General New Enrollment Form Questions

Q. Why were the forms changed?
A. It's part of CMS' overall culture of improving service and of responding to concerns, particularly to their partners - the physicians, non-physician health care practitioners and other providers and suppliers who care for Medicare beneficiaries. With these changes to the forms and the process, CMS hopes to reduce the burden on their partners and shorten the time it takes them to enroll.

Q. How are the new forms and process better than before?
A. The new process provides for a quicker, more responsive contractor review cycle (a set 60 days). The revised forms reflect enhancements made after discussions with physicians and other health care providers and suppliers from around the country:

• They are provider-specific, rather than one size fits all.
• The instructions are side-by-side with the questions rather than appearing all at once at the beginning of the form.
• The forms are standardized with consistent categories across all forms.

Q. Where can I find written information and guidance on the provider enrollment forms and procedures?
A. Visit the CMS website at http://www.hcfa.gov/medicare/enrollment where you can obtain information on the enrollment forms and our manual instructions, as well as the name, address, and telephone number of the Medicare contractor with whom you plan to do business. Otherwise, I will gladly transfer you (or give you the telephone number of) our provider enrollment unit.

Q. What are the new forms, and what form should I fill out?
A. There are five new forms that replace the existing ones. They are:

• CMS 855A (for Health Care entities that will bill Medicare Fiscal Intermediaries)
• CMS 855B (for Health Care organizations, such as group practices, that will bill Medicare Carriers)
• CMS 855I (for Physicians and Individual Health Care Practitioners)
• CMS 855R (for individual Reassignment of Benefits)
• CMS 855S (for DMEPOS suppliers)

• a health care entity that bills a fiscal intermediary, they should complete the CMS 855A.
• a health care organization, such as a group practice, that bills a carrier, they should complete the CMS 855B.
• a physician or an individual non-physician practitioner, s/he should complete the CMS 855I.
• making a change in reassignment information, s/he should complete the CMS 855R.
• a DMEPOS supplier, they should complete the CMS 855S.

Q. If I am already enrolled in Medicare, do I need to complete a new enrollment form?
A. No. There is no need to complete a new form unless there is a change to your enrollment information. For example, if there has been a change in your "pay to" address or there has been a reassignment of benefits, a new form may be requested.

Q. How do I report changes in my enrollment information? Has the HCFA 855C (Change of Information) form been eliminated? If so, what form do I use to report a change of information?
A. The HCFA 855C has been eliminated. If you need to report a change of information, you must now use one of the five applicable enrollment forms. The specific form depends on your provider/supplier type. Be sure you sign and date the certification statement in Section 15 and return it along with the correct form.

(CSR's: ask the caller what is the provider/supplier type. Once known, follow these instructions):

If the caller is:

• a health care entity that bills a fiscal intermediary, changes should be made on the CMS 855A.
• a health care organization, such as a group practice, that bills a carrier, changes should be made on the CMS 855B.
• a physician or an individual non-physician practitioner, s/he should make changes on the CMS 855I.
• making a change in reassignment information, s/he should use the CMS 855R.
• a DMEPOS supplier, changes should be made on the CMS 855S.

Q. How can I obtain the new forms?
A. The forms (which became effective November 1, 2001) can be obtained in two ways:

• You can print or download the forms from the CMS website at http://www.hcfa.gov/medicare/enrollment/forms/
  OR
• We can mail you an enrollment package.

Q.I have filled out an old application but have not yet mailed it in. Can I still submit that form or do I have to start all over again with a new form?
A. You can submit the old form, but only until December 31, 2001. If we receive an old form after December 31, 2001, we will mail you the appropriate blank new form to fill out.

Q. How long will it take for me to receive a billing number?
A. For healthcare entities that will bill fiscal intermediaries:
In general, the process normally takes several months, since the fiscal intermediary must review your application, the State Agency must perform a survey of your operations, and then our Regional Office must approve or deny your request for enrollment. If you would like more details on this process, our provider enrollment staff will gladly assist you.

For individual practitioners, DMEPOS suppliers, and other health care suppliers that will bill carriers:
Assuming you meet all the necessary qualifications, you will generally receive your billing number in 60 days or sooner after you have submitted your application. Of course, it could take longer than 60 days in certain cases, particularly if the contractor needs to obtain more information from you. Bear in mind also that some "certified suppliers," such as ambulatory surgical centers and portable x-ray suppliers, may not receive their billing number for several months. This is because the contractor must review the application, the State Agency may have to perform a survey of the supplier's operations, and then our Regional Office must approve or deny the request for enrollment.

Q. How long does it take to complete the new form?
A. The current estimate of timeframes for completing the forms is not only for filling out the form. It also includes time required for gathering all related materials that must accompany the enrollment form.

• CMS 855A: 5-8 hours
• CMS 855B: 5-8 hours
• CMS 855I: 3-5 hours
• CMS 855R: 1 hour
• CMS 855S: 5-8 hours

Q. How do I make sure I have accurately completed the form?
A. If you are filling out the form by hand, be sure to follow the instructions carefully. The last section of each form provides you with a checklist of attachments that should accompany the application. Refer to this list to be sure you submit all required documentation. If you are completing the forms electronically, the edit check feature will help you complete the form accurately.

In either case, the contractor will let you know if your application is incomplete after its receipt and will specifically request from you whatever additional information is needed. Contact our provider enrollment staff with specific questions that arise as you are completing the form. Whether completing the form by hand or electronically, do not forget to sign and date the document before mailing it to us. If completing the application by hand, please remember to make a photocopy for your records.

Q. Are there any other forms I need to complete in addition to this one?
A. Depending on the form you are completing or your particular situation, the following additional forms must also be completed.

(NOTE TO CSR's: Use the chart below for reference):

Attachments	855 S	855 I	855 B	855 A	855 R
Copy(s) of all Federal State and/or local (city/county) professional licenses, certifications and/or registrations	X				N/A
Copy(s) of all Federal State and/or local (city/county) professional licenses, certifications and/or registrations specifically required to operate as a health care facility		X	X	X	N/A
Copy(s) of all Federal, State, and/or local (city/county) business licenses, certifications and/or registrations	X				N/A
Copy(s) of all Federal, State, and/or local (city/county) business licenses, certifications and/or registrations specifically required to operate as a health care facility		X	X	X	N/A
Copy(s) of all professional school degrees or certificates or evidence of qualifying course work		X	X		N/A
Copy(s) of all documentation verifying IDTF Supervisory Physician(s) proficiency			X		>N/A
Copy(s) of all CLIA Certificates, FDA Mammography Certificates, and Diabetes Education Certificates		X	X	X	N/A
Copy(s) of all controlled substance registration certificates from the Federal Drug Enforcement Agency		X			N/A
Copy(s) of all adverse legal action documentation (e.g., notifications, resolutions, and reinstatement letters)	X	X	X	X	N/A
Copy(s) of all sales agreements (CHOWS, Acquisitions/Mergers, and Consolidations only) (2 copies)				X	N/A
Copy(s) of all documents that demonstrate meeting capitalization requirements (HHAs only)				X	>N/A
Completed Form CMS 855R – Individual Reassignment of Benefits		X	X		N/A
Copy(s) of all State pharmacy licenses	X		X	X	N/A
Copy(s) of all surety bonds and/or Agent’s Power of Attorney	X			X	N/A
Copy(s) of all liability insurance policies	X				N/A
Copy(s) of all partnership agreements	X		X	X	N/A
Copy(s) of all articles of incorporation and/or corporate charters	X		X	X	N/A
IRS documents confirming the tax identification number and legal business name (e.g., CP 575)	X	X	X	X	N/A
Any additional documentation or letters of explanation as needed	X	X	X	X	N/A
Optional Attachments:
Copy(s) of all current signed electronic data interchange (EDI) agreements	X	X	X	X	N/A
Completed Form HCFA-588 - Authorization Agreement for Electronic Funds Transfer	X	X	X	X<
Completed Form HCFA-460 – Medicare Participating Physician or Supplier Agreement		X			N/A

PDF Questions

Q. What are PDF Forms?
A. PDF stands for Portable Document Format. The PDF versions are read-only and can only be used to print out a hard copy form that will be completed manually. You cannot complete the PDF form using your computer.

Q. How do I print the provider enrollment forms from the CMS website?
A. The PDF forms can be printed without having to download them to your computer. To do this, follow these steps:

• Launch your internet browser then proceed to the CMS provider enrollment website (www.hcfa.gov/medicare/enrollment)
• Select "Application Forms and Instructions"
• Click on the form you wish to print. (When selected, Adobe Acrobat will automatically launch and open the document in the browser window.)

Q. How do I download the PDF forms to my computer?
A. Follow these steps:

• Launch your internet browser then proceed to the CMS provider enrollment website (www.hcfa.gov/medicare/enrollment)
• Select "Application Forms and Instructions"
• Right click on the name of the document you wish to download
• Choose "save target as"
• A window will appear titled "save as"
• Click on the pull-down window next to the 'save in' prompt, and select your desired location
• Make note of the name of the file (e.g., 855-rea.pdf) and select 'save'.

Q. How long does it take to download the PDF files?
A. The time to download the files depends on a number of factors including your connection speed (whether you are using a dial-up modem, cable modem, T-1 line, etc.), your operating system, and the amount of traffic on the Internet at the time of your download.

The file sizes are not large. The download time should therefore be minimal. Below are approximate times for downloading via a 56K modem:

CMS 855A 1.2 MB (Megabytes) 3 min. 45 sec.

CMS 855B 1.4 MB (Megabytes) 2 min. 54 sec.

CMS 855I 800 KB (Kilobytes) 2 min. 15 sec.

CMS 855R 300 KB (Kilobytes) 49 sec.

CMS 855S 900 KB (Kilobytes) 2 min. 30 sec.

Q. What software do I need to complete the PDF forms?
A. If you are completing the PDF forms, you will need Adobe Acrobat Reader. This software will enable you to read and print the forms. The PDF versions are read-only and are available for print to hard copy. You must first print the PDF forms in order to fill them out, then sign and date them before mailing.

Q. I don't have Adobe Acrobat Reader. What do I do?
A. Adobe Acrobat is available through the CMS provider enrollment website. At the top of the application forms and instructions page (located at http://www.hcfa.gov/medicare/enrollment/forms/), there is a link where you can check to see if Acrobat Reader is installed on your computer. Click on that link and follow the prompts. If you know you do not have the program, CMS has provided a link to a site where you can download the software for free.

Q. Can I submit the completed PDF form electronically?
A. No. The PDF forms cannot be submitted electronically. The PDF versions are read-only and can only be used to print out a hard copy form that will be completed manually. You cannot complete the PDF form using your computer.

Q. Are the PDF files the electronic forms I've heard about?
A. The PDF files are not the electronic forms. You cannot complete the PDF form using your computer. The advantage of the electronic forms is that they will provide real-time edit checks and instructions for completion. They cannot be submitted electronically.