General Overview of Medicare Enrollment Application Forms

10.1.4 - General Overview of Medicare Enrollment Application Forms (Rev. 12639; Issued: 05-16-24; Effective: 06-17-24; Implementation: 06-17-24) The enrollment applications are available online as well as in paper form: A. General Overview of Form CMS-855 and CMS-20134 Each Form CMS-855 application is used to enroll a specific provider or supplier type for a specific purpose. 1. CMS-855A – Medicare Enrollment Application for Institutional Providers This application should be completed by institutional providers (e.g., hospitals) that will furnish Medicare Part A services to beneficiaries. 2. CMS-855B –Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers This application should be completed by supplier organizations (e.g., ambulance companies) that will bill Medicare for Part B services furnished to Medicare beneficiaries. It is not used to enroll individuals. 3. CMS-855I - Medicare Enrollment Application for Physicians and Non-Physician Practitioners This application should be completed by physicians and non-physician practitioners who render Medicare Part B services to beneficiaries. (This includes a physician or practitioner who is: (1) the sole owner of a professional corporation, professional association, or limited liability company and will bill Medicare through this business entity; or (2) a sole proprietor.) (See section 10.6.4 of this chapter for more information on the business types discussed in this paragraph.) The CMS-855I captures reassignment information that was previously collected via the CMS-855R, which has been discontinued. 4. CMS-855S – Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers This application should be completed by DMEPOS suppliers. 5. CMS-855O – Medicare Enrollment Application for Eligible Ordering, Certifying Physicians, and other Eligible Professionals This form is used for physicians and other eligible professionals who wish to register in Medicare solely for the purpose of ordering and certifying the items and services described in 42 CFR § 424.507. These physicians and other eligible professionals do not and will not send claims to a MAC for any services they furnish. 6. CMS-20134 – Medicare Enrollment Application for Medicare Diabetes Prevention Program (MDPP) Suppliers This application should be completed by any supplier organizations that will furnish and bill Medicare Part B for the MDPP services furnished to Medicare beneficiaries. B. General Overview of Additional Enrollment Forms The following forms or form types are routinely submitted with an enrollment application: 1. CMS-588 – Electronic Funds Transfer (EFT) Authorization Agreement The EFT Agreement authorizes CMS to deposit Medicare payments directly into a provider/supplier’s bank account. For Form CMS-855S enrollments, CMS only requires collection of the Form CMS-588 with initial enrollment applications. 2. CMS-460 – Medicare Participating Physician or Supplier Agreement This agreement establishes that the Medicare provider/supplier accepts assignment of the Medicare Part B payment for all services for which the participant is eligible to accept assignment under the Medicare law and regulations and which are furnished while the agreement is in effect. The contractor shall explain to the provider or supplier the purpose of the agreement and how it differs from the actual enrollment process. (This only applies to suppliers that complete the Forms CMS-855B, CMS-855I and CMS-855S.) 3. CMS Standard Electronic Data Interchange (EDI) Enrollment Form See CMS Publication 100-04, Medicare Claims Processing Manual, chapter 24, sections 30 - 30.5 for further information. 4. State-Specific Forms for Certified Providers/Certified Suppliers If the applicant is a certified supplier or certified provider, it will need to contact the state agency for any state-specific forms and to begin preparations for a state survey. (This does not apply to those certified entities, such as federally qualified health centers, that do not receive a state survey.)