New
Applications Required for Enrollment into the Medicare Program
The Centers for Medicare & Medicaid Services (CMS) has issued revised Provider Enrollment applications. The revised 2006 applications replace the 11/01 versions of the 855B, 855I, and 855R Enrollment Applications. Additionally, with each enrollment, the National Provider Identifier (NPI) must be submitted along with a copy of the NPI notification furnished by the National Plan and Provider Enumeration System (NPPES). Providers and suppliers must also complete the Authorization Agreement for Electronic Funds Transfer (CMS-588) and submit it with initial enrollments, or, in the case of providers/suppliers who are not currently receiving payments via EFT, they must submit the CMS-588 agreement when making a change to their existing enrollment.
CIGNA Government Services has been instructed to use the new CMS-855 enrollment applications beginning May 1, 2006. Effective June 2, 2006, only the new CMS-855 applications were accepted. The new applications are currently available on the CMS Web site. Providers may download the new application by logging on to our Provider Enrollment section and selecting the "Applications" link.
The new version 06/2006 applications are as follows:
CMS-855I - Medicare Enrollment Application - Physicians and Non-Physician Practitioners
The 855I is used for all physicians and non-physicians who render medical services to Medicare beneficiaries. If you plan to provide services as part of an organization to which you will reassign your benefits, you must also complete and submit a CMS 855R with this application. An individual who has formed a professional corporation, professional association, limited liability company, etc., of which they are the sole owner completes the CMS-855I (2006 Version) and does not complete the CMS-855R.
The 855I will be used for the following situations:
- New Enrollees
- Enrolling with another fee-for-service contractor
- Reactivation
- Voluntary Termination (Individuals and Physician Assistants)
- Change of Information
- Revalidation
CMS-855R - Medicare Enrollment Application - Reassignment of Medicare Benefits
This application is to be completed for any individual practitioner who will be reassigning his or her benefits to an eligible provider or supplier.
- Adding a New Reassignment
- Terminating a Current Reassignment
CMS-855B - Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers
This application is used if you are an organization/group that plans to bill Medicare and you are a medical practice or clinic that will bill for Medicare Part B services, enrolling with another fee-for-service contractor or currently enrolled and making changes to your enrollment data.
The 855B will be used for the following situations:
- New Enrollees
- Enrolling with another fee-for-service contractor
- Reactivation
- Voluntary Termination
- Change of Information
- Revalidation
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