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Last Modified: 8/26/2013 Location: FL, PR, USVI Business: Part B

Step-by-step directions to completing CMS-855I application

Section 1

If you are a physician’s assistant, did you fill in both your Medicare identification number (if issued) and your national provider identifier (NPI) on page 3, Section 1A, in the two spaces provided within the first paragraph at the top of the page?
Yes
If you are reassigning all of your Medicare benefits (per Section 4B1 of this application), did you furnish both your Medicare identification number (if issued) and your NPI on page 3, Section 1A, in the two spaces provided within the second paragraph at the top of the page?
Yes
Did you check only one box on pages 3 & 4, Section 1A (Basic Information)?
Yes
Did you fill in the “required sections” denoted to the right side of the box you checked?
Yes
Did you check one or more boxes on page 4, Section 1B (Basic Information)?
Yes
Did you fill in the “required sections” denoted to the right side of each box you checked?
Yes

Section 2

Did you fill in your personal information on page 5 in Section 2A, (Identifying Information), relative to yourself as well as to your license and certification information?
Types of licenses required are:
Professional license
Yes
Did you provide your correspondence address (not a billing agency’s address) for Section 2B, on page 5?
Yes
Note: This address cannot be your billing agency address.
Did you complete questions 1-4 in Section 2C (Resident/Fellow Status) on page 6, if you are currently in an approved training program as a resident or are in a fellowship program?
Yes
If you are not in an approved training program, did you answer “no” to questions 1a and 1b?
Yes
Did you designate your primary specialty (only one) and your secondary specialties (one or more) on page 7, Section 2D (Medical Specialties), question 1.
Yes
If you checked Diagnostic Radiology as your specialty, and you will be billing Medicare for the technical component of the diagnostic tests, did you also complete a CMS-855B enrollment form as an independent diagnostic testing facility (IDTF)?
Yes
If applicable, did you designate your non-physician specialty on page 8, Section 2D, question 2.
Yes
Note: Non-physician practitioners do not need to complete this section. An additional CMS-855I must be completed for each non-physician specialty type.
If you are, or were, a physician’s assistant, did you fill in the required information on page 9, Sections E, F and G?
Yes
Note: In Section 2E the employer’s and physician’s NPI must be listed. Additionally, ensure that the name corresponding with your NPI is your legal business name as reported to the IRS and that it matches exactly. This includes any spacing or punctuation. If not, contact NPPES (https://nppes.cms.hhs.gov/NPPES/Welcome.do external link) and request the update.
Did you respond “yes” or “no” regarding whether or not you hold a doctoral degree in psychology in Section 2H on page 10?
Yes
If you checked “yes,” did you provide a copy of your degree with this application?
Yes
Did you complete Section 2I (questions 1-4) on page 10, if you are a psychologist billing independently.
Yes
Did you complete Section 2J (questions 1-5) on page 10, if you are a physical or occupational therapist in private practice?
Yes
If you responded “yes” to any question numbered 2-5, did you attach a copy of the lease agreement for your facility usage?
Yes
Did you respond “yes” or “no” regarding whether or not you are an employee of a Medicare skilled nursing facility (SNF) or an employee of another entity that has an agreement to provide nursing services to a SNF in Section 2K on page 10?
Yes
If you answered “yes,” did you provide the name and address of the applicable SNF?
Yes
you an individual practitioner that furnishes ADI services and will bill Medicare? Complete all sections on page 11.

Section 3

Did you report any Final Adverse Actions/Convictions that have been imposed against you in Section 3 (Final Adverse Actions/Convictions) page 13?
Yes
If yes, did you attach a copy of the final adverse action documentation and its resolution?
Yes
Note: Your application will be considered incomplete if the information is missing or you enter “not applicable.”

Section 4

Did you complete Section 4A on page 14, if you are the sole owner of a professional corporation, a professional association, or a limited liability company intending to bill Medicare through this business entity?
Yes
Note: Section 4A – Ensure that the name corresponding with your NPI is your legal business name as reported to the IRS and that it matches exactly. If not, contact NPPES (https://nppes.cms.hhs.gov/NPPES/Welcome.do external link) and request the update.
Has your organization, under any current or former name or business identity ever had any final adverse actions that have been imposed against it (page 14, Section 4 under "Final Adverse History," questions 1 & 2)?
Yes
If yes, did you attach a copy of the final adverse action documentation and its resolution?
Yes
On page 15, Section 4B Individual Affiliations, complete this section with information about your private practice and group affiliations.
1. If you are reassigning all of your payments to another group or organization furnish the name, Medicare identification number(s) and NPI of each group or organization below and proceed to Section 13
2. If any of your payments are part of your private practice and a group organization furnish the name and Medicare identification number(s) and NPI of each group or organization below and continue to Section 4C (where you will enter your private practice information.)
3. If you are not reassigning all or any of your payments to another group or organization, skip to Section 4C with information about your private practice.
Did you fill in the appropriate spaces in Section 4C (changes/additions/deletions) on page 16 regarding your solo practice or your organization’s practice location(s)?
Yes
Note: If you as a sole practitioner or your organization sees patients in more than one location, complete this section for each location. The NPI in this section will be the NPI associated with you individual name and social security number.
Did you fill in the requested information on page 17; Section 4D, for all locations where health care services are rendered in patients’ homes?
Yes
Did you fill in Section 4E on page 18 regarding your option to have your special payment address mirror your practice location address, or to be different from that?
Yes
Note: For electronic fund transfer (EFT), include CMS-588 for initial enrollments and/or if you are making changes to an existing Medicare provider number that has not already been set up for EFT. Remember to submit a voided check and/or confirmation of account information on bank letterhead.
Did you provide your employer identification number (EIN) in Section 4F (Employer ID Number Information), page 18 in order for your Medicare payments to be reported under your EIN?
Yes
Did you provide the storage facilities address where you maintain your medical records on pages 19; Section 4G (if it’s different than your practice/physical location)?
Yes
Did you explain any unique circumstances concerning your practice locations or the method by which you render health care services in Section 4H on page 19?
Yes

Section 6

Did you include the name(s) of all managing employees? A managing employee means a general manager, business manager, administrator, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operations of the supplies, either under contract or through some other arrangement, regardless of whether the individual is a W-2 employee or the supplier.
Yes
Note: If there is more than one managing employee, copy and complete this section as needed.
Did you identify any final adverse actions that have been imposed against those individuals in 6A, attach a copy of the final adverse action documentation and resolution?
Yes
If yes, did you attach a copy of the adverse legal action documentation and resolution?
Yes

Section 8

Did you complete Section 8 on page 21 with information specific to the billing agency you utilize?
Yes
Note: If you do not use a billing agency, you can continue with Section 13 on page 22). Make sure that you have first checked the box stating, “check here if this section does not apply.”

Section 13

Did you complete Section 13 on page 22, with the contact person information?
Yes

Section 14

Did you read Section 14 on pages 23 & 24 to ensure your understanding of the penalties for falsifying Medicare information?
Yes

Section 15

Did you complete the certification statement in Section 15 (page 26)?
Yes
Note: All signatures must be original. The use of blue ink is preferred.

Section 17

Did you read Section 17 on page 27 to ensure that you have submitted correct and complete supporting documentation?
Yes

Your application contact information

The following chart describes when and how First Coast will contact providers based on the contact information provided in your enrollment application.

Contact Type
During the Enrollment Process
Once Provider/Supplier Is Enrolled
Contact address
Used as a first contact for all for additional information requests.
N/A
Correspondence address
Used for additional information requests if the contact information on the application is incomplete.
N/A
Pay-to address
Used to send remittance to providers and or to notify groups and individual practitioner of approval/denial into the Medicare program.
Used to request additional claim information and or to send remittance advices and checks to providers.
Note: Upon request from the provider/supplier, requests for additional claim information may be sent to the practice address.

First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.