Last Modified: 2/3/2018 Location: FL, PR, USVI Business: Part A, Part B
Eliminate the guess work
The enrollment application assistance tool removes the guesswork for providers trying to figure out which enrollment form to use, whether they are submitting an initial enrollment, a change of information, revalidation or even terminating their Medicare enrollment.
This tool offers tips to clarify what should be included in each relevant section of the appropriate enrollment form as well as what additional documentation is needed to complete the process.
Understanding which enrollment forms to complete
Unsure which enrollment forms to complete? View the following form descriptions to assist you in determining which application to complete.
Note: Internet-based PECOS is the preferred method for submitting initial applications or making changes to your enrollment information. Expedite your application, use Internet-based PECOS .
Where can I learn more?
Please review our Part A or Part B Provider enrollment FAQs as well as our online education opportunities.
CMS-855A is to be used by Institutional providers -- Complete this application if you are a health care organization and you plan to bill Medicare for Part A medical services or would like to report a change to your existing Part A enrollment data.
Who should complete this application? The following health care organizations must complete this application to initiate the enrollment process:
• Community Mental Health Center
• Comprehensive Outpatient Rehabilitation Facility
• Critical Access Hospital
• End-Stage Renal Disease Facility
• Federally Qualified Health Center
• Histocompatibility Laboratory
• Home Health Agency
• Indian Health Services Facility
• Organ Procurement Organization
• Outpatient Physical Therapy/Occupational Therapy /Speech Pathology Services
• Religious Non-Medical Health Care Institution
• Rural Health Clinic
• Skilled Nursing Facility
• View a simulation on how to complete the CMS-855A form
When to complete a CMS-855B
CMS-855B is to be used by Clinics/group practices and certain other suppliers -- Complete this application if you are an organization/group that plans to bill Medicare and you are:
• A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, portable x-ray suppliers).
• A hospital or other medical practice or clinic that may bill for Medicare Part A services but will also bill for Medicare Part B practitioner services or provide purchased laboratory tests to other entities that bill Medicare Part B.
• Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor’s jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another Medicare fee-for-service contractor).
• Currently enrolled in Medicare and need to make changes to your enrollment data (e.g., you have added or changed a practice location). Changes must be reported in accordance with the timeframes established in 42 C.F.R. § 424.516(d). (IDTF changes of information must be reported in accordance with42 C.F.R. § 410.33.)
The following suppliers must complete this application to initiate the enrollment process:
• Ambulance Service Supplier
• Ambulatory Surgical Center
• Clinic/Group Practice
• Hospital Department(s)
• Independent Clinical Laboratory
• Independent Diagnostic Testing Facility (IDTF)
• Intensive Cardiac Rehabilitation
• Mammography Center
• Mass Immunization (Roster Biller Only)
• Physical/Occupational Therapy Group in Private Practice
• Portable X-ray Supplier
• Radiation Therapy Center
Note: Are you a supplier looking for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) enrollment? Please visit CGS Medicare , the DMEPOS Medicare Administrative Contractor (MAC) for Florida, Puerto Rico, and the U.S. Virgin Islands.
• View how to avoid the errors that result in the CMS-855B form not being processed, specifically missing signatures or dates in Section 15B and Section 16A.
When to complete a CMS-855I
CMS-855I is to be used by Physicians and non-physician practitioners (including clinical psychologists) -- Complete this application if you are an individual practitioner who plans to bill Medicare and you are:
• An individual practitioner who will provide services in a private setting.
• An individual practitioner who will provide services in a group setting. If you plan to render all of your services in a group setting, you will complete Sections 1-4 and skip to Sections 14 through 17 of this application.
• Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for- service contractor’s jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another Medicare fee-for-service contractor).
• Currently enrolled in Medicare and need to make changes to your enrollment information (e.g., you have added or changed a practice location).
• An individual who has formed a professional corporation, professional association, limited liability company, etc., of which you are the sole owner.
• If you provide services in a group/organization setting, you will also need to complete a separate application, the CMS-855R, to reassign your benefits to each organization. If you terminate your association with an organization, use the CMS-855R to submit that change.
All physicians, as well as all non-physician practitioners listed below, must complete this application to initiate the enrollment process:
• Anesthesiology Assistant
• Certified nurse midwife
• Certified registered nurse anesthetist
• Clinical nurse specialist
• Clinical social worker
• Mass immunization roster biller
• Nurse practitioner
• Occupational therapist in private practice
• Physical therapist in private practice
• Physician assistant
• Psychologist, Clinical
• Psychologist billing independently
• Registered Dietitian or Nutrition Professional
• Speech Language Pathologist
• Find step-by-step directions to completing the CMS-855I form.
• View how to avoid the errors that result in the CMS-855I form not being processed, specifically missing signatures or other required information.
CMS-855R is to be used for Reassignment of Medicare Benefits -- Complete this application if you are reassigning your right to bill the Medicare program and receive Medicare payments, or are terminating a reassignment of benefits.
Reassigning your Medicare benefits allows an eligible supplier to submit claims and receive payment for Medicare Part B services that you have provided. Such an eligible supplier may be an individual, a clinic/group practice or other organization.
Things to consider:
• Both the individual practitioner and the eligible supplier must be currently enrolled (or concurrently enrolling via submission of the CMS-855B for the eligible supplier and the CMS-855I for the practitioner) in the Medicare program before the reassignment can take effect.
• Generally, this application is completed by a supplier, signed by the individual practitioner, and submitted by the supplier.
• When terminating a current reassignment, either the supplier or the individual practitioner may submit this application with the appropriate sections completed.
• The individual or authorized/delegated official, by his/her signature, agrees to notify the Medicare fee-for service contractor of any future changes to the reassignment in accordance with 42 C.F.R. 424.516(d)(2).
• An individual will not need to reassign benefits to a corporation, limited liability company, professional association, etc., of which he/she is the sole owner. See the CMS-855I Application for Physicians and Non-Physician Practitioners for more information.
• Physician assistants: This application should not be used to report employment arrangements. Employment arrangements must be reported in Sections 2E through 2G of the CMS-855I application.
• Find step-by-step guidance to completing the CMS-855R form
• View a simulation on how to avoid the No. 1 reason applications are denied
When to complete a CMS-855O
CMS-855O is to be used by Eligible Ordering and Referring Physicians and Non-physician Practitioners -- CMS requires certain physicians and non-physician practitioners to register in the Medicare program for the sole purpose of ordering or referring items or services for Medicare beneficiaries. These physicians and non-physician practitioners do not and will not send claims to a Medicare Administrative Contractor for the services they furnish.
Note: Ordering/referring providers must meet the criteria specified by SE 1305
The physicians and non-physician practitioners who may register in Medicare solely for the purpose of ordering and referring include, but are not limited to, those who are:
• Employed by the Department of Veterans Affairs (DVA)
• Employed by the Public Health Service (PHS)
• Employed by the Department of Defense (DOD)/Tricare
• Employed by the Indian Health Service (IHS) or a Tribal Organization
• Employed by Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC) or Critical Access Hospitals (CAH)
• Licensed and Non-licensed Interns, Residents and Fellows in an approved medical residency program
• Dentists, including oral surgeons
Once registered, you will be placed on the Medicare Ordering and Referring Registry and will be deemed eligible to order and refer patients to Medicare enrolled providers and suppliers.
An EFT (CMS-588) is to be used to enroll in electronic payments. All providers enrolling in Medicare are required to submit an EFT in order to receive payments.
• View this tutorial and discover the advantages of Electronic Funds Transfer (EFT), and the most common problem seen with the EFT application.
• View the following EFT FAQs for additional information
The CMS-460 may only be completed by new physicians, practitioners, and suppliers looking to become participating providers during initial enrollment and during annual participation open enrollment. Learn more about the purpose of the Medicare Participating Physician or Supplier Agreement (CMS-460).
Where do I submit my provider enrollment documentation?
Medicare Provider Enrollment
First Coast Service Options Inc.
P.O. Box 44021
Jacksonville, FL 32231-4021
P.O. Box 44021
Jacksonville, FL 32231-4021
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.