CMS-855S
Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
Form CMS-855S is the Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers from the Centers for Medicare & Medicaid Services. The form says DMEPOS suppliers complete it to enroll in Medicare and receive a Medicare billing number, and also to report changes, add a business location, revalidate, reactivate or voluntarily terminate their enrollment.
The application opens with an abbreviated summary of the 30 DMEPOS supplier standards from 42 C.F.R. section 424.57, then instructions, followed by the numbered sections: basic and identifying information, final adverse legal actions, addresses, ownership and managing control, liability insurance and surety bond, billing agency, supporting documents, contact person, penalties and the certification statement. Sections 9 to 11 are intentionally left blank. Which sections to complete depends on the reason checked in Section 1.
The form says suppliers can apply on paper or through PECOS online. You can fill it out free in your browser on this page and download the result without an account.
The reason for submitting and what is changing, then the business location and posted hours, legal business name, NPI, TIN, business structure, states where items are provided, supplier type, accreditation and products and services.
Federal and state convictions within the preceding 10 years, exclusions, revocations, suspensions and other sanctions, with the date and who took each action.
1099 mailing address, correspondence and medical record correspondence addresses, revalidation package address, remittance and special payments address, and where beneficiary medical records are stored.
Organizations in Section 5 and individuals in Section 6 with 5 percent or more ownership interest or managing control. The form says a supplier reports at least one owner and one managing employee.
Comprehensive liability insurance, which the form says is at least $300,000 for each incident, surety bond details or an exception, and any billing agency or agent used.
The supporting documentation checklist, an optional contact person, the penalties for falsifying information, and the certification statement with Authorized and Delegated Official signatures.
The form says all information is required except fields marked optional.
The form lists an NPI, a surety bond and/or accreditation before submitting, and the application fee paid through PECOS for initial enrollment, a new location, revalidation and, if requested, reactivation.
Check one reason in Section 1A. The form shows which sections each reason needs, and Section 1B lists the sections for each kind of change.
The form says to type or print legibly, not in pencil, with blue ink preferred, and to copy a section when more space is needed.
Section 12 lists licenses, the certificate of liability insurance, IRS confirmation of the TIN and legal business name, Form CMS-588 with a voided check and the fee receipt, plus documents that apply, such as Form CMS-460.
The form says only an Authorized Official signs the initial application, signatures are original and in ink, and they are less than 120 days old at submission.
Send it to Novitas Solutions or Palmetto GBA, based on the business's state, at the addresses on page 5.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
Novitas Solutions, NPEAST DMEPOS, PO Box 3704, Mechanicsburg, PA 17050. Customer service for NPE East: 1-866-520-5193. Page 5 lists the states it covers.
Palmetto GBA, NPWEST DMEPOS, PO Box 100142, Columbia, SC 29202-3142. Customer service for NPE West: 1-866-238-9652. Page 5 lists the states it covers and the overnight addresses for both contractors.
The form says suppliers can apply or make changes either through the Internet-based PECOS or with the paper CMS-855S, using the most current version.
The form says the fee is paid through PECOS before the application is submitted, in the calendar year it is submitted. It does not state an amount.
The form says the contractor reviews the application, conducts a site visit, may request fingerprints and further documents, and notifies the supplier in writing. Billing privileges start only once a Medicare Identification Number is assigned.
The form estimates 0.5 to 4 hours per response. It says not to mail applications to the CMS address in its Paperwork Reduction Act notice.
CMS-588
39 fields, 4 pages
CMS-460
11 fields, 3 pages
CMS-855B
960 fields, 54 pages
CMS-855I
513 fields, 26 pages
CMS-855A
1,236 fields, 72 pages
CMS-20134
323 fields, 31 pages
The form is for DMEPOS suppliers that bill or plan to bill Medicare, not for beneficiaries.
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The form says DMEPOS suppliers complete it to enroll in Medicare and receive a Medicare billing number, and to report changes, add a location, revalidate, reactivate or voluntarily terminate.
To Novitas Solutions (NPEAST) or Palmetto GBA (NPWEST), depending on the state where the business is located. Page 5 of the form lists the states and the PO Box and overnight addresses for each.
The form says DMEPOS suppliers can apply or change their enrollment information either through the Internet-based PECOS or with the paper CMS-855S.
The form says the application fee is paid through PECOS before submitting, for initial enrollment, a new business location, revalidation and, if requested, reactivation. It does not list the amount.
Section 7A says comprehensive liability insurance of at least $300,000 for each incident, in force at all times, with the contractor listed as certificate holder. It says professional and malpractice insurance does not meet this requirement.
The form says any change to existing enrollment data is reported within 30 days of the effective date of the change.
The form says a separate CMS-855S is completed for each physical location used to furnish Medicare covered DMEPOS, except locations used only as warehouses or repair facilities. Each location also has its own NPI, unless enrolling as a sole proprietor with multiple locations.
The form says only an Authorized Official signs the initial application. After that, an Authorized or Delegated Official can sign. Signatures are original and in ink, and less than 120 days old when submitted.