Medicare Enrollment Application
In the enrollment process, CMS collects information about the applying provider or supplier and secures documentation to ensure that the he or she is qualified and eligible to enroll in the Medicare Program. Depending upon provider or supplier type, one of the following forms is completed to enroll in the Medicare Program
Form CMS-855A/Medicare Enrollment Application for Institutional Providers: Application: Application used by institutional providers to initiate the Medicare enrollment process or to change Medicare enrollment information
Form CMS-855B/Medicare Enrollment Application for Clinics/Group Practices and Certain Other Suppliers: Application used by group practices or other organizational suppliers, except DMEPOS suppliers, to initiate the Medicare enrollment process or to change Medicare enrollment information
Form CMS-855I/Medicare Enrollment Application for Physicians and Non-Physician Practitioners: Application used by individual physicians or NPPs to initiate the Medicare enrollment process or to change Medicare enrollment information
Form CMS-855R/Medicare Enrollment Application for Reassignment of Medicare Benefits: Application used by individual physicians or NPPs to initiate reassignment of a right to bill the Medicare Program and receive Medicare payments or to terminate a reassignment of benefits; and
Form CMS-855S/Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Suppliers: Application used by DMEPOS suppliers to initiate the Medicare enrollment process or to change Medicare enrollment information.
The following forms are often required in addition to the Medicare Enrollment Application:
Form CMS-588/Electronic Funds Transfer (EFT) Authorization Agreement: Medicare authorization agreement for EFTs (for providers who choose to have payments sent directly to their financial institution);
And CMS Standard Electronic Data Interchange (EDI) Enrollment Form: Agreement executed by each provider of health care services, physician, or supplier that intends to submit electronic media claims (EMC) or other EDI transactions to Medicare. This form is available from Medicare Carriers, FIs, A/B MACs, and Durable Medical Equipment Medicare Administrative Contractors and must be completed prior to submitting EMC or other EDI transactions to Medicare.
The following optional form is submitted if the provider or supplier wishes to enroll as a Medicare participating provider or supplier:
Form CMS-460/Medicare Participating Physician or Supplier Agreement: Agreement to become a Part B participating provider or supplier who will accept assignment of Medicare benefits for all covered services for all Medicare beneficiaries. The Participating and Nonparticipating Providers and Suppliers Section of this chapter provides additional information about participating in the Medicare Program.
The above forms are available at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp on the CMS website.
