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This document serves to collect information from organizations seeking to enroll as healthcare suppliers under Medicare, including their qualifications and service details.

How to fill out medicare enrollment application for

How to fill out Medicare Enrollment Application for Clinics/Group Practice and Certain Other Suppliers

1. Begin by obtaining the Medicare Enrollment Application Form from the CMS website or local Medicare office.
2. Fill out the provider type. Choose 'Clinic/Group Practice' or 'Certain Other Suppliers' as applicable.
3. Provide the legal business name of the clinic/group practice as well as any doing business as (DBA) names.
4. Complete the ownership information, including the names and identifiers of all owners and managing employees.
5. Fill out the business address, mailing address, and phone number.
6. Provide the clinical services offered or specialty of the practice.
7. If applicable, include information about any prior Medicare enrollment or billing history.
8. Sign and date the application where indicated, confirming the information is accurate.
9. Submit the application through the appropriate channel, either by mail or online, as instructed.

Who needs Medicare Enrollment Application for Clinics/Group Practice and Certain Other Suppliers?

1. Clinics and group practices that wish to provide covered services to Medicare beneficiaries.
2. Certain other suppliers who need to enroll to bill Medicare for their services.
3. Health care providers who operate in a group setting and want to participate in the Medicare program.

People Also Ask about

What is the difference between 855I and 855B?

The difference between enrolling a practice using an 855I and 855B is the reporting of ownership information. When one individual owns the whole practice, Medicare can utilize the 855I to verify that the owner meets Medicare requirements.

What is Medicare 855b?

What is the 855B? ❖ The CMS form used for the enrollment of Clinic/Group practices and Certain Other Suppliers. This form is also used to submit changes to your enrollment data.

Who is the CMS Form 855I the enrollment application for?

All physicians, as well as all eligible professionals as defined in section 1848(k)(3)(B) of the Social Security Act must complete this application to enroll in the Medicare program and receive a Medicare billing number.

What is a Medicare participating supplier?

Participating providers accept Medicare and always take assignment. Taking assignment means that the provider accepts Medicare's approved amount for health care services as full payment. These providers are required to submit a bill (file a claim) to Medicare for care you receive.

What is the Medicare 855i form for?

All physicians, as well as all eligible professionals as defined in section 1848(k)(3)(B) of the Social Security Act must complete this application to enroll in the Medicare program and receive a Medicare billing number.

What is the difference between Medicare A and B?

By CPT definition, a new patient is “one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.” By contrast, an established patient has received professional services from the physician or

For pdfFiller’s FAQs

What is Medicare Enrollment Application for Clinics/Group Practice and Certain Other Suppliers?

The Medicare Enrollment Application for Clinics/Group Practice and Certain Other Suppliers is a form that healthcare providers, specifically clinics, group practices, and certain other suppliers, must complete to enroll in the Medicare program. This application ensures that the providers meet the necessary standards and requirements to participate in Medicare.

Who is required to file Medicare Enrollment Application for Clinics/Group Practice and Certain Other Suppliers?

Clinics, group practices, and certain other healthcare suppliers that wish to provide services under the Medicare program are required to file the Medicare Enrollment Application. This includes organizations that deliver services such as outpatient care, physical therapy, and diagnostic testing.

How to fill out Medicare Enrollment Application for Clinics/Group Practice and Certain Other Suppliers?

To fill out the Medicare Enrollment Application, providers must complete the designated application form (typically the CMS-855A) accurately. This includes providing information about the practice structure, services offered, ownership, and compliance with Medicare regulations. Detailed instructions are provided with the form to assist applicants.

What is the purpose of Medicare Enrollment Application for Clinics/Group Practice and Certain Other Suppliers?

The purpose of the Medicare Enrollment Application is to ensure that clinics, group practices, and certain suppliers meet the Medicare program's eligibility and compliance requirements. It allows Medicare to evaluate the provider's qualifications and determine their ability to deliver care reimbursable under the program.

What information must be reported on Medicare Enrollment Application for Clinics/Group Practice and Certain Other Suppliers?

The application must report information such as the legal business name, practice location, ownership details, affiliated staff credentials, services provided, and any criminal history of the owners or key personnel. Accurate financial information and prior Medicare enrollment history are also necessary.