3/13/2008 1 2 How to Complete the Medicare CMS-855B Enrollment Application Presented by Provider Outreach & Education and Provider Enrollment Navigation This CBT is made up of a collection of slides. Use the navigation buttons located at the bottom of each slide to navigate through this CBT. 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Welcome Revised CMS-855B Is this the correct form for you? Do you have the CMS-855B form? Provider Enrollment Hotline Significant Changes Have you applied for your National Provider Identifier (NPI)? Electronic Funds Transfer (EFT) Did you know you may not have to complete the entire application? Section 1A: Basic Information Section 1B: Basic Information Section 1: Attachments 1 and 2 Section 2: Identifying Information Section 2: Identifying Information Section 2B2: Identifying Information Section 2B3: Identifying Information Section 2C: Identifying Information Section 2D: - Identifying Information Section 2F: Identifying Information Section 3: Adverse Legal Actions Section 3: Adverse Legal Actions Section 4: Practice Location Information Section 4: Practice Location Information Section 4: Practice Location Information Section 4: Practice Location Information Section 4: Practice Location Information Section 4: Practice Location Information Section 4: Practice Location Information Section 4: Practice Location Information 1 3/13/2008 Section 5: Ownership Interest Organizations Section 5: Ownership Interest Organizations Section 5: Ownership Interest Organizations Section 5: Ownership Interest Organizations Section 5: Ownership Interest Organizations Section 6: Ownership Interest Individuals Section 6: Ownership Interest Individuals Section 8: Billing Agency Section 8: Billing Agency Section 13: Contact Person Section 14: Penalties for Falsifying Information Section 15: Certification Statement Section 15: Certification Statement Section 16: Delegated Official Section 17: Supporting Documents Attachment 1 – Ambulance Suppliers Attachment 2: Independent Diagnostic Testing Facility (IDTF) Prescreening Prescreening – Missing Information Prescreening – Missing Information Rejected vs. Returned Criteria For Returned Applications 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 No signature on application. Old version of application submitted. Copied or stamped signature. CMS-855I signed by someone other than individual practitioner applying for enrollment. Applicant failed to submit all forms needed to process a reassignment package. Completed application in pencil. Wrong application submitted. Web-generated application submitted but does not appear to have been downloaded off CMS' Web site. Application not mailed (i.e., it was faxed or e-mailed). 1 2 Application received more than 30-days prior to the effective date listed on the application. (This does not apply to certified providers, ASCs or portable X-ray suppliers.) Provider submitted new enrollment application prior to expiration of time in which provider is entitled to appeal the 2 3/13/2008 denial of his previously submitted application. Submitted CMS-855 for sole purpose of enrolling in Medicaid. CMS-855 not needed for the transaction in question. CMS-588 sent in as a stand-alone change of information request (i.e., it was not accompanied by a CMS-855) but was 1) unsigned, 2) undated, or 3) contained copied, stamped or faxed signature. 54 55 56 Most Common Reasons for Delays Application Processing Reminders 57 58 Thank you for participating in this Computer-Based Training Provider Enrollment and Provider Outreach & Education 3 3/13/2008 Publish Date:6/28/2007 Publish Date:6/28/2007 Publish Date:6/28/2007 Navigation How to Complete the Medicare CMSCMS-855B Enrollment Application This CBT is made up of a collection of slides. Use the navigation buttons located at the bottom of each slide to navigate through this CBT. Presented by Provider Outreach & Education and Provider Enrollment Slide 1 Out of 58 Slide 2 Out of 58 Welcome Welcome to the Computer-Based Training (CBT) module for Provider Enrollment. This presentation was developed by the Provider Outreach & Education department along with the Provider Enrollment department in an attempt to assist you with correctly completing the CMS-855B enrollment form the first time. Slide 3 Out of 58 1 3/13/2008 Publish Date:6/28/2007 Revised CMSCMS-855B On May 1, 2006, the Centers for Medicare & Medicaid Services (CMS) released and implemented a new version of the CMS-855 Medicare enrollment applications (versions 04/06 and 06/06). The appearance and format of the enrollment applications were revised to help providers accurately complete the applications. Revisions included: • Larger font and plain language. • Tips on how to avoid delays. • Updated instructions to help you know which application to submit. • Redesigned Section 17. Slide 4 Out of 58 Publish Date:6/28/2007 Is this the correct form for you? Publish Date:6/28/2007 Do you have the CMSCMS-855B form? The CMS-855B form is used by the following: • Ambulance service supplier. • Ambulatory surgical center. • Clinic/group practice. • Competitive Acquisition Program (CAP) Part B drug vendor. • Independent clinical laboratory. • Independent diagnostic testing facility. • Mammography center. • Mass immunization (roster biller only). • Portable X-ray supplier. • Radiation therapy center. • Slide preparation facility. • Voluntary health/charitable agency. Slide 5 Out of 58 If you do not have a copy of the form, please take a few minutes to print it. You will use it as a guide throughout this presentation. The form is located on the CMS Web site at: www.cms.hhs.gov/cmsforms/downloads/cms855b.pdf Slide 6 Out of 58 2 3/13/2008 Publish Date:6/28/2007 Provider Enrollment Hotline Publish Date:6/28/2007 Significant Changes Publish Date:6/28/2007 Have you applied for your National Provider Identifier (NPI)? If after completing the CBT you still have questions, contact the Provider Enrollment department for your area: Providers are required to submit the new version of the enrollment form and additional information with all initial enrollment applications and changes of information . As a Medicare health provider, you must obtain an NPI prior to enrolling in Medicare or before submitting a change of existing enrollment information. The NPI notification must be submitted with the enrollment form. • Texas and Indian Health facilities: ((866)) 528-1602. Required additional information includes: NPI was mandated by the Health Insurance Portability and Accountability Act Act. • The NPI notification (if it was not previously submitted with an application that was processed completely). • Completed CMS-588 form (Electronic Funds Transfer (EFT)). • All required documentation necessary to process the enrollment form. • Virginia: (866) 697-9670. • DC/Delaware/Maryland: (866) 828-6254. NPI is a 10-digit number that will replace current Medicare identifiers. The NPI will not change and will remain with the provider regardless of job and location changes. Effective May 23, 2007, all Medicare claims must be submitted with only the NPI. The Web site of the NPI Enumerator is: https://nppes.cms.hhs.gov/NPPES/Welcome.do Slide 7 Out of 58 Slide 8 Out of 58 Slide 9 Out of 58 3 3/13/2008 Publish Date:6/28/2007 Electronic Funds Transfer (EFT) EFT is a way for Medicare to pay providers with a money transfer directly into a bank account. This eliminates the need for a provider to wait for a check to be mailed. CMS requires that providers filing a CMS-855 form have EFT. The application is to be included with the enrollment form. The EFT form, CMS-588, is located at: www.cms.hhs.gov/cmsforms/downloads/CMS588.pdf Slide 10 Out of 58 Publish Date:6/28/2007 Section 1A: Basic Information Publish Date:6/28/2007 Did you know you may not have to complete the entire application? Not every circumstance requires the CMS-855B to be completed in its entirety. Those include: • Voluntarily terminating Medicare enrollment. • Changing information: o Identifying information. o Adverse legal actions. o Practice location, payment address or record storage. o Ownership interest and/or managing control. o Billing agency information. o Authorized official. o Delegated official. This CBT will now review each section of the CMS-855B form. Slide 11 Out of 58 Complete the form in blue or black ink. DO NOT USE PENCIL. This section captures information about why you are completing the application. It also provides a list of required sections pertaining p g to your y reason. √ Find the section that applies to you. Only one reason per application should be checked. Select this checkbox If you are changing your Medicare Identification Number or NPI information. (Page 4) Slide 12 Out of 58 4 3/13/2008 Publish Date:6/28/2007 If you are reporting a change to your Medicare enrollment information, you will need to complete Section 1B. Check all areas that are being revised revised. Section 1B: Basic Information Publish Date:6/28/2007 Section 1: Attachments 1 and 2 Read and follow each section requirement for the change(s) you've selected. Section 2: Identifying Information Section 2 is for information about the provider. It identifies the type, name, address and information for specific suppliers. Ambulance Suppliers and Independent Diagnostic Testing Facilities (IDTF) must complete the appropriate sections on Page 6 if they are reporting changes to their Medicare enrollment information. √ Publish Date:6/28/2007 If you do not find your supplier type under Section 2A, 2A mark "Other" and write the supplier type on the line provided. All other providers can move on to Section 2. Not all providers will need to complete all of Section 2. √ ABC Health Clinic 123456789 √ If you are an American Indian and/or an Alaska Native facilities, see next slide. Section 6 is also required if adding a delegated official. (Page 5) (Page 6) Slide 13 Out of 58 (Page 7) Slide 14 Out of 58 Slide 15 Out of 58 5 3/13/2008 Publish Date:6/28/2007 Section 2: Identifying Information If you are an American Indian and/or an Alaska Native facilities, check the "Other" Other boxes in Section 2B. Identify if you are tribe or Indian Health Services (IHS) facility. Section 2B2: Identifying Information Section 2B2 identifies any state license or certification information required for you to operate as the provider type for which you are enrolling. √ Tribe Name 123456789 Tribal Health Clinic Publish Date:6/28/2007 √ √ Part of Tribe or IHS Tribe or IHS If applicable, you must provide the license or certification number, state where issued, and effective and expiration dates. Publish Date:6/28/2007 In Section 2B3, list the correspondence address for the entity listed in question 2B1. √ Section 2B3: Identifying Information 123 Medical Way y Suite 1A Medical City √ (123)456-7890 Any ST. 12345-6789 (123)456-7891 [email protected] You must indicate if a state license or certification is not applicable for the type of provider you are enrolling. (Page 8) Slide 16 Out of 58 (Page 8) Slide 17 Out of 58 Slide 18 Out of 58 6 3/13/2008 Publish Date:6/28/2007 Section 2C: Identifying Information Publish Date:6/28/2007 Section 2D: - Identifying Information Use Section 2D to list any comments that will help explain information provided in Section 2. Section 2C is only for hospitals needing a Medicare Part B billing number for a specific department. Indian Health clinic with no street address. Located 1 mile east of county road 121 and highway 40. Publish Date:6/28/2007 Section 2E: - Identifying Information If your facility does not meet this criteria, skip to Section 2D. You have now completed Section 2, move to Section 3. (Pages 9 and 10) (Page 9) Slide 19 Out of 58 Section 2G: Identifying Information This section is to report the termination information of a physician assistant from your group/clinic. Section 2E is for physical therapy and occupational therapy groups only. Each question must be answered by selecting “Yes” or “No.” (Pages 8 and 9) Section 2F: Identifying Information Section 2F is for free-standing Ambulatory Surgical Centers (ASCs). Check either “Yes” or “No” and complete other information as required. Slide 20 Out of 58 Slide 21 Out of 58 7 3/13/2008 Publish Date:6/28/2007 Section 3: Adverse Legal Actions Complete Section 3 for all past or present legal convictions, exclusions, revocations and suspensions regardless of whether or not the record has been expunged or an appeal is pending. pe d g A list s o of reportable epo ab e items is provided on Page 11. Publish Date:6/28/2007 Section 3: Adverse Legal Actions You must answer question No. 1. Publish Date:6/28/2007 Section 4: Practice Location Information Section 4 must include information about where the group or organization provides health care services. Provide the specific street address as recorded by the United States Postal Service. Do not provide a P.O. Box. √ If you answer "Yes" to question No. 1, you must complete question No. 2. Section 4 will identify where medical records are stored, the address for remittance notices and special payments. You have now completed Section 3, move to Section 4. (Page 11) All providers are required to complete Section 4. (Page 13) (Page 12) Slide 22 Out of 58 Slide 23 Out of 58 Slide 24 Out of 58 8 3/13/2008 Publish Date:6/28/2007 Section 4: Practice Location Information Provide the practice location name used in everyday operation in Section 4A. Enter the full street number, city, state and nine-digit ZIP code. Do not list P.O. Box numbers. List the telephone number for the physical location. A fax number or e-mail address is not necessary. American Indian and/or Alaska Native clinics with no street address should list General Delivery or Main Street as the address address. Enter the first date a Medicare patient was seen at this location. This does not have to be the date the location opened for business. Enter the Medicare identification number, if issued, and the NPI for the clinic. Select the option that best fits this practice location. If the practice has a CLIA and/or an FDA certification, enter the numbers and attach a copy of the certification. ABC Health Clinic 123 Medical Way S it 1A Suite Medical City (123)456-7890 01/02/2007 √ Publish Date:6/28/2007 Publish Date:6/28/2007 Section 4: Practice Location Information Section 4B contains information about where the group's remittance notices will be sent. This address will also be used to send any special Medicare payments that are not sent electronically. y Any ST. (123)456-7891 12345-6789 [email protected] 2468101214 12D345678 (Page 14) Medicare will issue payments via Electronic Funds Transfer (EFT). Since payments will be made via EFT, the “Special Payments" address should indicate where all other payment information should be sent. If you store patients' medical records at a location other than what is reported in Section 4A or 4E, complete this section. If this section is not completed, you are indicating that all records are stored at the practice locations reported in Section 4A or 4E. √ (Pages 15 and 16) (Page 15) Slide 25 Out of 58 Section 4: Practice Location Information Slide 26 Out of 58 Slide 27 Out of 58 9 3/13/2008 Publish Date:6/28/2007 Section 4: Practice Location Information Complete Section 4D If you provide services in patients' homes. If you do not render services in patient's homes, skip this section. If you provide services to an entire state, enter the state. You do not need to list each city/town separately. Publish Date:6/28/2007 Publish Date:6/28/2007 Section 4: Practice Location Information In Section 4E, enter the base of operations information. Enter the location where personnel is dispatched, where mobile/portable equipment is stored and where vehicles are parked when not in use. Dallas Ft. Worth Not all providers will need to complete this section. Texas Texas If you only provide services in a city/town, enter the city or town’s name and the state. The ZIP code is only required if you are not servicing the entire city/town. (Page 17) Do not report vehicles that are used to o transport a spo medical ed ca equipment if services are not provided in the vehicle. √ Copy and complete Section 4F if there are more than two vehicles to report. Up to two vehicles can be reported per form. If the address for the base of operations is the same as Section 4A, check the Indicated box. (Page 18) Slide 28 Out of 58 Section 4: Practice Location Information In Section 4F, list vehicles that are used to provide medical services. This does not include ambulances. (Page 18) Slide 29 Out of 58 Slide 30 Out of 58 10 3/13/2008 Publish Date:6/28/2007 Publish Date:6/28/2007 Section 4: Practice Location Information Publish Date:6/28/2007 Section 5: Ownership Interest Organizations Section 5 is for any organization that owns 5 percent or more of the provider facility completing the application. (Section 5 is not for reporting individuals). Organizations that have managing control or partnership interests must also be listed listed. Section 4G is used to report the rendering location of mobile or portable services. Reporting can be by an entire state or by cities/towns cities/towns. Additions and deletions can be made on the same application. Section 5: Ownership Interest Organizations If Section 5A does not pertain to your situation then indicate "Not Applicable." √ American Indian and/or Alaska Native organizations must list the name of the government (i.e., Indian Health Service) or tribal organization that will be legally and financially responsible. (Page 20) (Page 19) Slide 31 Out of 58 (Page 21) Slide 32 Out of 58 Slide 33 Out of 58 11 3/13/2008 Publish Date:6/28/2007 Publish Date:6/28/2007 Section 5: Ownership Interest Organizations If you check change, add or delete, you must furnish the effective date. Publish Date:6/28/2007 Section 5: Ownership Interest Organizations Section 5B is to report any adverse legal history of the controlling organization. Example of American Indian and/or Alaska Native information. Indicate at least one ownership or managing g g control category. g y Section 5: Ownership Interest Organizations √ You must answer question No. 1. Refer to Page 11 for a description of adverse legal actions. The business name must be what is reported to the IRS. √ The Doctors Partnership ABC Health Clinic 123 Medical Way Suite 1A Medical City 246810121 Tribal Name √ Tribal Health Clinic 123 Native Way Any ST. 12345-6789 (Page 21) Indian Country (Page 21) Slide 34 Out of 58 Any ST 24680-1214 369121518 (Page 22) Slide 35 Out of 58 Slide 36 Out of 58 12 3/13/2008 Publish Date:6/28/2007 Section 6: Ownership Interest Individuals Publish Date:6/28/2007 Section 6: Ownership Interest Individuals If there is more than one individual Adverse legal actions must be completed for each individual reported reported. If the provider listed in Section 2 is a corporation, p , list all officers and directors. American Indian and/or Alaska Native groups report its managing employees in Section 6. List all individuals with partnership interests regardless of percent of ownership. √ 01/02/2007 John 111-11-1111 12/25/1950 √ Doe N/A N/A (Page 23) (Page 24) Slide 37 Out of 58 A billing agency may perform other services for you you, but claims completion and/or submission are included in your contract. If you do not use a billing agency, you must indicate by checking the first box. √ You must check either "Yes" or "No" in response to question No. 1 in Section 6B. List all authorized and delegated officials in this section. Section 8: Billing Agency Use Section 8 to report any individual or entity with whom you have contracted to prepare and √ submit claims for the business. who needs to be reported, copy and complete this section for each individual. Section 5 contains the information for individuals having ownership of 5 percent or more of the group. Publish Date:6/28/2007 (Page 25) Slide 38 Out of 58 Slide 39 Out of 58 13 3/13/2008 Publish Date:6/28/2007 Section 8: Billing Agency Publish Date:6/28/2007 Section 13: Contact Person The contact person should be someone who can answer questions about the information on the application. If you check the box indicating a change, add or delete, you must furnish the effective date And complete the appropriate fields. 987654321 369 Billing Ave. Claims Town (369)101-2345 Any St. 78910-2345 (369)101-2346 (Page 25) Slide 40 Out of 58 If the contact person will be either the authorized or delegated office, check the appropriate box and skip to the indicated section. There can be more than one contact person. Copy and complete this page for each contact. (Page 26) Jane (123) 456-7890 Section 14: Penalties for Falsifying Information Section 14 outlines the penalties for falsifying information and should be read by the authorized and delegated officials legally responsible ibl for f the th provider id listed in Section 2. Medicare will not list the contact person on the Medicare provider’s record. ABC Billing Publish Date:6/28/2007 Doe (123) 456-7891 This section does not have an area to be completed. 123 Medical Way Suite 1A Medical City Any ST. 12345-5678 [email protected] (Pages 27 and 28) Slide 41 Out of 58 Slide 42 Out of 58 14 3/13/2008 Publish Date:6/28/2007 Section 15: Certification Statement Page 29 provides a description of an authorized official and a delegated official. Publish Date:6/28/2007 Section 15: Certification Statement Sections 15B and 15C are for authorized official(s) only. Authorized official(s) must sign this p page. g Use blue ink which will indicate an original signature and not a copy. Examples of an authorized official are chief executive officer officer, chief financial officer, general partner, chairman of the board, or direct owner. Only an authorized official has the authority to sign the initial enrollment application. A delegated official does not have this authority. John (246)810-1214 John Doe, CEO Doe CEO 1/2/2007 (Pages 29 and 30) Slide 43 Out of 58 If no delegated official is appointed, the authorized office will be responsible for all changes and updates made to the provider's record. All signatures must be original and signed in ink. Applications with signatures deemed not original will not be processed. Stamped, faxed or copied signatures will not be accepted. All signatures must be original and signed in ink. Applications with signatures deemed not original will not be processed. Stamped, faxed or copied signatures will not be accepted. (Page 31) The officials must read and understand Pages 29 and 30. Section 16: Delegated Official Section 16 is optional. Authorized official(s) must also be listed in Section 6 of this form. Authorized officials and delegated officials must be reported in Section 6 of this application. Publish Date:6/28/2007 Charlie Charlie Brown John Doe, CEO Brown (246)810-1214 1/2/2007 1/2/2007 (Pages 32 and 33) Slide 44 Out of 58 Slide 45 Out of 58 15 3/13/2008 Publish Date:6/28/2007 Section 17: Supporting Documents Indicate in Section 17 what is attached to the application. Check the corresponding boxes for all information being attached to the application. Publish Date:6/28/2007 Attachment 1 – Ambulance Suppliers Pages 35–37 of Attachment 1 contains information on geographic location of services, state licensure information, paramedic intercept services and vehicle information. √ √ √ Don't forget: √ • Tax documents (IRS CP-575). √ • CMS-588 CMS 588 Electronic El t i Funds. F d √ • NPI notification. • Copies of any State licenses or certifications. • If applicable, copies of CLIA, √ • FDA and/or Diabetes Program √ certifications. • Copy of attestation for government and tribal organizations. (Page 34) Attachment 2: Independent Diagnostic Testing Facility (IDTF) IDTFs are to complete Pages 38–44. On Page 36, Paramedic intercept service is defined as a basic life support ambulance providing the transport, while advance life support paramedics from another ambulance supplier provides the personnel for the transport. You must check “Yes” or “No.” An IDTF is required to provide all codes that are allowed to be performed equipment and model performed, numbers. Information on an interpreting physician, technicians who perform tests and supervising physicians are required. Copy and complete Page 37 for each vehicle used by the ambulance company. Page 44 requires an original signature by the supervising physician. (Pages 35–37) Slide 46 Out of 58 Publish Date:6/28/2007 (Pages 38–44) Slide 47 Out of 58 Slide 48 Out of 58 16 3/13/2008 Publish Date:6/28/2007 Prescreening All applications are prescreened, including changes of information and reassignments, within 15 calendar days of receipt. Publish Date:6/28/2007 Prescreening – Missing Information If an application is received that contains at least one missing required data element, or the provider fails to submit all required supporting documentation: • TrailBlazer will send a letter to the provider (where appropriate the letter can be sent via e appropriate, e-mail mail or fax) fax), that documents and requests the missing information. • The letter must be sent to the provider within the 15-day prescreening period. • TrailBlazer is not required to make any additional requests for the missing data elements or documentation after the initial letter. Prescreening ensures providers submit all required supporting documentation and a complete enrollment application. This process applies to all applications. Slide 49 Out of 58 Slide 50 Out of 58 Publish Date:6/28/2007 Prescreening – Missing Information The provider must furnish all missing information within 60 calendar days of the request. If the provider fails to do so the application will be rejected. The provider will be notified by letter with the reasons for rejection and how to reapply. reapply If the provider wishes to reapply he will be required to begin a new process. Slide 51 Out of 58 17 3/13/2008 Publish Date:6/28/2007 Rejected vs. Returned Publish Date:6/28/2007 The difference between a rejected and returned application is that an application is rejected based on the provider's failure to respond to TrailBlazer's request for missing information or clarification. An application is subject to immediate return based on specific ifi criteria. it i All resubmissions b i i mustt contain t i a newly l signed i d and dated certification statement page. Slide 52 Out of 58 Criteria For Returned Applications No signature on application. Old version of application submitted. Copied or stamped signature. CMS-855I signed by someone other than individual practitioner applying for enrollment. Applicant failed to submit all forms needed to process a reassignment package package. Completed application in pencil. Wrong application submitted. Web-generated application submitted but does not appear to have been downloaded off CMS' Web site. Application not mailed (i.e., it was faxed or e-mailed). Application received more than 30days prior to the effective date listed on the application. (This does not apply to certified providers, ASCs or portable X-ray suppliers.) Provider submitted new enrollment application prior to expiration of time in which provider is entitled to appeal the denial of his previously submitted application. Submitted CMS-855 for sole purpose of enrolling in Medicaid. CMS-855 not needed for the transaction in question. CMS-588 sent in as a stand-alone change of information request (i.e., it was not accompanied by a CMS-855) but was 1) unsigned, 2) undated, or 3) contained copied, stamped or faxed signature. Slide 53 Out of 58 Publish Date:6/28/2007 Most Common Reasons for Delays TrailBlazer is allowed to reject for missing information. The top reasons for rejections that we see in our Provider Enrollment area are: • Missing NPI notification. • Missing g CMS-588 – Authorization Agreement g for Electronic Funds Transfer. • Failure to document the reason for application submittal. • "Change" was selected in 1A, but no indication was given of what was changing. • The effective date for the change, add or deletion was missing. • Application not signed or dated. • IRS tax identification or documentation not received. Slide 54 Out of 58 18 3/13/2008 Publish Date:6/28/2007 Application Processing Publish Date:6/28/2007 Reminders 1. Request and obtain an National Provider Identifier (NPI) before enrolling or making a change. Once it is determined that the application will not be returned, it goes through different phases of verification, validation, and then on to final processing. If additional information is needed during these phases of processing the application, you could receive a telephone call or a letter requesting the information. This phone call or letter will be directed to the person listed on this application as the contact person in Section 13 of the CMS-855B form. Slide 55 Out of 58 2. The CMS-855B application is not complete. A CMS-855B application must be completed by all organizations that will be billing Medicare carriers for medical services furnished to Medicare beneficiaries. This form must also be completed if a tax ID number has changed for an established organization. 3. CP575 not submitted. A CP575 must be submitted with the CMS-855I and the CMS-855B application anytime a tax ID number is used. The CP575 is the official letter from the IRS confirming the tax identification number with the legal business name. If the CP575 is not available, we will also accept a copy of the quarterly tax payment coupon or any official letter from the IRS that lists the legal business name and tax ID number. 4 Include all necessary supporting documentation. 4. documentation This supporting documentation includes professional licenses, business licenses, certifications, IRS form (CP575), the National Provider Identifier (NPI) notification and the 588 authorization form for Electronic Funds Transfer (EFT). Publish Date:6/28/2007 Congratulations, you have completed the CMS-855B enrollment form CBT. Prior to mailing the form, review the application to ensure all Items are completed, if appropriate, and copies of all Attachments are included. If you have any questions, contact Provider Enrollment for your area: 5. Complete the application in its entirety. Each section of the application should be completed. If a section does not apply, check the “not applicable” statement where appropriate and skip to the next section. • Texas and Indian Health facilities: (866) 528-1602. 6. Identify a contact person. Once your application has passed CMS prescreening guidelines, a provider enrollment analyst will conduct research and validation of the enrollment application. By identifying a contact person who is familiar with the application and who has access to the physician, practitioner or administrator, you can help our analyst obtain the necessary information and/or documentation in a timely manner. • Virginia: (866) 697-9670. 7. Sign and date the application. In accordance with CMS regulations, any unsigned CMS-855 applications will be returned to the applicant and any changes requested must include the effective date of the change. • DC/Delaware/Maryland: (866) 828-6254. Slide 56 Out of 58 Slide 57 Out of 58 19 3/13/2008 Publish Date:6/28/2007 Thank you for participating in this Computer--Based Training Computer Provider Enrollment and Provider Outreach & Education Slide 58 Out of 58 20