Last Modified: 4/26/2019
Location: FL, PR, USVI
Business: Part A, Part B
Medicare enrollment applications/forms (CMS-855A, CMS-855B, CMS-855I (07/11 Version) CMS-855R (04/16 Version) and CMS-855O (01/13 Version) submitted to First Coast must be completed with accurate information and must have all supporting documentation attached. First Coast provider enrollment staff will review all submitted applications, and as necessary, will send a letter asking for additional information and/or documentation. The following tips regard the most common reasons for which First Coast must request additional information and/or documentation.
1. Ensure the name reflected on your national provider identifier (NPI) application form identically matches your legal business name.
Access the following website address or phone number to validate that the legal business name the Internal Revenue Service (IRS) has for you (CP-575) matches the business name registered with the National Plan & Provider Enumeration System (NPPES): https://nppes.cms.hhs.gov/NPPES/Welcome.do
, 1-800-465-3203 or 1-800-692-2326 for TTY services.
Applying for an NPI is a separate process from requesting provider enrollment in the Medicare program. The Centers for Medicare & Medicaid Services (CMS) requires that providers and suppliers obtain their NPI prior to enrolling for, or updating, their Medicare enrollment information. Based on this regulation, each enrollment application form (initial applications and changes/updates) must include your NPI. If your NPI is not submitted, your enrollment into the Medicare program will be delayed.
First Coast will send a letter to the contact person you named in Section 13 of the enrollment application, or if there is no contact person listed, the letter will be sent to your correspondence address.
2. Attach a copy of your Internal Revenue Service (IRS) CP-575 form.
The IRS CP-575 is a letter you receive from the IRS granting your employer identification number (EIN). This IRS form reflects your legal business name. It also provides proof of your employer tax identification number (TIN), which is required for First Coast’s Medicare records.
Medicare records must have a written confirmation from the IRS validating your TIN with your legal business name. Acceptable tax documents must be generated or pre-printed by the IRS. Examples of acceptable documentation are IRS CP-575, IRS Form 8109 and IRS substitute letter 147C. A W-9 is not acceptable documentation.
3. Attach a copy of your Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588 -- not to be confused with CMS-855 enrollment forms).
First Coast requires this form if you are submitting an initial provider enrollment application or a change to an existing Medicare provider number that has not previously been set up for EFT. Remember to also include a copy of a voided pre-printed check or confirmation of account on bank letterhead. Be aware that with the EFT authorization, Medicare can send payments directly to your financial institution whether claims are filed electronically or on paper.
Note: First Coast has determined that some banks may not use the routing number located at the bottom of your pre-printed check, but may use the automated clearinghouse (ACH) number located elsewhere on the check. Please check with your bank for the proper number to report as the routing number on your EFT form.
4. Read each section of the application form(s)
For each section of the provider enrollment forms, CMS has provided detailed instructions. Ensure that, where applicable, boxes are checked, signatures (in ink) are provided and all required fields have been completed.
5. Include copies of all professional and business licenses.
Examples include, but are not limited to:
• Licenses, certifications and registrations required by your state, city and/or county boards (e.g., State of Florida Professional License, CRNA Recertification, Health Care Clinic Licenses, Radiation Control License, FDA Mammography Certification, CLIA, Diabetes Education Certificate)
• Certifications and/or registrations required to operate a health care facility
• Provisional licenses
6. Obtain other helpful information
• Within the instructions in the “Medicare enrollment application” itself. See “Tips,” and Section 17 “Supporting Documents.”
• From your Medical Association or Medical Society.
7. Send completed provider enrollment applications to:
Medicare Provider Enrollment
P.O. Box 3409
Mechanicsburg, PA 17055-1849
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.