Reminder – Updated CMS-855I and CMS-855B Enrollment Applications

Reminder – Updated CMS-855I and CMS-855B Enrollment Applications

(6/11/2010)

CMS has revised the CMS-855I Enrollment Application for Solo Providers and the CMS-855B Enrollment Application for Groups and Organizations. The revised forms contain “(02/08) (EF 07/09)” in the footer of the application pages. Effective December 1, 2009, only the “(02/2008) (EF 07/09)” version of the CMS-855I and CMS-855B applications will be accepted. If an outdated version is submitted on or after December 1, 2009, it will be returned to the provider.

Note: Providers should make sure the “CMS-855I (02/08) (EF 07/09)” footer information is included in the printed version of any CMS-855I or CMS-855B form. If the footer is missing, we will be unable to process the application. Providers may download the latest version of Adobe Reader at http://get.adobe.com/reader/

CMS has released Special Edition (SE) article SE 0924, which outlines the significant revisions to the CMS-855I and CMS-855B enrollment applications. Providers should review the “Key Points” section of the article for detailed information. The article, titled “Announcing the Release of the Revised CMS-855 Medicare Enrollment Applications,” is available on the CMS MLN Matters Web page. 

Revisions to the CMS-855I include:  

  • Incorporated conforming regulatory changes throughout the application.
  • Added “Speech-Language Pathologist” to pages 1 and 9.
  • Changed the term “adverse legal action” to “final adverse action” throughout the document.
  • Removed the reference to the Healthcare Integrity and Protection Data Bank from page 12.
  • Clarified that “individual (type 1) NPI” should be provided on page 4.
  • Removed the paragraph on page 8 that makes reference to “Diagnostic Radiology.”
  • Revised and clarified item 2 on the certification statement (page 25).
  • Added the phrase “(blue preferred)” after “All signatures must be original and signed in ink” on page 26.
  • Supporting documentation section has been revised to limit the amount of supporting documentation required. 

Revisions to the CMS-855B include:   

  • Incorporated conforming regulatory changes throughout the application.
  • Removed “Slide Preparation Facility” from pages 1 and 9.
  • Removed “Public Health/Welfare Agency” from page 9.
  • Removed the sentence “If you are a single specialty clinic/group practice, the specialty must be reported” from page 9.
  • Changed the term “adverse legal action” to “final adverse action” throughout the document.
  • Removed the reference to the Healthcare Integrity and Protection Data Bank from page 11.
  • Revised and clarified item 1 on the certification statement (page 30).
  • Added the phrase “(blue preferred)” after “All signatures must be original and signed in ink” on pages 31–33 and 46.
  • Removed language on page 43 referring to Independent Diagnostic Testing Facility (IDTF) personnel.
  • Supporting documentation section has been revised to limit the amount of supporting documentation required. 

Applications submitted on the older 02/08 version will be accepted until November 30, 2009.

These changes will also be incorporated into the Internet-Based Provider Enrollment, Chain and Ownership System (PECOS).  

(CMS Joint Signature Memorandum (JSM) 09386, dated August 10, 2009, and JSM 09421, dated September 9, 2009)

Provider Enrollment Q&A

For more information on avoiding application rejections or general information on the completion of the CMS-855 applications, please visit the  TrailBlazer Health Enterprises Web site or call their Customer Service line at (866) 528-1602.


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