CMS-855S 2016 free printable template

MEDICARE ENROLLMENT APPLICATION Durable Medical Equipment Prosthetics Orthotics and Supplies DMEPOS Suppliers CMS-855S SEE PAGE 1 FOR A LIST OF THE DMEPOS SUPPLIER STANDARDS. TO ENROLL IN THE MEDICARE PROGRAM AND BE ELIGIBLE TO SUBMIT CLAIMS AND RECEIVE PAYMENTS EVERY DMEPOS SUPPLIER APPLICANT MUST MEET AND MAINTAIN THESE ENROLLMENT STANDARDS. SEE PAGE 2 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION. SEE PAGE 4 FOR INFORMATION ON WHERE TO MAIL THIS APPLICATION. SEE SECTION 12 FOR...

How to fill out cms 855s application form

How to fill out CMS-855S

1. Obtain the CMS-855S application form from the CMS website or your local Medicare Administrative Contractor (MAC).
2. Complete the applicant's information section, including legal business name, Medicare number, and tax identification number.
3. Fill out the practice location details, including address, phone number, and any other relevant contact information.
4. Provide information about the ownership of the practice, including names and addresses of owners or managing employees.
5. Include details regarding services provided and any relevant credentials or certifications.
6. Answer any questions related to previous enrollment or disciplinary actions.
7. Review the application for accuracy and completeness, ensuring that all required fields are filled out.
8. Sign the application to certify accuracy of information and submit the form as instructed.

Who needs CMS-855S?

1. Health care providers or suppliers who wish to enroll in the Medicare program.
2. Providers who are updating their existing enrollment information.
3. Professionals providing specific services such as imaging, diagnostic, or non-physician practitioners.

Video instructions and help with filling out and completing form cms 855

Instructions and Help about cms 855 application

Music Hello and welcome to one of our many PECOS demonstrations. In this demonstration, we will be walking you through the process of submitting an application in PECOS if you were a practitioner providing healthcare services and work in a group setting like a private practice or a hospital. In order to begin this application, we'll have to log in to the PECOS homepage. To obtain your login credentials and find other helpful information regarding Medicare and the application process, please visit the PECOS homepage. Please note that if you are a practitioner working in the setting other than what we've just described or have some other business arrangement, these steps for beginning your application are identical to what we'll be showing here, and the process of enrolling will have many of the same screens shown in this demonstration. After logging in, you'll need to select this My Enrollments button here first. And because we're now creating a new application for the practitioner Jenny Lewis you'll want to select this New Application button here. After doing this, you will be prompted to answer a series of questions to help personalize the application to your specific scenario. You'll first need to indicate who the application is being created for. So here you'll select yourself and select the Next Page button to continue. On this screen, you're being prompted to enter whether you, as the practitioner solely order and refer services. So for the purpose of this demonstration, I'm going to select now and continue. On this screen, you will be selecting the business setting in which you work. Because this demonstration is for a provider working in a group setting, we'll be selecting the group member only field shown here. I'll go ahead and scroll down and select the Next Page button to continue. Here, you're identifying information will be displayed to you as a label, so you can go ahead and select the Next Page button now. You'll then need to indicate the state where healthcare services are rendered. So for this example, the practitioner works and provides services in Arizona, so that's what we'll select and then move on by clicking the Next Page button at the bottom of the screen. And here you'll indicate your physician or non-physician specialty type. So in this example, Jenny Lewis practices internal medicine, so we'll select that from the drop-down and then move forward with the Next Page button at the bottom of the screen. You'll then be brought to a page which simply serves to inform you that the provider group you work for must already be enrolled in Medicare. So please ensure that this is the case before continuing your application. And if you'd like to continue, you'll just select this Yes option here and move forward. Finally, we've completed the initial set of questions for this enrollment, and you can then verify at the top of the screen that the information presented here is correct for your situation. In this example, the...

People Also Ask about 855s form

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.

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

Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change in their enrollment information using either: The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or • The paper CMS-855I enrollment application.

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).

What is an 855 in healthcare?

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 a CMS 855s form?

CMS 855S. Form Title. Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers.

What is CMS 855I used for?

When to complete a CMS-855I. CMS-855I is to be used by Physicians and non-physician practitioners (including clinical psychologists) -- Complete this application if you are an individual practitioner who plans to bill Medicare and you are: An individual practitioner who will provide services in a private setting.

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What is CMS-855S?

CMS-855S is a form used by healthcare providers to enroll or update their enrollment information in the Medicare program as a supplier of durable medical equipment (DME), prosthetics, orthotics, or supplies.

Who is required to file CMS-855S?

Healthcare suppliers who provide DME, prosthetics, orthotics, or supplies to Medicare beneficiaries are required to file CMS-855S. This includes companies and individuals that wish to enroll in Medicare as DME suppliers.

How to fill out CMS-855S?

To fill out CMS-855S, applicants must complete the required sections of the form which include basic identification information, ownership details, and compliance with Medicare requirements. It is important to provide accurate and complete information and to review the form thoroughly before submission.

What is the purpose of CMS-855S?

The purpose of CMS-855S is to collect necessary information from healthcare suppliers to establish their eligibility to participate in the Medicare program and ensure compliance with Medicare regulations.

What information must be reported on CMS-855S?

CMS-855S requires reporting of information such as the supplier's legal business name, tax identification number, contact information, ownership details, and any previous Medicare enrollment history. Additionally, it may ask for information regarding compliance with Medicare policies.