CMS-855B
Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers
Form CMS-855B is the Medicare Enrollment Application for Clinics/Group Practices and Certain Other Suppliers from the Centers for Medicare & Medicaid Services (CMS). The form says clinics, group practices and other suppliers complete it to enroll in Medicare and receive a Medicare billing number, and that applicants using it require a Type 2 NPI. It is also used to revalidate, reactivate, enroll with another MAC, report changes, report a change of ownership (CHOW) for certain certified Part B providers, handle reassignments of benefits with individual practitioners and voluntarily end enrollment.
Section 1 asks why you are submitting and which sections to complete. The rest covers identifying information and supplier type, final adverse legal actions, practice locations and reassignments, ownership and managing control, a billing agency, supporting documents, a contact person, penalties and certification statements. Sections 7, 9, 10 and 11 are intentionally left blank. Attachments cover ambulance suppliers, independent diagnostic testing facilities (IDTFs) and opioid treatment programs (OTPs).
The form says the same actions can be done online through PECOS, that the paper form is to be typed, not handwritten, and that it goes to your designated Medicare Administrative Contractor (MAC). You can type it free in your browser on this page and download the result without an account.
The reason for submitting, from new enrollment to voluntary termination. Section 1B maps each kind of change to the sections to complete, and the form says sections 1, 2A1, 3 and 15 are always completed when reporting any information.
Legal business name and TIN, PTAN and NPI, IRS business designation and structure, licenses and certifications, correspondence and medical record addresses, supplier type, and parts for hospitals, PT/OT groups and ASC accreditation.
Convictions within the preceding 10 years, exclusions, revocations and suspensions, and a table of each action. The form says to report them regardless of whether records were expunged or appeals are pending.
Each practice location (a street address, not a P.O. Box), remittance and records storage addresses, services in patients' homes, base of operations, vehicles and area for mobile suppliers, and in 4H reassignment of benefits.
Organizations (5) and individuals (6) with 5 percent or more ownership or managing control, officers, directors, managing employees, partners and officials, plus a billing agency or agent (8). The form says a supplier has at least one owner, one managing employee and one authorized official.
A supporting documents list, an optional contact person, the penalties for falsifying information, and certification statements for authorized and delegated officials and, in 15E, an individual practitioner. Attachments 1 to 3 cover ambulance suppliers, IDTFs and OTPs.
The form says all information is required except fields marked optional, and to copy a section when more space is needed.
The form says the NPI comes from NPPES in a separate process, and that the legal business name and TIN in Section 2A are the same ones used to obtain the NPI. Sole proprietors report a Type 1 NPI.
The form says the supplier pays the required application fee through PECOS upon initial enrollment, the addition of a new business location and revalidation, before submitting the application to the MAC. It does not list the amount.
Check one box in Section 1A. For a change, Section 1B lists the sections to complete. Ambulance suppliers, IDTFs and OTPs also complete their attachment.
Section 12 lists documents such as licenses, final adverse legal action records, CMS-460 to be a participating supplier, CMS-588 with a voided check or bank letter, IRS confirmation of the TIN and legal business name, and an ownership structure diagram.
The form says it is to be typed. Only an authorized official signs the initial application and adds or removes officials. A new reassignment also needs Section 15E signed by the individual practitioner.
Send the application with original signatures and all required documents to the MAC that services your State, or make the same request through PECOS.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
To your designated Medicare Administrative Contractor (MAC), the one that services your State. The form points to CMS.gov/Medicare/Provider-Enrollment-and-Certification for the MAC's mailing address, and says not to mail applications to the CMS address in the PRA statement.
The form says enrollment and changes can be done through Internet-based PECOS, and that your current enrollment record can be viewed at PECOS.cms.hhs.gov.
The form says the MAC may request more documentation and that it is due within 30 days of the request, citing 42 C.F.R. section 424.525(a)(1) and (2).
The form says changes are reported within the timeframes in 42 C.F.R. section 424.516, and IDTF changes under 42 C.F.R. section 410.33. For IDTFs, Attachment 2 lists 30 calendar days for ownership, location, supervision and adverse legal action changes and 90 days for others.
Section 14 lists criminal and civil penalties for deliberately furnishing false information, citing laws such as 18 U.S.C. section 1001, section 1128B(a)(1) of the Social Security Act and the Civil False Claims Act.
The form estimates 0.5 to 3 hours per response, including reviewing instructions and gathering the information.
CMS-855I
513 fields, 26 pages
CMS-460
11 fields, 3 pages
CMS-588
39 fields, 4 pages
CMS-1561
14 fields, 2 pages
CMS-370
10 fields, 2 pages
CMS-855A
1,236 fields, 72 pages
Page 1 of the form lists who completes this application. The form uses the word supplier for every applicant that files it.
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The form says clinics, group practices and other suppliers can enroll or make changes using either Internet-based PECOS or the paper CMS-855B. You can also fill out the PDF here free and download it.
The form says applicants using it require a Type 2 NPI, the kind for organizations. It notes that sole proprietors are Type 1 providers, so their individual Type 1 NPI is reported.
No. The instructions in the form say it is to be typed and may not be handwritten.
The form says only an authorized official can sign the initial application and add or remove officials. After that, an authorized or delegated official can sign. A new reassignment needs Section 15E signed by the individual practitioner and Section 15B or 15D by an official of the organization/group.
The form says the supplier pays the required application fee through PECOS upon initial enrollment, the addition of a new business location and revalidation, before submitting the application. It does not state the amount.
Section 2B says to submit a separate application for each supplier type, and to submit a new application if you become a different supplier type.
To your designated MAC. The form says the MAC that services your State processes the application, and points to CMS.gov/Medicare/Provider-Enrollment-and-Certification for its mailing address.