CMS-855B 2020 free printable template

MEDICARE ENROLLMENT APPLICATION Clinics/Group Practices and Other SuppliersCMS855B SEE PAGE 12 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION. SEE PAGE 3 FOR INFORMATION ON WHERE TO MAIL

How to fill out CMS-855B

How to fill out CMS-855B

1. Obtain the CMS-855B form from the CMS website or your local Medicare Administrative Contractor (MAC).
2. Fill in the provider's legal name as it appears on the relevant documents.
3. Provide the provider's Social Security Number (SSN) or Employer Identification Number (EIN).
4. Enter the provider's contact information including phone number and email address.
5. Indicate the type of enrollment being requested (new, change of information, etc.).
6. Complete the section on practice location(s) by providing the address and other required details.
7. Specify the applicable Medicare program(s) involved and any specialty designations.
8. Include information about any prior Medicare enrollment history or current status.
9. Review the form for accuracy and completeness.
10. Sign and date the application before submission to the designated address.

Who needs CMS-855B?

1. Healthcare providers looking to enroll in the Medicare program or make changes to their existing enrollment.
2. Organizations that bill Medicare for services rendered by their staff or affiliate providers.
3. Suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) seeking enrollment.

• Who needs the CMS Form 885B?
• What is the CMS Form 885B for?
• Is the Medicare Enrollment Application CMS-885B accompanied by any other forms?
• • How to fill out the CMS-885B Form?
  • Where do I send the completed CMS-885B Application Form?

Who needs the CMS Form 885B?

The 885B form is the Centers for Medicare and Medicaid Services (CMS) form also known as the Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers. There is a list of suppliers that are supposed to file the CMS-885B in order to commence the process of enrollment. These suppliers are:

• Ambulance Service Supplier

• Ambulatory Surgical Center

• Clinic/Group Practice

• Independent Clinical Laboratory

• Independent Diagnostic Testing Facility

• Intensive Cardiac Rehabilitation Supplier

• Mammography Center

• Mass Immunization

• Part B Drug Vendor

• Portable X-ray Supplier

• Radiation Therapy Center

What is the CMS Form 885B for?

The CMS Form 885B has been specifically designed for specific types of suppliers to enable them to apply for enrollment in the Medicare program or to update or amend their previously indicated information.  

Is the Medicare Enrollment Application CMS-885B accompanied by any other forms?

The Enrollment Application requires a list of supporting forms and may not be filed as a single document. All the mandatory attachments to the CMS-885B form are clearly defined on page 36 of the fillable application form itself.

However, here are the two commonly attached documents:

1. Form CMS-588 (Electronic Funds Transfer Authorization Agreement)

2. CMS Form 460 (Medicare Participating Physician or Supplier Agreement)

How to fill out the CMS-885B Form?

The voluminous 49-page form contains 17 sections and 2 attachments to fill out. Broadly put, the form requests basic identifying information, practice location, ownership interest, billing agency information, certification statement, etc.

Where do I send the completed CMS-885B Application Form?

Having completed the form and all the required attachments, the applicant should deliver them to the Medicare fee-for-service contractor operating in the relevant geographic location.

 

People Also Ask about

What is a CMS 855A?

What is the 855A? ❖ The Medicare Enrollment Application for Institutional Providers. ❖ This form is also used to submit changes to your enrollment data.

What is one reason why a provider would complete a CMS 855B form?

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.

What is CMS 855B used for?

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.

What type of provider would use the CMS 855A?

If you submit a paper application, your MAC processes your approved Medicare enrollment and creates a PECOS record. Medicare Enrollment Application: Institutional Providers (CMS-855A): Institutional providers use this form to begin the Medicare enrollment or revalidation process or change enrollment information.

What is Medicare Form 855B?

What is Medicare CMS-855B? The Medicare CMS-855B application is completed for Diabetic Education and Mass Immunization. This application is submitted to your states Medicare Fee-for-Service Provider and can take up to 3 months to be processed.

What is the difference between CMS 855B and 855s?

The 855b is used for Diabetic Education and Mass Immunization while the 855s is for Durable Medical Equipment and non-accredited drugs. What is the difference between 855b and 855s? Medicare requires a $50,000 surety bond from an authorized surety company as required in 42 C.F.R. section 424.57(d).

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What is CMS-855B?

CMS-855B is a form used by providers to enroll or update their enrollment information in the Medicare program, specifically for organizations and entities.

Who is required to file CMS-855B?

Organizations that provide Medicare services, including group practices, clinics, and certain types of medical suppliers, are required to file CMS-855B.

How to fill out CMS-855B?

To fill out CMS-855B, providers must complete sections detailing their organization’s information, ownership, and management structure, as well as any relevant practice locations and services provided.

What is the purpose of CMS-855B?

The purpose of CMS-855B is to collect necessary information from providers to ensure they meet Medicare enrollment requirements and to update enrollment data as needed.

What information must be reported on CMS-855B?

The CMS-855B requires reporting information such as the organization’s name, address, phone number, taxonomy codes, ownership details, and any locations where services are provided.