How do I change my address or update other provider enrollment information (e.g., practice name or change of ownership)?

I submitted an application to change my address. What should I do to check the status of my enrollment application?

What information should be in Section 4 of the CMS-855R form?

What is the provider’s legal business name that should appear on CMS-855 Medicare enrollment applications?

As an established provider with Medicare who receives paper checks, does an EFT Agreement need to be included when I submit a change to my provider enrollment file?

Who should sign the certification statement of the CMS-855 provider enrollment application?

What are the differences in completing Section 4 of a CMS 855I application for a sole proprietor versus a sole owner?

When do I need to complete a new CMS-855?

May an authorized official delegate their authority to sign CMS 855B applications?

What happens to my application if it is submitted and is found to be incomplete?

What is PECOS?

A. Address changes and provider file updates must be submitted on the proper CMS form, depending on the type of provider/supplier. A CMS 855I is required for an individual; a CMS 855B is required for an organization. For more information, refer to the Medicare Provider-Supplier Enrollment page on the Centers for Medicare & Medicaid Services (CMS) Web site. This page provides an overview of provider-supplier enrollment, as well as links to enrollment applications, DMEPOS accreditation, and enrollment demonstrations. Also refer to the Provider Enrollment section of this Web site.

Information on where to mail completed applications may be found in the Florida Medicare Mail Directory.

A: For all enrollment applications, contact the Part B Interactive Voice Response (IVR) unit for current status. This functional enhancement was added over the summer of 2008.

A: The following information is required:

Section 4A on page 5 is signed and dated by the person reassigning their benefits. Section 4B is signed and dated by the group’s authorized official or delegated official. If either signature is missing, FCSO will return the application.

If the individual terminates a reassignment, the individual signs and dates section 4A.

If the organization terminates a reassignment, the group’s authorized official or delegated official signs and dates Section 4B.

For terminations, both signatures are not required. However, if no signatures are present, FCSO will return the application.

The authorized or delegated official who signs section 4 must be currently on file with FCSO. All signatures must be original, preferably in blue ink. Faxed, stamped, or photocopied signatures cannot be accepted.

If the application is not signed and dated appropriately, the application will be returned. The application will need to be corrected and resubmitted. Any application resubmission must contain a brand new authorization page with proper signatures and dates. The provider cannot simply add its signature to the original authorization it submitted.

A: A provider’s legal business name is the name that is registered with the Internal Revenue Service (IRS) and should appear on IRS documents, such as the CP-575 that contains a provider’s Employee Identification Number (EIN) or Tax Identification Number (TIN).

The provider’s legal business name with the IRS should identically match (including any or no punctuation) the business name registered with the National Plan & Provider Enumeration System (NPPES), which issues the National Provider Identifier or NPI. This is the information that will be loaded into PECOS. PECOS and NPPES must match exactly.

Access the following Web site address or phone number to validate that the legal business name the IRS has for you matches the business name registered with NPPES: https://nppes.cms.hhs.gov/NPPES/Welcome.do ; 1-800-465-3203 or 1-800-692-2326 for TTY services.

A: Yes, unless you are reassigning all of your Medicare benefits to your employer or a clinic/group practice.

FCSO requires the Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588) form if you are submitting an initial Provider Enrollment Application or a change to an existing Medicare provider file that has not previously been set up for EFT.

As of December 1, 2006, FCSO can only accept the CMS-588 (08/06) version of the form. This form may be downloaded from the CMS Web site (http://www.cms.hhs.gov/cmsforms/downloads/CMS588.pdf ). The form must be complete, accurate, and include the original signature of the authorized/delegated official, as well as the signature date. Remember to include a copy of a voided check and/or a deposit slip. With the EFT authorization, Medicare can send payments directly to your financial institution whether claims are filed electronically or on paper.

Note: Please check with your bank for the proper number to report as the routing number on your EFT form. FCSO has determined that some banks may not use the routing number located at the bottom of your pre-printed check or deposit ticket for direct deposits but may use the automated clearing house (ACH) number located elsewhere on the check or deposit ticket.

An organization does not need to submit an EFT for each of its members, only for the legal entity.

A: The following shows the information for the various applications.

For initial enrollment and revalidation, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization’s status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.

The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.

The provider can have an unlimited number of authorized officials. However, each authorized official must be listed in section 6 of the CMS-855. Anyone listed as a “Contracted Managing Employee” in section 6 of the CMS-855 cannot be an authorized official.

The only person who may sign the CMS-855I is the individual practitioner, including solely-owned entities listed in section 4A. This applies to initial enrollments, changes of information, reactivations, etc. An individual practitioner may not delegate authority to any other person to sign the CMS-855I on his/her behalf.

The provider reassigning his/her benefits must sign section 4A of the CMS-855R, as there is no authorized or delegated official involved.

For initial reassignment, both the individual and the group’s authorized or delegated official must sign section 4. If either signature is missing, FCSO will return the application.

If terminating a reassignment, either party may sign section 4; both signatures are not required. If no signatures are present, FCSO will return the application.

The authorized or delegated official who signs section 4 must be currently on file with FCSO.

If the application is not signed and dated appropriately, the application will be returned. The application will need to be corrected and resubmitted. Any application resubmission must contain a brand new certification statement page containing a signature and date. The provider cannot simply add its signature to the original certification statement it submitted.

A: Sole Proprietorship - Section 4F of the CMS-855I is completed with the tax ID number. The instructions in this section state, “if you are a sole proprietor and you want Medicare payments reported under your EIN, list it below.” Only one NPI number is needed for the provider.

Sole Ownership - Section 4A of the CMS-855I is completed. If anything is listed in section 4A, a separate NPI number must be obtained for the group number that will be assigned. The individual’s NPI number and information must be listed in section 4C. The group’s NPI number will be listed in section 4A.

CMS recently made available a document that will assist physicians and non-physician practitioners in completing the CMS-855I form titled “Medicare Provider Enrollment of Individuals-Physicians and Non-Physician Practitioners” (http://www.cms.hhs.gov/Medicareprovidersupenroll/Downloads/EnrollmentNPI.pdf ). Scenarios 2a, 2b, 3 & 4 are very helpful in determining if you are a sole proprietor or sole owner.

A. You need to complete a new CMS-855 when:

A. An authorized official of an organization may delegate authority to make changes to enrollment information and to add physicians/practitioners. The organization must complete the section 16 of the CMS 855B and an authorized official must sign the certification statement. The delegated official must be an individual with an “ownership or control interest” in or be a W-2 managing employee of the supplier. These individuals must be reported in Section 6.

An individual physician or practitioner cannot delegate authority and must sign the certification statement of the CMS 855I.

A. When an incomplete application is submitted or is missing documents, the provider enrollment specialist will send a letter, send a fax or contact you by telephone outlining the missing information or attachment(s). For missing information on the CMS 855 application, the corrected sections of the application along with a new certification statement must be signed by an authorized official. This information can be faxed back to us since we have your original signature on file. If we are only missing supported documentation the provider does not need to submit a new certification. You are only required to fax us copies of the missing documentation (e.g., copy of your Internal Revenue Service (IRS) CP-575 form).

A. The Provider Enrollment Chain and Ownership System (PECOS) is a national database of Medicare provider, physician, and supplier enrollment information. PECOS is used to collect and maintain the data submitted on CMS 855 enrollment forms.