↦

Fill Out Your Cms 855R Form

The CMS-855R form is a Medicare Enrollment Application for Reassignment of Medicare Benefits. This form is completed by individual practitioners and organizations to reassign billing rights and receive Medicare payments for services rendered to beneficiaries. If you need to fill out this form, please click the button below.

Launch Cms 855R Editor Now

Article Structure

The CMS 855R form is essential for healthcare providers looking to manage their Medicare billing rights effectively. It serves as the Medicare Enrollment Application for the Reassignment of Medicare Benefits. This form allows individual practitioners such as physicians and non-physician practitioners to reassign their billing rights to an organization or group. This reassignment enables the designated healthcare organization to submit claims on behalf of the practitioner and receive Medicare payments for services rendered to beneficiaries. In the process, the organization/group must be actively enrolled in Medicare to accept these benefits. The application covers various purposes, including establishing new reassignments and terminating existing ones. A separate CMS 855R must be submitted for each organization involved. The form requires attention to detail, as the information provided must match that reported on tax documents and other Medicare applications. Completing the CMS 855R correctly is vital, as any inaccuracies could lead to delays or issues with payment processing. For both the individual practitioners and the organizations, understanding the process and requirements is crucial for maintaining compliance with Medicare regulations.

Cms 855R Example

MEDICARE ENROLLMENT APPLICATION

REASSIGNMENT OF MEDICARE BENEFITS

CMS-855R

SEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION. SEE PAGE 2 FOR INFORMATION ON WHERE TO MAIL THIS COMPLETED APPLICATION.

TO VIEW YOUR CURRENT MEDICARE REASSIGNMENTS GO TO:

HTTPS://PECOS.CMS.HHS.GOV

	Form Approved
DEPARTMENT OF HEALTH AND HUMAN SERVICES	OMB No. 0938-1179
CENTERS FOR MEDICARE & MEDICAID SERVICES	Expires: 01/2023

WHO SHOULD COMPLETE AND SUBMIT THIS APPLICATION

Complete this application if you are reassigning your right to bill the Medicare program and receive Medicare payments for some or all of the services you render to Medicare beneficiaries, or are terminating a currently established reassignment of benefits. 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.

Physicians and non-physician practitioners, other than physician assistants, can reassign Medicare benefits or terminate a reassignment of Medicare benefits after enrollment in the Medicare program or make a change in their reassignment of Medicare benefit information using either:

•The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or

•The paper CMS-855R application. Be sure you are using the most current version.

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. Generally, this application is completed by the organization/group, signed by the Delegated/Authorized Official of the organization/group and the individual practitioner, and submitted by the organization/group. When terminating a current reassignment, either the organization/group or the individual practitioner may submit this application with the appropriate sections completed and signed.

NOTE: A separate CMS-855R must be submitted for each organization/group where a reassignment is being established or terminated.

The individual or delegated/authorized official, by his/her signature, agrees to notify the Medicare Administrative Contractor (MAC) of any future changes to this reassignment in accordance with 42 C.F.R. section 424.516(d)(2).

NOTE: An individual does not need to reassign their benefits to a corporation, limited liability company, professional association, etc., when he/she is the sole owner. See the CMS-855I application for Physicians and Non- Physician Practitioners for more information.

NOTE: Physician Assistants: This application should not be used to report employment arrangements. Employment arrangements must be reported using the CMS-855I application.

For additional information regarding the Medicare enrollment and reassignment process, including Internet-based PECOS and to get the current version of the CMS-855R, go to http://www.cms.gov/MedicareProviderSupEnroll.

INSTRUCTIONS FOR COMPLETING THIS APPLICATION

•All information on this form is required with the exception of those fields specifically marked as “optional.” Any field marked as optional is not required to be completed nor does it need to be updated or reported as a “change of information” as required in 42 C.F.R. section 424.516. However, it is highly recommended that if reported, these fields be kept up-to-date.

•Type or print all information so that it is legible. Do not use pencil.

•Ensure that the legal business name shown in Section 2 matches the name on the tax documents.

•Enter all NPIs in the applicable sections.

•Sign and date the certification statement(s) as appropriate.

•Keep a copy of your completed Medicare reassignment package for your own records.

CMS-855R (Rev. 01/20)

ADDITIONAL INFORMATION

When establishing a new reassignment, Section 6A must be signed by the individual practitioner and Section 6B must be signed by a delegated or authorized official of the organization/group. If the reassignment is to an individual, that person must sign Section 6B. When terminating a reassignment, either Section 6A or Section

6B can be completed. Reassigned claims for services rendered by the individual will no longer be paid to the organization/group after the effective date of the termination.

•You may visit our website to learn more about the enrollment process via the Internet-Based Provider Enrollment Chain and Ownership System (PECOS) at: https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/MedicareProviderSupEnroll/InternetbasedPECOS.html. Also, all of the CMS-855 applications are all located on the CMS webpage: https://www.cms.gov/medicare/cms-forms/cms-forms/cms-forms-list.html.

Simply enter “855” in the “Filter On:” box on this page and only the application forms will be displayed to choose from.

•The MAC may request additional documentation to support and validate information reported on this application. You are responsible for providing this documentation within 30 days of the request per 42 C.F.R. section 424.525(a)(1).

•The information you provide on this form is 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 to read the Privacy Act Statement.

DEFINITIONS

NOTE: For the purposes of this CMS-855R application, the following definitions apply:

Add: You are adding additional information to your existing information (e.g. practice locations).

Change: You are replacing existing information with new information (e.g. contact person) or updating existing information (e.g. change in suite #, telephone #).

Remove: You are removing existing information.

WHERE TO MAIL YOUR APPLICATION

Send this completed application with original signatures and all required documentation to your designated MAC. The MAC that services your State is responsible for processing your enrollment application. To locate the mailing address for your designated MAC, go to www.cms.gov/MedicareProviderSupEnroll.

CMS-855R (Rev. 01/20)

SECTION 1: BASIC INFORMATION

ALL APPLICANTS MUST COMPLETE THIS SECTION

Reason for Submitting this Application

Check the applicable box and complete the required sections.

You are enrolling or are currently enrolled in	Effective Date (mm/dd/yyyy):	Complete all sections
Medicare and will be reassigning your benefits

You are an individual practitioner/organization	Effective Date (mm/dd/yyyy):	Complete sections 1, 2 or
changing information on a currently existing		3, as applicable, sections 4
reassignment		and/or 5, as applicable,
		and section 6A or 6B, as
		applicable

You are an individual practitioner terminating a	Effective Date (mm/dd/yyyy):	Complete sections 1, 2, 3,
reassignment with an organization/group		5, and 6A

You are the organization/group terminating a	Effective Date (mm/dd/yyyy):	Complete sections 1, 2, 3,
reassignment with an individual		5, and 6B

SECTION 2: ORGANIZATION/GROUP RECEIVING THE REASSIGNED BENEFITS

A. Organization/Group Identification

Provide the information below for the organization/group to whom benefits are being reassigned, or a reassignment is being terminated. If the organization/group’s initial enrollment application is being submitted concurrently with this reassignment application, write “pending” in the Medicare identification number block. The organization/group’s name as reported to the IRS must be the same as reported on the organization/group’s CMS-855B when it enrolled.

Organization/Group Legal Business Name (as Reported to the Internal Revenue Service)

Tax Identification Number (TIN)

Medicare Identification Number (PTAN) (if issued)

National Provider Identifier (NPI)

B. Individual Practitioner Identification

Provide the information below for the individual to whom benefits are being reassigned, or a reassignment is being terminated. If the individual’s initial enrollment application is being submitted concurrently with this reassignment application, write “pending” in the Medicare identification number block. The individual’s name as reported to the Social Security Administration must be the same as reported on the individual’s CMS-855I when the individual enrolled. If the individual is a sole proprietor with an Employee Identification Number (EIN), check the appropriate box and report the EIN.

First Name (Print)	Middle Initial	Last Name (Print)		Jr., Sr., M.D., etc.

Social Security Number (SSN) (List number below if applicable)			Employer Identification Number (EIN) (List number below if applicable)

Medicare Identification Number (PTAN) (if issued)			National Provider Identifier (NPI)

CMS-855R (Rev. 01/20)

SECTION 3: INDIVIDUAL PRACTITIONER WHO IS REASSIGNING BENEFITS

Individual Practitioner Identification

Provide the information below for the individual practitioner who will be reassigning his/her benefits, or who will be terminating a reassignment. If the individual’s initial enrollment application is being submitted concurrently with this reassignment application, write “pending” in the Medicare identification number field.

First Name (Print)	Middle Initial	Last Name (Print)		Jr., Sr., M.D., etc.

Social Security Number (SSN)	Medicare Identification Number (PTAN) (if issued)		National Provider Identifier (NPI)

SECTION 4: PRIMARY PRACTICE LOCATION(S) (Optional)

A. Primary Practice Location

Identify the primary practice location of the organization/group where the individual practitioner will render services most of the time. This practice location must be currently enrolled or enrolling in Medicare.

If you are changing information about a currently reported primary practice location or adding or removing primary practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section.

Change	Add	Remove	Effective Date (mm/dd/yyyy):

Practice Location Name (“Doing Business As” Name)

Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)

Practice Location Address Line 2 (Suite, Room, Apt. #, etc.)

City/Town				State		ZIP Code +4

Medicare Identification Number for this location – PTAN (if issued)					National Provider Identifier (NPI)

B. Secondary Practice Location

Identify additional practice location.

If you are changing information about a currently reported an additional practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section.

Change	Add	Remove	Effective Date (mm/dd/yyyy):

Practice Location Name (“Doing Business As” Name)

Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)

Practice Location Address Line 2 (Suite, Room, Apt. #, etc.)

City/Town				State		ZIP Code +4

Medicare Identification Number for this location – PTAN (if issued)					National Provider Identifier (NPI)

CMS-855R (Rev. 01/20)

SECTION 5: CONTACT PERSON INFORMATION (Optional)

If questions arise during the processing of this reassignment, the designated MAC will contact the individual indicated below. If a contact person is not furnished, the MAC will contact the individual practitioner is Section 3.

If you are changing information about a currently reported contact person or adding or removing a contact person, check the applicable box, furnish the effective date, and complete the appropriate fields in this section.

Change	Add	Remove		Effective Date (mm/dd/yyyy):

First Name				Middle Initial	Last Name				Jr., Sr., M.D., etc.

Contact Person Address Line 1		(Street Name And Number)

Contact Person Address Line 2		(Suite, Room, Apt. #, etc.)

City/Town						State		ZIP Code +4

Telephone Number			Fax Number (if applicable)				Email Address (if applicable)

Relationship or Affiliation to Individual or Organization/Group (Spouse, Secretary, Attorney, Billing Agent, etc.)

NOTE: The Contact Person listed in this section will only be authorized to discuss issues concerning this or any other enrollment application. Your designated MAC will not discuss any other Medicare issues about you with the above Contact Person.

CMS-855R (Rev. 01/20)

SECTION 6: CERTIFICATION STATEMENTS AND SIGNATURES

Title XVIII of the Social Security Act prohibits payment for services provided by an individual practitioner to be paid to another individual or organization/group unless the individual practitioner who provided the services specifically authorizes another individual or organization/group to receive said payments in accordance with

42 C.F.R. section 424.73 and 42 C.F.R. section 424.80. All individual practitioners who allow another individual or organization/ group to receive payment for their services must sign the Reassignment of Medicare Benefits Statement below. By signing this Reassignment of Medicare Benefits Statement, you are authorizing the organization/group or individual identified in Section 2 to receive Medicare payments on your behalf.

The signature(s) below authorize the reassignment of benefits, or the termination of a reassignment of benefits, between the individual practitioner shown in Section 3 and the organization/group or individual shown in Section 2. The employment of, or contract between, the individual practitioner and organization/group or individual must be in compliance with CMS regulations and applicable Medicare program safeguard standards described in 42 C.F.R. section 424.80. These signatures also serve as an attestation and acknowledgment to the compliance with all laws and regulations pertaining to the reassignment of Medicare benefits.

A. Individual Practitioner Certification Statement and Signature

Under penalty of perjury, I, the undersigned, certify that the above information is true, accurate and complete. I understand that any misrepresentation or concealment of any information requested in this application may subject me to liability under civil and criminal laws.

Individual Practitioner First Name (Print)

Middle Initial

Last Name (Print)

Jr., Sr., M.D., etc.

Individual Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)

Date Signed (mm/dd/yyyy)

In order to process this application it MUST be signed and dated.

B. Delegated or Authorized Official of Organization/Group Certification Statement and Signature

Delegated or Authorized Official’s First Name (Print)

Middle Initial

Last Name (Print)

Jr., Sr., M.D., etc.

Delegated or Authorized Official’s Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)

Date Signed (mm/dd/yyyy)

In order to process this application it MUST be signed and dated.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1179 (Expires: 01/2023). The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please visit http://www.cms.gov/MedicareProviderSupEnroll.

CMS-855R (Rev. 01/20)

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

MEDICARE SUPPLIER ENROLLMENT APPLICATION PRIVACY ACT STATEMENT

The Authority for maintenance of the system is given under provisions of sections 1102(a) (Title 42 U.S.C. 1302(a)), 1128 (42 U.S.C. 1320a–7), 1814(a)) (42 U.S.C. 1395f (a)(1), 1815(a) (42 U.S.C. 1395g(a)), 1833(e) (42 U.S.C. 1395I(3)),1871 (42 U.S.C. 1395hh), and 1886(d)(5)(F), (42 U.S.C. 1395ww(d)(5)(F) of the Social Security Act; 1842(r) (42 U.S.C.1395u(r)); section 1124(a)(1) (42 U.S.C. 1320a–3(a)(1), and 1124A (42 U.S.C. 1320a–3a), section 4313, as amended, of the BBA of 1997; and section 31001(i) (31 U.S.C. 7701) of the DCIA (Pub. L. 04–134), as amended.

The information collected here will be entered into the Provider Enrollment, Chain and Ownership System (PECOS).

PECOS will collect information provided by an applicant related to identity, qualifications, practice locations, ownership, billing agency information, reassignment of benefits, electronic funds transfer, the NPI and related organizations. PECOS will also maintain information on business owners, chain home offices and provider/chain associations, managing/ directing employees, partners, authorized and delegated officials, supervising physicians of the supplier, ambulance vehicle information, and/or interpreting physicians and related technicians. This system of records will contain the names, social security numbers (SSN), date of birth (DOB), and employer identification numbers (EIN) and NPI’s for each disclosing entity, owners with 5 percent or more ownership or control interest, as well as managing/directing employees. Managing/directing employees include general manager, business managers, administrators, directors, and other individuals who exercise operational or managerial control over the provider/ supplier. The system will also contain Medicare identification numbers (i.e., CCN, PTAN and the NPI), demographic data, professional data, past and present history as well as information regarding any adverse legal actions such as exclusions, sanctions, and felonious behavior.

The Privacy Act permits CMS to disclose information without an individual’s consent if the information is to be used for a purpose that is compatible with the purpose(s) for which the information was collected. Any such disclosure of data is known as a “routine use.” The CMS will only release PECOS information that can be associated with an individual as provided for under Section III “Proposed Routine Use Disclosures of Data in the System.” Both identifiable and non-identifiable data may be disclosed under a routine use. CMS will only collect the minimum personal data necessary to achieve the purpose of PECOS. Below is an abbreviated summary of the six routine uses. To view the routine uses in their entirety go to: https://www.cms.gov/Research-Statistics-Data- and-Systems/Computer-Data-and-Systems/Privacy/Downloads/0532-PECOS.pdf.

1.To support CMS contractors, consultants, or grantees, who have been engaged by CMS to assist in the performance of a service related to this collection and who need to have access to the records in order to perform the activity.

2.To assist another Federal or state agency, agency of a state government or its fiscal agent to:

a.Contribute to the accuracy of CMS’s proper payment of Medicare benefits,

b.Enable such agency to administer a Federal health benefits program that implements a health benefits program funded in whole or in part with federal funds, and/or

c.Evaluate and monitor the quality of home health care and contribute to the accuracy of health insurance operations.

3.To assist an individual or organization for research, evaluation or epidemiological projects related to the prevention of disease or disability, or the restoration or maintenance of health, and for payment related projects.

4.To support the Department of Justice (DOJ), court or adjudicatory body when:

a.The agency or any component thereof, or

b.Any employee of the agency in his or her official capacity, or

c.Any employee of the agency in his or her individual capacity where the DOJ has agreed to represent the employee, or

d.The United States Government, is a party to litigation and that the use of such records by the DOJ, court or adjudicatory body is compatible with the purpose for which CMS collected the records.

5.To assist a CMS contractor that assists in the administration of a CMS administered health benefits program, or to combat fraud, waste, or abuse in such program.

6.To assist another Federal agency to investigate potential fraud, waste, or abuse in, a health benefits program funded in whole or in part by Federal funds.

The applicant should be aware that the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-

503)amended the Privacy Act, 5 U.S.C. section 552a, to permit the government to verify information through computer matching.

CMS-855R (Rev. 01/20)

Get Cms 855R PDF Form

Form Characteristics

Fact Name	Description
Purpose	The CMS 855R form is used for reassigning Medicare benefits from an individual practitioner to an organization/group.
Eligibility	Physicians and non-physician practitioners, except physician assistants, can use this form if they are enrolled in Medicare.
Submission Process	Both the individual practitioner and the organization/group must be enrolled in Medicare for the reassignment to be effective.
Reporting Changes	A signed form must be submitted to notify any changes regarding the reassignment, per federal regulations.
Separate Forms	A separate CMS 855R form is required for each organization/group when establishing or terminating a reassignment.
Information Fields	All information on the form is mandatory unless marked as optional. Accurate information is crucial for processing.
Application Timeline	The form must be mailed to the designated Medicare Administrative Contractor (MAC), who processes the application.
Documentation Requests	The MAC may request additional documentation to support the reported information within 30 days of a request.
Confidentiality	The information submitted on this form is protected under specific federal privacy laws to ensure confidentiality.

Guidelines on Utilizing Cms 855R

Completing the CMS-855R form is an important step for reassigning your Medicare benefits or terminating an existing reassignment. Follow these steps carefully to ensure your application is filled out correctly.

Begin by checking if you are using the most current version of the CMS-855R form.
Complete Section 1: Basic Information. Indicate your reason for submitting the application and fill in the effective date.
Move to Section 2: Organization/Group Receiving the Reassigned Benefits. Provide the legal business name, tax identification number, Medicare identification number, and national provider identifier for the organization/group.
If you are reassigning benefits, fill in Section 3 with individual practitioner information. Include your first and last name, social security number, and national provider identifier.
Optional: In Section 4, detail your primary practice locations. Indicate if you are changing, adding, or removing a location, and provide the effective date and corresponding address details.
Ensure that all fields marked as required are completed. Use legible type or print and do not write in pencil.
Sign and date the certification statement(s) in Section 6A or 6B as appropriate. Ensure both the individual practitioner and organization/group have signed.
Keep a copy of your completed application package for your records, including original signatures and documentation.
Submit your completed application to your designated Medicare Administrative Contractor (MAC) by mail to the address indicated on the form.

Once submitted, your application will be processed by the designated MAC. You may need to provide additional documentation if requested. It is advisable to monitor the status of your application to ensure a smooth reassignment process.

What You Should Know About This Form

What is the purpose of the CMS 855R form?

The CMS 855R form is used for the reassignment of Medicare benefits. It allows healthcare providers to transfer their billing rights to an organization or group, enabling that entity to receive payments for Medicare services rendered. This form is essential for any individual practitioner or organization seeking to manage their Medicare billing arrangements effectively. Additionally, it can also be used to terminate an existing reassignment of benefits.

Who should complete the CMS 855R form?

This form should be completed by any healthcare professional who wishes to reassign their Medicare billing rights or terminate an existing reassignment. Physicians and non-physician practitioners, apart from physician assistants, are eligible to use this form. Both the individual practitioner and the organization must be enrolled in the Medicare program for the reassignment to be valid. Each reassignment must be submitted separately for cada organization or group involved.

What specific information is required on the CMS 855R form?

When filling out the CMS 855R form, several key details are necessary. Applicants must provide identification for both the individual practitioner and the organization receiving the reassigned benefits, including names and tax identification numbers. Sections related to current practice locations and the nature of the reassignment (whether it's a new assignment or a termination) must also be completed. Each section must be signed by appropriate officials—both parties are responsible for notifying Medicare of any changes to the reassignment following submission.

Where should the completed CMS 855R form be mailed?

The completed CMS 855R form should be mailed to the designated Medicare Administrative Contractor (MAC) that services your state. Each MAC is responsible for processing the enrollment application. For accurate mailing addresses and to find your assigned MAC, visit the official Medicare Provider Enrollment site. Your application must include original signatures and all required documents to ensure prompt processing.

Common mistakes

Completing the CMS-855R form is a crucial step in reassigning Medicare benefits. However, individuals often make mistakes during this process. One common error is failing to select the correct reason for submitting the application. The applicants must carefully read Section 1 to ensure they check the appropriate box indicating their reason for completing the form. Neglecting this can lead to delays or the rejection of the application.

Another frequent mistake occurs when applicants do not provide accurate or complete information in Section 2 regarding the organization or group receiving the reassigned benefits. It is imperative that the legal business name, tax identification number, and Medicare identification number match official documents. Any discrepancies can cause the application to be invalidated or slow down processing time.

Legible handwriting is essential when filling out the form. Many individuals use cursive writing or pencil, which can be difficult to read. This may result in processing issues. It is advisable to type or print all information in a clear manner using black or blue ink. Ensuring that all entries are easily readable will facilitate a smoother approval process.

Section 3 asks for the individual practitioner's information, but sometimes applicants omit their National Provider Identifier (NPI) or make errors in entering their Social Security Number (SSN). Both identifiers are necessary for proper identification within the Medicare system. Missing or incorrect information in this section can result in additional requests for information, thereby delaying the process.

Further confusion arises when applicants do not maintain a copy of their completed Medicare reassignment package. Keeping a copy for personal records is encouraged, as it provides a reference if any follow-up is required. Failure to do so may complicate future communications with Medicare.

Finally, applicants occasionally overlook the requirement for original signatures in the application. The CMS-855R requires the individual practitioner’s signature as well as that of a delegated or authorized official to be valid. Incomplete signatures can lead to immediate rejection of the application, creating unnecessary stress and potential loss of benefits.

Documents used along the form

When dealing with the CMS 855R form, there are several other important forms and documents that often accompany it. Each of these documents serves a distinct purpose in the Medicare enrollment process, ensuring proper documentation and compliance for both practitioners and eligible organizations. Here is a brief overview of these forms and documents.

CMS-855I: This is the Medicare enrollment application for individual practitioners. It is necessary for eligible healthcare professionals who wish to enroll in the Medicare program, maintaining their individual provider status.
CMS-855B: Similar to the CMS-855I, this application is specifically for organizations or group practices. It allows these entities to enroll in the Medicare program, ensuring they can bill for services rendered by their practitioners.
CMS-588: The Authorization Agreement for Electronic Funds Transfer (EFT) must be completed to set up direct deposit of Medicare payments. This ensures timely access to funds for services delivered.
CMS-460: This document is the Medicare Additional Documentation Request form. It may be required in certain circumstances when additional information or supporting documents are needed for claims already submitted.
W-9: The Request for Taxpayer Identification Number and Certification is often needed for compliance with IRS regulations. It helps in confirming the identity of the payee and ensuring correct tax reporting.
State Licensure Documents: These documents serve as evidence that the practitioner is legally allowed to practice medicine in their state. Verification ensures that all providers meet state requirements.
Malpractice Insurance Documentation: Proof of insurance coverage protects both the provider and patients. It is an important component in demonstrating the practitioner’s professional liability coverage.
Organizational Chart: Sometimes, an organizational chart is necessary to illustrate the structure of the healthcare organization. This aids in establishing clear roles and responsibilities within the group.
Provider Credentialing Files: Credentialing files are important for demonstrating that healthcare providers have met the required qualifications and standards. These files often include education, training, and professional references.

Each of these forms and documents plays a vital role in the enrollment and reassignment process for Medicare services. Ensuring that they are accurately completed and submitted alongside the CMS 855R can lead to smoother processing and fewer delays in payment and approvals. Proper attention to detail in these materials is essential for compliance with Medicare regulations.

Similar forms

CMS-855I: This form is for individual practitioners who need to enroll in Medicare. Like the CMS-855R, it involves reporting essential information but focuses on initial enrollment rather than just reassignment.
CMS-855B: Used by organizations or groups to enroll in Medicare. Similar to CMS-855R, it allows organizations to establish a billable relationship with Medicare but is concerned with enrollment, not the reassignment of benefits.
CMS-855S: This form is for suppliers that provide services but are not physicians or non-physician practitioners. It shares the purpose of reporting and certifying information for Medicare participation similar to CMS-855R.
CMS-855O: This application is for non-physician practitioners who want to enroll in Medicare as independent contractors. Much like CMS-855R, it involves reassignment aspects but is specific to independent contractors.
CMS-10214: This form is used for reassigning benefits specifically for Part B services. Similar to CMS-855R, it governs the process of how payments are handled, though it focuses only on the Part B service context.
CMS-588: This is the Electronic Funds Transfer Authorization Form. While not an enrollment application itself, like CMS-855R, it deals with how Medicare payments are directed, thereby linking fiscal management of Medicare benefits.
CMS-460: This form is the Medicare Advantage election form. It is similar in that it must be completed by beneficiaries and affects how Medicare benefits are directed and reassigned among providers.

Dos and Don'ts

Things to Do When Filling Out the CMS-855R Form:

Ensure all information fields are completed accurately, especially those not marked as “optional.”
Type or print legibly, avoiding the use of pencil.
Match the legal business name with the tax documents provided.
Include all necessary NPIs in the proper sections.
Sign and date the certification statements, ensuring correctness.
Keep a copy of the completed application for your records.

Things to Avoid When Filling Out the CMS-855R Form:

Do not leave any required fields blank.
Avoid using pencil for completing the form.
Do not mismatch organization names with IRS documents.
Do not submit forms that are outdated.
Never omit signatures on certification statements.
Avoid sending incomplete applications without necessary documentation.

Misconceptions

Here are 9 common misconceptions about the CMS 855R form, clarified for better understanding:

The CMS 855R form is only for new providers. This form is also essential for current providers looking to reassign or terminate their Medicare benefits.
I can skip fields marked as optional. While optional fields are not required, updating them can help maintain accurate records.
The form only needs to be submitted once. Each organization or group requires a separate CMS 855R submission for reassignments. Every change means a new submission.
It's okay to use a pencil for filling out the form. All entries must be typed or printed in ink, ensuring legibility.
If I own my practice, I don’t need to reassign benefits. Sole owners must still submit this form if they wish to reassign benefits to an organization.
Delegated officials can sign without the individual practitioner's consent. Both the practitioner and the organization's official must sign when establishing or terminating a reassignment.
The MAC will process my application immediately. Processing may take time, and additional documentation might be requested, so be prepared for follow-up.
The CMS 855R form can be submitted online only. While online submissions through PECOS are a choice, a paper version is still valid.
Physician assistants should use the CMS 855R. Physician assistants must utilize the CMS 855I to report their employment arrangements, not the 855R.

Key takeaways

Here are some important points to consider when filling out and using the CMS 855R form:

Who should use the CMS 855R form? This form is for individuals who are reassigning their right to bill Medicare and receive payments for services provided to Medicare beneficiaries.
If you are terminating an existing reassignment, you can also use this form.
Both the individual practitioner and the organization/group must be enrolled in Medicare for the reassignment to be valid.
Make sure to sign and date the form correctly. Each signature is important for the application’s legitimacy.
Keep a copy of your completed CMS 855R application for your records. You may need it for future reference.
Complete all required sections of the form, but optional fields are not mandatory. However, keeping this information up-to-date is wise.
If submitting a reassignment to an organization/group, ensure that the legal business name matches the name on tax documents.
Submit a separate CMS 855R for each organization/group for which you are establishing or terminating a reassignment.
The Medicare Administrative Contractor (MAC) may request more documentation. You must provide this within 30 days of their request.
Mail your completed application to the specific MAC that services your state, ensuring that all required documentation is included.

Browse Other Templates

Fl-100 - This form aims to protect parental responsibilities and rights during divorce proceedings.

What Is a Dwc 1 Form - You may request an Information & Assistance officer for help in understanding the claim process.

Arkansas Sales Tax Exemption Certificate - Remain aware of any follow-up actions needed post-submission of the form.