Important Information About the Enrollment Process
BEFORE YOU SUBMIT AN APPLICATION:
- You MUST have a National Provider Identifier (NPI). An NPI is required for a change of information or to apply for a new Medicare number. Your application will be delayed if you fail to provide an NPI with your original submission. See below for additional details.
- You MUST agree to accept Electronic Payment. This federally-mandated requirement applies to established providers submitting a change of information that are not already set up for electronic payment, as well as all new enrollees. An Electronic Funds Transfer Authorization Agreement (EFT) form must be included with your application request. Your application will be delayed if you fail to include a completed EFT Agreement with your original submission. See below for additional details.
Providers' Responsibilities in the Enrollment Process:
Providers are responsible for submitting a COMPLETE AND ACCURATE enrollment application. You must comply with all the directions on the enrollment applications. Incomplete or inaccurate applications cannot be processed.
Providers who submit an incomplete application will receive a letter within 30 days requesting the missing items required to complete processing. If a provider does not respond timely to this request for additional information, the application may not be processed.
How to Submit a Paper Provider Enrollment Application:
All enrollment applications/forms must be submitted via regular mail to:
CIGNA
Government Services
Provider Enrollment Department
P.O. Box 25226
Nashville, TN 37202
Special mail handling can delay the delivery and processing of your application.
Current Enrollment Process Details:
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To obtain the most current versions of the CMS-855 applications, please download the forms from the CMS website at: http://www.cms.gov/CMSForms/CMSForms/list.asp.
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All new enrollments or changes to existing provider information must include the individual National Provider Identifier (NPI) in the designated sections of the application. If an individual is joining a group, the group NPI is also required. To apply for an NPI, you can access the NPI application form at: http://www.cms.gov/CMSForms/CMSForms/list.asp. If you need additional information regarding the NPI you may contact the enumerator company (Fox Systems) directly by calling 1-800-465-3203, or e-mail them at: customerservice@npienumerator.com.
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At the time of initial enrollment or a change to existing provider information, an Electronic Funds Transfer Authorization Agreement (CMS-588) must be submitted. The CMS-588 form can be downloaded at: http://www.cms.gov/CMSForms/CMSForms/list.asp
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If a provider wants to enroll as a Participating Provider (PAR ), the Participation Provider Agreement (CMS-460) must be included with the enrollment application. The provider has up to 90 days after enrollment to submit a PAR Agreement. The current PAR Agreement form can be downloaded at: http://www.cms.gov/CMSForms/CMSForms/list.asp
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Providers should attach an actual copy of their medical/professional license to their initial enrollment applications. An "internet copy" is not acceptable .
Reminders:
- If applying under a Tax Identification Number, you must submit IRS documentation. Acceptable documentation includes a CP575 (a computer-generated letter), a Form 990, a quarterly tax coupon or other IRS correspondence that contains the applicant's legal name and tax identification number. A W-9 and SS-4 Form are not acceptable.
- Individual practitioners joining a group are not required to submit an Electronic Funds Transfer Agreement (EFT) (CMS-588). For groups not currently set up for EFT, only one EFT agreement is required for the entire group.
Common Errors that Delay the Enrollment Process:
- The provider submits an outdated application. These forms will be immediately rejected and returned. They cannot be processed. All applications must include a current release date.
- The application does not include the NPI. Providers must obtain an NPI before submitting a Medicare enrollment application. The NPI must be entered in the appropriate field on the application(s).
- A Physician Assistant submits a CMS-855R instead of a CMS-855I application.
- A provider fails to submit a newly signed certification page when submitting changes to the application.
- A provider submits a photocopied or faxed signature page when submitting their initial application. Signature pages must contain an original signature.
- Section 4B of the CMS-855R (Authorized/Delegated Official) is not signed or dated.
- All required sections on the CMS-855 applications are not completed and/or all questions are not answered.
- The CMS-855 application is missing the date the supplier and/or individual started rendering services at that location.
- The CMS-855B does not include one managing employee in addition to listing all owners/directors/officers and/or partners. This section is also to be completed for any authorized and delegated officials listed on the application.
- The section of the CMS-855 pertaining to adverse legal actions is not completed.
- Section 15 of the CMS-855B is not signed by the authorized official.
Additional Provider Enrollment Tips:
- If you are a new provider that will be reassigning your benefits to an entity, you must complete the CMS-855R application along with the CMS-855I application.
- Sole owners must complete the CMS 855I application. The requirement of the 855R to reassign to one's own entity has been eliminated.
- The legal business name must be written on the CMS-855 application exactly as it appears on the IRS document.
