
regardless of percent of ownership. List all
authorized and delegated officials in this
section.
pg. 23
37
Section 6 Ownership InterestIndividuals
If there is more than one individual that needs
to be reported, copy and complete this section
for each individual. Adverse legal actions must
be completed for each individual reported. Americ
an Indian and/or Alaska Native groups report its
managing employees in Section 6. You must check
either "Yes" or "No" in response to question
one in 6B.
v
01/02/2007
John
Doe 111-11-1111 12/25/1950
N/A N/A
v
v
pg. 24
38
Section 8 Billing Agency
Section 8 is looking for information about any
individual or entity with whom you have
contracted to prepare and submit claims for the
business. A billing agency may perform other
services for you, but claims completion and/or
submission are included in your contract. If you
do not use a billing agency, you must indicate by
checking the first box.
v
pg. 25
39
Section 8 Billing Agency
If you check the box indicating change, add or
delete you must furnish the effective date
and complete the appropriate fields.
ABC Billing 987654321
369 Billing Ave. Claims Town
Any St. 78910-2345 (369)101-
2345 [phone]
pg. 25
40
Section 13 Contact Person
The contact person should be someone who can
answer questions about the information on the
application. Medicare will not list the
contact person on the Medicare providers' record.
If the contact person will be either the
authorized or delegated office, check the
appropriate box and skip to the indicated
section. There can be more than one contact
person. Copy this page for each individual.
Jane
Doe [phone]
[phone] 123 Medical Way Suite
1A Medical City
Any ST. 12345-5678 jane.doe_at_medical.com
pg. 26
41
Section 14 Penalties for Falsifying Information
Section 14 outlines the penalties for falsifying
information and should be read by the
authorized and delegated officials
legally responsible for the provider listed in
Section 2. This section does not have an area to
be completed.
pg. 27 - 28
42
Section 15 Certification Statement
Page 29 provides a description of an Authorized
Official and a Delegated Official. Authorized
officials and delegated officials must be
reported in Section 6 of this application. Exampl
es of an authorized official are Chief Executive
Officer, Chief Financial Officer, General
Partner, Chairman of the Board or direct
owner. Only an authorized official has
the authority to sign the initial enrollment
application. A delegated official does not have
this authority. The officials must read and
understand pages 29 and 30.
pg. 29 - 30
43
Section 15 Certification Statement
Sections 15B and 15C are for Authorized
Official(s) only. Authorized Official(s) must
also be listed in Section 6 of this form. Authori
zed Official(s) must sign this page. Use blue ink
which will indicate an original signature and
not a copy. All signatures must be original
and signed in ink. Applications with signatures
deemed not original will not be processed.
Stamped, faxed or copied signatures will not be
accepted.
John
Doe [phone]
CEO John Doe,
CEO
1/2/2007
pg. 31
44
Section 16 Delegated Official
Section 16 is optional. If no delegated official
is appointed, the Authorized Office will
be responsible for all changes and updates made
to the provider's record. All signatures must
be original and signed in ink. Applications
with signatures deemed not original will not be
processed. Stamped, faxed or copied signatures
will not be accepted.
Charlie
Brown Charlie Brown
1/2/2007
[phone] John Doe, CEO
1/2/2007
pg. 32 - 33
45
Section 17 Supporting Documents

• Section 17 indicates what is
• attached to the application. Check
• the corresponding boxes for all
• information being attached to
• the application.
• Don't forget
• Tax documents (IRS CP-575).
• CMS-588 Electronic Funds.
• NPI notification.
• Copies of any State licenses or
• certifications.
• If applicable, copies of CLIA,
• FDA and/or Diabetes Program
• certifications.
• Copy of attestation for
• government and tribal organizations.

v
v
v
v
v
v
v
v
pg. 34
46
Attachment 1 Ambulance Suppliers
Pages 35 through 37 of Attachment 1 contains
information on geographical location of
services, state licensure information,
paramedic intercept services and vehicle
information. On page 36, Paramedic intercept
service is a basic life support ambulance
providing the transport, while advance
life support paramedics from another ambulance
supplier provides the personnel for the
transport. The Yes or No box must be
checked. Copy and complete page 37 for
each vehicle used by the ambulance company.
pg. 35 - 37
47
Attachment 2 Independent Diagnostic Testing
Facility (IDTF)
Pages 38 through 44 are to be completed by
IDTFs. An IDTF is required to provide all codes
that are allowed to be performed, equipment and
model numbers. Information on an interpreting
physician, technicians who perform tests and
supervising physicians is required. Page 44
requires an original signature by the
supervising physician.
pg. 38 - 44
48
Prescreening
All applications are prescreened, including
changes of information and reassignments, within
15 calendar days of receipt. Prescreening
ensures providers submit all required supporting
documentation and a complete enrollment
application. This process applies to all
applications.
49
Prescreening Missing Information

• If an application is received that contains at
  least one missing
• required data element, or the provider fails to
  submit all required
• supporting documentation
• TrailBlazer will send a letter to the provider
  (where
• appropriate we can send it by email or fax),
  that documents
• and requests the missing information.
• The letter must be sent to the provider within
  the 15-day
• prescreening period.
• TrailBlazer is not required to make any
  additional requests
• for the missing data elements or documentation
  after the
• initial letter.

50
Prescreening Missing Information
The provider must furnish all of the missing
information within 60 calendar days of the
request. If the provider fails to do so
the application is rejected. The provider will be
notified by letter with the reasons for rejection
and how to reapply. If the provider wishes to
reapply they will be required to begin a new
process.
51
Rejected vs. Returned
The difference between a rejected and returned
application is that an application is rejected
based on the provider's failure to respond to
TrailBlazer's request for missing information or
clarification. An application is subject to
immediate return based on specific criteria. All
resubmissions must contain a newly signed and
dated certification statement page.
Return to Sender
52
Criteria For Returned Applications

• Application received more than 30-days prior to
  the effective date listed on the application.
  (This does not apply to certified providers, ASCs
  or portable X-ray suppliers.)
• Provider submitted new enrollment application
  prior to expiration of time in which provider is
  entitled to appeal the denial of its previously
  submitted application.
• Submitted CMS-855 for sole purpose of enrolling
  in Medicaid.
• CMS-855 not needed for the transaction in
  question.
• CMS-588 sent in as a stand-alone change of
  information request (i.e., it was not accompanied
  by a CMS-855) but was 1) unsigned, 2) undated, or
  3) contained copied, stamped or faxed signature.

• No signature on application.
• Old version of application submitted.
• Copies or stamped signature.
• CMS-855I signed by someone other than individual
  practitioner applying for enrollment.
• Applicant failed to submit all forms needed to
  process a reassignment package.
• Completed application in pencil.
• Wrong application submitted.
• Web-generated application submitted but does not
  appear to have been downloaded off of CMS' Web
  site.
• Application not mailed (i.e., it was faxed or
  e-mailed).

53
Most Common Reasons for Delays

• TrailBlazer is allowed to reject for missing
  information. The top
• reasons for rejections that we see in our
  Provider Enrollment
• area are
• Missing NPI notification.
• Missing CMS-588 Authorization Agreement for
  Electronic
• Funds Transfer.
• Failure to document the reason for application
  submittal.
• "Change" was selected in 1A, but no indication
  of what
• was changing.
• The effective date for the change, add or
  deletion was
• missing.
• Application not signed or dated.
• IRS tax identification or documentation not
  received.

54
Application Processing
Once it is determined that the application will
not be returned, it goes through different phases
of verification, validation, and then on to final
processing. If additional information is needed
during these phases of processing the
application, you could receive a telephone
call or a letter requesting the information.
This phone call or letter will be directed to
the person listed on this application as the
Contact Person in Section 13 of the CMS-855B form.
55
Reminders
1. Request and obtain an National Provider
Identifier (NPI) before enrolling or making a
change. 2. The CMS-855B application is not
complete. A CMS-855B application must be
completed by all organizations that will be
billing Medicare carriers for medical services
furnished to Medicare beneficiaries. This form
must also be completed if a tax ID number has
changed for an established organization. 3.
CP575 not submitted. A CP575 must be submitted
with the CMS-855I and the CMS-855B application
any time a tax ID number is used. The CP575 is
the official letter from the IRS confirming the
tax identification number with the legal business
name. If the CP575 is not available, we will also
accept a copy of the quarterly tax payment coupon
or any official letter from the IRS that lists
the legal business name and tax ID number. 4.
Include all the necessary supporting
documentation. This supporting documentation
includes professional licenses, business
licenses, certifications, IRS form (CP575), the
National Provider Identifier (NPI) notification
and the 588 authorization form for Electronic
Funds Transfer (EFT). 5. Complete the
application in its entirety. Each section of the
application should be completed. If a section
does not apply, check the not applicable
statement where appropriate and skip to the next
section. 6. Identify a contact person. Once
your application has passed CMS prescreening
guidelines, a provider enrollment analyst will
conduct research and validation of the enrollment
application. By identifying a contact person who
is familiar with the application and who has
access to the physician, practitioner or
administrator, you can help our analyst obtain
the necessary information and/or documentation in
a timely manner. 7. Sign and date the
application. In accordance with CMS regulations,
any unsigned CMS-855 applications will be
returned to the applicant and any changes
requested must include the effective date of the
change.
56
Reminders
5. CP575 not submitted. A CP575 must be
submitted with the CMS-855I and the CMS-855B
application any time a tax ID number is used.
The CP575 is the official letter from the IRS
confirming the tax identification number with the
legal business name. If the CP575 is not
available, we will also accept a copy of the
quarterly tax payment coupon or any official
letter from the IRS that lists the legal business
name and tax ID number. 6. Include all the
necessary supporting documentation. This
supporting documentation includes professional
licenses, business licenses, certifications, IRS
form (CP575), the National Provider Identifier
(NPI) notification and the 588 authorization form
for Electronic Funds Transfer (EFT). See the
enrollment application for applicable
documentation requirements. 7. Complete the
application in its entirety. Each section of the
application should be completed. If a section
does not apply, check the not applicable
statement and skip to the next section. 8.
Identify a contact person. Once your application
has passed CMS prescreening guidelines, a
provider enrollment analyst will conduct
research and validation of the enrollment
application. By identifying a contact person who
is familiar with the application and who has
access to the physician, practitioner or
administrator, you can help our analyst obtain
the necessary information and/or documentation in
a timely manner. 9. Sign and date the
application. In accordance with CMS regulations,
any unsigned CMS-855 applications will be
returned to the applicant and any changes
requested must include the effective date of the
change.
57

• Congratulations, you have completed the CMS-855B
• enrollment form.
• Prior to mailing, review the application to
  ensure all items
• are completed, if appropriate, and copies of all
  attachments
• are included.
• If you have any questions, contact Provider
  Enrollment for
• your area
• Texas and Indian Health facilities
• [phone]
• Virginia
• [phone]
• DC/Delaware/Maryland
• [phone]

58
Thank you for participating in this
Computer-Based Training

• Provider Enrollment
• and
• Provider Outreach and Education