Medicare Enrollment Application Physicians And Non-Physician Practitioners {CMS 855I}

CMS-855I - MEDICARE ENROLLMENT APPLICATION PHYSICIANS AND NON-PHYSICIAN PRACTITIONERS. All physicians, as well as all eligible professionals as defined in section 1848(k)(3)(B) of the Social Security Act must complete this application to enroll in the Medicare program and receive a Medicare billing number. Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change to their enrollment information (including adding or terminating a reassignment of benefits) using either: • The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or • The paper CMS-855I enrollment application. Be sure you are using the most current version. NOTE: All reassignment actions should now be reported via the CMS-855I. The CMS-855R (Reassignment of Medicare Benefits) form has been discontinued. Complete this application if you are an individual practitioner or eligible professional who plans to bill Medicare and you are: • Currently enrolled in Medicare to order and certify and want to enroll as an individual practitioner to submit claims for services rendered. • An individual practitioner or eligible professional who has formed a professional corporation, professional association, limited liability company, etc., of which you are the sole owner. • Currently enrolled in Medicare and you received notice to revalidate your enrollment. • Previously enrolled in Medicare and you need to reactivate your Medicare billing number to resume billing. • Currently enrolled in Medicare and need to enroll in another Medicare Administrative Contractor’s (MAC’s) jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another MAC). • 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 practitioner (physician, physician assistant, nurse practitioner, or clinical nurse specialist) who furnishes acupuncture services. • An individual practitioner, including physician assistant, who is reassigning Medicare benefits, terminating a reassignment of Medicare benefits after enrollment in the Medicare program, or making a change in their reassignment of Medicare benefits information. Reassigning your Medicare benefits allows an eligible organization/group to submit claims and receive payment for Medicare Part B services that you have provided as a member of the organization/group. Such an eligible organization/group may be an individual, a clinic/group practice or other health care organization. • An organization/group who is accepting a new reassignment of Medicare benefits, terminating a reassignment of Medicare benefits, or making a change in reassignment of Medicare benefit information, between the organization/group and an individual practitioner. NOTE: Both the individual practitioner and the eligible organization/group must be currently enrolled (or concurrently enrolling via submission of the CMS-855B for the eligible organization/group and the CMS-855I for the individual practitioner) in the Medicare program before the reassignment can take effect. • An individual practitioner voluntarily terminating your Medicare enrollment, including all reassignment of benefits. NOTE: If you are a sole owner and intend to add an Authorized/Delegated Official to your Medicare enrollment, do not complete the CMS-855I application; rather, use the CMS-855B application. www.FormsWorkflow.com