Medicare Enrollment Application Clinics-Group Practices And Certain Other Suppliers {CMS-855B}

MediCare enrollMent aPPliCation Clinics/group Practices and Certain other Suppliers CMS-855B See Page 1 to deterMine if you are CoMPleting the CorreCt aPPliCation. See Page 2 for inforMation on where to Mail thiS aPPliCation. See Page 35 to find a liSt of the SuPPorting doCuMentation that MuSt Be SuBMitted with thiS aPPliCation. American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB NO. 0938-0685 Expires: 08/19 who Should SuBMit thiS aPPliCation Clinics and group practices can apply for enrollment in the Medicare program or make a change in their enrollment information using either: · The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or · The paper enrollment application process (e.g., CMS 855B). For additional information regarding the Medicare enrollment process, including Internet-based PECOS, go to http://www.cms.gov/MedicareProviderSupEnroll. Clinics and group practices who are enrolled in the Medicare program, but have not submitted the CMS 855B since 2003, are required to submit a Medicare enrollment application (i.e., Internet-based PECOS or the CMS 855B) as an initial application when reporting a change for the first time. The following suppliers must complete this application to initiate the enrollment process: · Ambulance Service Supplier · Mammography Center · Ambulatory Surgical Center · Mass Immunization (Roster Biller Only) · Clinic/Group Practice · Part B Drug Vendor · Independent Clinical Laboratory · Portable X-ray Supplier · Independent Diagnostic Testing Facility (IDTF) · Radiation Therapy Center · Intensive Cardiac Rehabilitation Supplier Complete and submit 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 with 42 C.F.R. § 410.33.) If your supplier type is not listed above, contact your designated fee-for-service contractor before you submit this application. Billing nuMBer inforMation The National Provider Identifier (NPI) is the standard unique health identifier for health care providers and is assigned by the National Plan and Provider Enumeration System (NPPES). As a Medicare health supplier, you must obtain an NPI prior to enrolling in Medicare or before submitting a change for your existing Medicare enrollment information. Applying for an NPI is a process separate from Medicare enrollment. As a supplier, it is your responsibility to determine if you have "subparts." A subpart is a component of an organization (supplier) that furnishes healthcare and is not itself a legal entity. If you do have subparts, you must determine if they should obtain their own unique NPIs. Before you complete this enrollment application, you need to make those determinations and obtain NPI(s) accordingly. CMS-855B (07/11) American LegalNet, Inc. www.FormsWorkFlow.com 1 Important: For NPI purposes, sole proprietors and sole proprietorships are considered to be "Type 1" providers. Organizations (e.g., corporations, partnerships) are treated as "Type 2" entities. When reporting the NPI of a sole proprietor on this application, therefore, the individual's Type 1 NPI should be reported; for organizations, the Type 2 NPI should be furnished. To obtain an NPI, you may apply online at https://NPPES.cms.hhs.gov. For more information about subparts, visit www.cms.gov/NationalProvIdentStand to view the "Medicare Expectations Subparts Paper." The Medicare Identification Number, often referred to as a Provider Transaction Access Number (PTAN) or Medicare "legacy" number, is a generic term for any number other than the NPI that is used to identify a Medicare supplier. inStruCtionS for CoMPleting and SuBMitting thiS aPPliCation · Type or print all information so that it is legible. Do not use pencil. · Report additional information within a section by copying and completing that section for each additional entry. · Attach all required supporting documentation. · Keep a copy of your completed Medicare enrollment package for your records. · Send the completed application with original signatures and all required documentation to your designated Medicare fee-for-service contractor. aVoid delayS in your enrollMent To avoid delays in the enrollment process, you should: · Complete all required sections. · Ensure that the legal business name shown in Section 2 matches the name on the tax documents. · Ensure that the correspondence address shown in Section 2 is the supplier's address. · Enter your NPI in the applicable sections. · Enter all applicable dates. · Ensure that the correct person signs the application. · Send your application and all supporting documentation to the designated fee-for-service contractor. additional inforMation For additional information regarding the Medicare enrollment process, visit www.cms.gov/ MedicareProviderSupEnroll. The fee-for-service contractor may request, at any time during the enrollment process, documentation to support and validate information reported on the application. You are responsible for providing this documentation in a timely manner. Certain information you provide on this application is considered to be protected under 5 U.S.C. Section 552(b)(4) and/or (b)(6), respectively. For more information, see the last page of this application for the Privacy Act Statement. Mail your aPPliCation The Medicare fee-for-service contractor (also referred to as a carrier or a Medicare administrative contractor) that services your State is responsible for processing you