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 If an outdated version is submitted on or after December 1, 2009, it will be returned to the provider.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)
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