Completing the Medicare CMS-855A enrollment application

Section 1A: Check one box and complete the required sections

Select the reason for submitting the application.

Section 1B: Check all that apply and complete the required sections

If you are performing a change of information, please select the sections you are changing:

• Required sections for the change of information are listed in the right column

Section 2A: Type of provider

Indicate the provider type as either a type other than a hospital (list under 2A1) or a hospital (list under 2A2):

• If the provider is a hospital, the question 2A3 must be answered
• Answer whether the provider is a physician-owned hospital

The provider must meet all Federal and State requirements for the type of provider checked.

Section 2B: Identification information

Legal business name must match exactly what is reported to the IRS.

Provide the year end cost report date.

Be sure to provide the state license or certification, if applicable:

• Include a copy of the license or certification with the enrollment application

Section 2C: Correspondence address

Correspondence address is the address we can contact the supplier directly:

• Address cannot be a billing agent or agency's address or a medical management company

Section 2D: Medical record correspondence address

Medical record correspondence address is the address we can contact the supplier directly for any medical record review requests:

• Address cannot be a billing agent or agency's address or a medical management company

Section 2E: Accreditation

List any accreditation for the provider.

Must be completed for those who select home health agency as the provider type.

CMS recognizes the Joint Commission on Accreditation of Healthcare Organizations accreditation organization:

• Refer to www.jointcommission.org

Section 2F: Comments

Section is used to clarify any information in this section.

Section 2G: Change of ownership (CHOW) information

Both the seller or former owner and the new owner must complete this application:

• The seller or former owner must complete sections 1A, 2G, 13, and 15
• The new owner must complete the entire application

A copy of the bill of sale must be submitted with the application. A copy of the final sales agreement must be submitted once the sale is executed. 

Section 2H: Acquisitions and mergers

Both the seller or former owner (provider being acquired) and the new owner (acquiring provider) must complete information in this section:

• The seller or former owner must complete sections 1A, 2H, 13, and either 15 or 16
• The new owner must complete sections 1A, 2H, 4, 13, and 15

A copy of the bill of sale must be submitted with the application. A copy of the final sales agreement must be submitted once the sale is executed. 

Section 2I: Consolidations

Providers being consolidated are reported in sections 2I1 and 2I2:

• The newly formed provider completes the entire application

In section 2I3, the newly created provider must report the legal business name as reported to the IRS. Be sure to include the tax identification number.

A copy of the bill of sale must be submitted with the application. A copy of the final sales agreement must be submitted once the sale is executed.

Section 4A: Practice location information

If you or your organization sees patients in more than one practice location, copy and complete this section for each location.

Be sure to include the date you saw your first Medicare patient at this location.

Hospitals and home health agencies must identify the type of practice location.

Hospital Provider Based Department (PBD) must indicate the type of practice location:

• If you are a PBD site that provides services in hospital outpatient departments that are integrated with a hospital, mark your Practice Location Type as Outpatient Provider-Based Department (PBD) Site, and then mark the appropriate PBD type from the selections on the application.
• Select Outpatient Physical Therapy Extension Site for PBDs that provide only PT/OT/SLP therapy services.
• Select “Other Hospital Practice Location” and put “Mid-Build Exception” in the free form text field for paper 855As when the PBD record is for a hospital with an approved mid-build exception until the paper application is updated.
• It is imperative to provide the appropriate practice location type.

Note: If your organization is going through a change of ownership (CHOW), merger, or consolidation, the effective date of each practice location should reflect the date the location was established and not the date of sale.

Section 4B: Where do you want remittance notices or special payments sent?

Provide address where payment information (e.g., remittance notices, non-routine special payments) should be sent.

Section 4C: Where do you keep patients' medical records

If you store patients' medical records at a location other than the location in section 4A or store patients’ medical records electronically, complete this section with the address or service of the storage location. 

P.O. boxes and drop boxes are not acceptable for the medical records storage location.

Section 4D: Base of operations address for mobile or portable providers

The base of operations is the location from where personnel are dispatched, where mobile or portable equipment is stored, and when applicable, where vehicles are parked when not in use. 

Section 4E: Vehicle information

This section is applicable to mobile vehicles where health care services are provided:

• This section is not applicable to vehicles that are used only to transport medical equipment (e.g., transported in a van, but used in a fixed setting)

If more than three vehicles are used, copy this section, and complete it for each additional vehicle.

Section 4F: Geographic location for mobile or portable providers where the base of operations and/or vehicle renders services

For home health agencies and mobile or portable providers, furnish information identifying the geographic area(s) where health care services are rendered. 

If you are initially reporting or adding an entire state or territory, check the applicable box and furnish the state or territory.

If you are not servicing an entire state or territory, provide the city or town or county where you provide services:

• Only list the ZIP codes if you are not servicing the entire city or town or county

This section only applies to organizations. Any organization that exercised operational or managerial control over the provider or conducts the day-to-day operations, is a managing organization.

Section 5A: Ownership and/or managing control organization

Enter the legal business name as reported to the IRS. If there is another name the provider uses, enter this in the Doing business as box. 

Section 5B: Ownership and/or managing control information

Mark all applicable ownership or managerial control types applicable for the organization.

Organizational diagram must be submitted when section 5 is completed.

Section 5C: Chain Home Office

Specify the type of action the provider is reporting, effective date of this action, and then complete the applicable fields about the chain home office:

• For initial enrollment, complete all sections
• For a change of information, complete the elements that are changing

Section 5D: Final adverse legal action history

Complete this section by answering "Yes" or "No" if the organization has ever had a final adverse legal action imposed against it. 

If yes, make sure to include a copy of all final adverse legal action documentation and resolution, if applicable.

Section 6A: Identifying information

The name, date of birth, and social security number of each person listed in this section must coincide with the individual's information listed with the Social Security Administration.

Note: If you are a managing employee, you must provide an effective date in section 6A under the W-2 managing employee role. We understand there is confusion as the effective date field states "Effective date of 5% or greater direct ownership interest"; however, the effective date of when this individual accepted the managing employee role should be reported on this line. It is a required field that needs completed before we can approve the application. 

Section 6B: Final adverse legal action history

Complete this section by answering "Yes" or "No" if the organization has ever had a final adverse legal action imposed against it. 

If yes, make sure to include a copy of all final adverse legal action documentation and resolution, if applicable

A billing agency is a company or individual you contract with to prepare and submit your claims:

• If you are using a billing agency, you are responsible for the claims submitted on your behalf

The OTP must include the following information for all employees and contracted staff, whether W-2 or not, who are legally authorized to order controlled substances, whether or not the individual is currently ordering at the OTP facility.

A. Ordering personnel identification

Copy and complete this section if more than three OTP ordering personnel need to be reported.

B. Dispensing personnel identification

Copy and complete this section if more than three OTP dispensing personnel need to be reported.

All home health agencies and home health agency sub-units enrolling in the Medicare program must complete this section.

To assist in determining the home health agency or home health agency sub-units have the required funds, complete the requested information on type of HHA / sub-unit, number of visits projected, business structure, use of nursing registry, etc.

Please submit financial documentation.

Captures the person we will contact about the application.

Be sure to include all information, including the e-mail address.

This section explains the penalties for deliberately furnishing false information:

• Read this section as it outlines criminal penalties and civil liability on individuals who knowingly furnish false information

Please include section 15A in addition to the signature page.

For initial enrollments, all individuals listed in section 6 as an authorized official, must sign section 15B.

For initial enrollments, all individuals listed in section 6 as an delegated official, must sign section 15C.

All signatures must be handwritten or an eligible digital signature (e.g., DocuSign, AdobeSign), as well as dated. Stamped signatures are not acceptable.

• Licenses, certifications and registrations required by Medicare or State law
• Federal, State / Territory, and/or local (city / county) business licenses, certifications and/or registrations required to operate a health care facility
• Written confirmation from the IRS confirming your Tax Identification Number with the Legal Business Name (e.g., IRS CP 575) provided in section 2A
• Completed Form CMS-588, Authorization Agreement for Electronic Funds Transfer. Include a voided check or bank letter CMS-588)

Note: If a provider already receives payments electronically and is not making a change to its banking information, the CMS-588 is not required.

• Copy(s) of all bills of sale or sales agreements for all ownership changes. This includes CHOWS, Acquisition / Mergers, Consolidations, and all other ownership changes that are required to be reported, regardless of the percentage involved (e.g., new 15 percent owner).
• Copy(s) of all documents that demonstrate meeting capitalization requirements (HHAs only)
• If Medicare payment due a provider of services is being sent to a bank (or similar financial institution) with whom the provider has a lending relationship (that is, any type of loan), the provider must provide a statement in writing from the bank (which must be in the loan agreement) that the bank has agreed to waive its right of offset for Medicare receivables
• Copy(s) of all final adverse legal action documentation (e.g., notifications, resolutions, and reinstatement letters)
• Copy of an attestation for government entities and tribal organizations
• Copy of HRSA Notice of Grant Award if that is a qualifying document for FQHC status
• Copy of IRS Determination Letter, if provider is registered with the IRS as non-profit (e.g., IRS Form 501(c)(3))
• Written confirmation from the IRS confirming your Limited Liability Company (LLC) is automatically classified as a Disregarded Entity (e.g., Form 8832, if applicable)

Note: A disregarded entity is an eligible entity that is not treated as a separate entity from its single owner for income tax purposes.

• Organizational structure diagram / flowchart identifying all of the entities listed in section 5 and their relationships with the provider and each other
• Copy of all mobile vehicle registrations (all mobile services)
• Rural Emergency Hospital (REH) Action Plan