TrailBlazer Health Enterprises

Education Makes the Difference

How to Complete the Paper CMS-855I Enrollment Application

Provider Outreach and Education

Published November 2011 96672 2011 TrailBlazer Health Enterprises/TrailBlazer. All rights reserved.

Important
The information contained in this presentation was current as of October 2011. Provider Enrollment information can be found on the TrailBlazer Provider Enrollment Web page at: http://www.trailblazerhealth.com/Provider Enrollment/Default.aspx

Slide 2

CMS-855I Enrollment Application

This presentation was developed by the Provider Outreach and Education department, along with the Provider Enrollment department, to assist new providers in correctly completing the CMS-855I enrollment application.
The following slides will denote the page number from the 855 application. 3 Slide

Obtaining the CMS-855I Application

The current version of the CMS-855I application should be used. The application will be used as a guide throughout this job aid. Please take a moment to print the application. The current version of this form can be obtained from the following CMS Web site at: http://www.cms.gov/CMSforms/downloads/cms 855I.pdf. A quick link to the form on the CMS Web site can also be found on the TrailBlazer Web site at: http://www.trailblazerhealth.com/Provider Enrollment/PartBGettingStarted.aspx. Note: The current version has (07/11) in the footer of the form. Effective January 1, 2012, only the 07/11 version of the CMS-855I application will be accepted. Slide 4

Internet-Based PECOS
When enrolling, providers have the option of using:
Internet-based Provider Enrollment, Chain and Ownership System (PECOS). Or, Standard 855 paper enrollment.

Using Internet-based PECOS is easy! Internet-based PECOS allows physicians and non-physicians to enroll, make changes in their enrollment, or view their Medicare enrollment information. Internetbased PECOS has the following benefits:
Faster than paper-based enrollment. Scenario-driven application process. Built-in help screens.

Additional information about Internet-based PECOS can be located at: http://www.cms.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp

Slide 5

CMS-855I Enrollment Application

The CMS-855I form is for:
All physicians. Non-physician practitioners, including:

Anesthesiology assistant. Audiologist. Certified nurse midwife. Certified registered nurse anesthetist. Clinical nurse specialist. Clinical social worker. Mass immunization roster biller. Nurse practitioner. Occupational therapist in private practice. Physical therapist in private practice. Physician assistant. Psychologist, clinical. Psychologist billing independently. Registered dietitian or nutrition professional. Speech-language pathologist. Slide 6

Who Should Submit This Application

This section assists in determining whether the 855I is the correct application for the type of provider. Use the Who Should Submit This Application section to determine the types of providers who should complete the 855I.
Page 1

Slide 7

Who Should Submit This Application (Cont.)

Complete the 855I application if you are an individual practitioner who plans to bill Medicare and you are:
An individual practitioner who will provide services in a private setting. An individual practitioner who will provide services in a group setting. If you plan to render all of your services in a group setting, you will complete Sections 14 and skip to Sections 1417 of this application. Currently enrolled with a Medicare Fee-for-Service (FFS) contractor but need to enroll in another FFS contractors jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another Medicare FFS contractor).
Slide 8

Who Should Submit This Application (Cont.)

Complete the 855I application if you are an individual practitioner who plans to bill Medicare and you are:
Currently enrolled in Medicare and need to make changes to your enrollment information (e.g., you have added or changed a practice location). An individual who has formed a professional corporation, professional association, limited liability company, etc., of which you are the sole owner. Note: If you provide services in a group/organization setting, you will also need to complete a separate application, the CMS-855R, to reassign your benefits to each organization. If you terminate your association with an organization, use the CMS-855R to submit that change.
Slide 9

Instructions for Completing and Submitting the 855I Application

Type or print all information so it is legible. Do not use pencil. Report additional information within a section by copying and completing that section for each individual entry. Attach all required supporting documentation. Keep a copy of the completed Medicare enrollment package for the office records. Send completed applications with original signatures and all required documentation to the designated Medicare FFS contractor.

Slide 10

Billing Number Information

Providers must first obtain a National Provider Identifier (NPI) before enrolling in Medicare. An NPI number can be obtained from the CMS Web site at: https://nppes.cms.hhs.gov/. The NPI number is required for enrollment.

Page 2

Slide 11

Section 1: Basic Information

Complete in blue or black ink. Do not use pencil. Section 1A This section captures information about why the application is being completed. If you are a physician assistant, furnish your individual NPI on the first line. If you are reassigning all of your benefits to a group organization, furnish your individual NPI on the second line. If you are a new enrollee, find the section that applies to new enrollees. Only one reason per application should be checked.
Page 3

Slide 12

Section 1: Basic Information (Cont.)

Section 1A (Cont.) Check this box if enrolling in another FFS contractors jurisdiction. Example: Provider has moved from one contractor jurisdiction to another. Complete all sections.

Page 3

Slide 13

Section 1: Basic Information (Cont.)

Section 1A (Cont.) Example: To change an existing provider profile, select change and go to Section 1B to indicate the type of change needed. Section 1B will indicate the required sections of the application you must complete. Only one reason per application should be checked for Section 1A.

Page 3

Slide 14

Section 1: Basic Information (Cont.)

Section 1B New enrollees will not complete this section. If you are making changes to an existing profile, mark the type of change needed and refer to the required sections (column to the right in the table) for further instructions. The additional instructions will help prevent missing information when submitting changes or updates.

Page 4

Slide 15

Section 1: Basic Information (Cont.)

Section 1B New enrollees will not complete this section. Identifying Information Selecting this category will allow changes to be made to: Personal information. Medical specialties. Correspondence address. If this category is selected, continue to Sections 1, 2, 3, 13 and 15.

Page 4

Slide 16

Section 1: Basic Information (Cont.)

Section 1B (Cont.) New enrollees will not complete this section. Final Adverse Legal Actions/ Convictions Selecting this category will allow changes to be made to: Business information. Adverse legal actions. If this category is selected, continue to Sections 1, 2A, 3, 13 and 15.

Page 4

Slide 17

Section 1: Basic Information (Cont.)

Section 1B (Cont.) New enrollees will not complete this section. Practice Location Information, Payment Address and Medical Record Storage Information If this category is selected, continue to Sections 1, 2A, 3, 4, 13 and 15.

Page 4

Slide 18

Section 1: Basic Information (Cont.)

Section 1B (Cont.) New enrollees will not complete this section. Individuals Having Managing Control This section captures information about all managing employees. If this category is selected, Sections 1, 2A, 3, 6, 13 and 15 must be completed.

Page 4

Slide 19

Section 1: Basic Information (Cont.)

Section 1B (Cont.) New enrollees will not complete this section. Billing Agency Information A company or individual with whom you contract to prepare and submit the claims. If this category is selected, Sections 1, 2A, 3, 8, 13 and 15 must be completed.

Page 4

Slide 20

Section 2: Identifying Information

Section 2A
This section is for personal information and should be completed in its entirety. List the name as it appears with the Social Security Administration (SSA). If the provider has recently had a name change, the name must be updated with the SSA before Medicare can enroll or update the providers record. The Social Security Number (SSN) must be included in this section. Include copies of all licenses and/or certifications.
Page 5

Slide 21

Section 2: Identifying Information (Cont.)

Section 2B The correspondence address is where the applicant in 2A can be contacted. The address cannot be a billing agencys address or the providers representative.

Page 5

Slide 22

Section 2: Identifying Information (Cont.)

Section 2C Physicians are required to complete this section. If the provider is not a resident or in a fellowship program, check No for questions 1a and 1b and skip to Section 2D. If either question 1a or 1b is answered Yes, questions 2, 3 and 4 must be completed. The date of completion in question 2 must be furnished.
Page 6

Slide 23

Section 2: Identifying Information (Cont.)

Section 2D.1 Designate the primary and all secondary specialties. Enter a P for primary in the box next to the specialty. If there is a secondary specialty, enter an S in the box next to the secondary specialty. List only one primary specialty. Multiple secondary specialties can be listed if applicable.

S Page 7

Slide 24

Section 2: Identifying Information (Cont.)

Section 2D.2 This section is for non-physician practitioners only. Check the appropriate box to indicate your specialty. Note: Only one can be selected. Please see application instructions for non-physician practitioners.

Page 8

Slide 25

Section 2: Identifying Information (Cont.)

Section 2EG These sections establish the employment arrangement or terminate employment for a physician assistant. Please see application instructions for non-physician practitioner.

Page 9

Slide 26

Section 2: Identifying Information (Cont.)

Section 2HK These sections are completed if applicable to the providers specific specialty. Leave this page blank if not applicable to the providers specific specialty. Requirements for these types of specialists may be found at: http://www.trailblazerhealth.com/Pu blications/Manuals.

Page 10

Slide 27

Section 2: Advanced Diagnostic Imaging (ADI) Suppliers Only

Section L This section must be completed by all individual practitioners who also furnish and will bill Medicare for ADI services. Leave this page blank if not applicable to the providers specific specialty.

Page 11

Slide 28

Section 3: Adverse Legal Actions/Convictions

Section 3 For all past or present legal convictions, exclusions, revocations and suspensions, regardless of whether the record has been expunged or an appeal is pending. A list of reportable items is provided on page 12.

Page 12

Slide 29

Section 3: Adverse Legal Actions/Convictions (Cont.)

Section 3 (Cont.) Providers must answer question 1. If the answer is Yes to question 1, providers must complete question 2. Failure to supply this information could result in the Medicare provider number(s) not being issued to new providers.

Page 13

Slide 30

Section 4: Practice Location Information

Section 4A

Providers reassigning benefits to a group will skip Section 4A. Complete only if the provider is the sole owner of a professional corporation, professional association, or a limited liability company and enrolling using an Employer Identification Number (EIN). Example: John Q. Public, MDPA. A tax document from the Internal Revenue Service (IRS) (CP-575, tax coupon or letter from the IRS) showing this as the providers legal business name must be submitted with the application. Question 1 must be answered. If the answer to question 1 is Yes, complete question 2. After completing this section, skip to Section 4C and complete the information about the business entity.
Page 14

Slide 31

Section 4: Practice Location Information (Cont.)

Section 4A (Cont.)
Providers reassigning benefits to a group will skip Section 4A and complete Section 4B. Section 4B identifies the groups/ organizations to which the providers will reassign benefits. Section 4A is not needed for a change to an existing profile.

Example: If the provider is resigning from a solo practice or reassigning benefits to a solo group (sole owner), an application for termination of the solo provider number would be required, and then an initial enrollment application for the entity would follow. This is not considered a change.
Page 14

Slide 32

Section 4: Practice Location Information (Cont.)

Section 4B This section identifies the groups/organizations to which the providers will reassign benefits.

Page 14

Slide 33

Section 4: Practice Location Information (Cont.)

Section 4B Example Situation 1 Providers reassigning all of their payments to another group or organization will complete this section and then skip to Section 13. Enter the name of the group/organization, Medicare number and NPI where you will work. Skip to Section 13.

Page 14

Slide 34

Section 4: Practice Location Information (Cont.)

Section 4B Example Situation 2 If you will be practicing as a solo provider and also with a group or organization, provide the group or organization information you will be reassigning benefits to and then continue to Section 4C.

Page 14

Slide 35

Section 4: Practice Location Information (Cont.)

Section 4B Example Situation 3 If you are working solo only and not reassigning any of your payments, skip to Section 4C.

Page 14

Slide 36

Section 4: Practice Location Information (Cont.)

Section 4C If Section 4A is completed or the provider is establishing his own private practice, list those locations in this section. Do not list the groups/organizations to which the provider is reassigning benefits.

Page 15

Slide 37

Section 4: Practice Location Information (Cont.)

Section 4C Enter the practice location name (Doing Business As (DBA) name if different from the legal business name), complete address, telephone number, fax number and e-mail address. New enrollees do not use this area. Initial enrollees should enter Pending or leave the Medicare field blank. Enter the providers NPI number and the date the provider first saw the Medicare patient at this location. Identify the type of practice location you have. Enter the Clinical Laboratory Improvement Amendments (CLIA) number and the Food and Drug Administration (FDA) number, if applicable.
Page 16

Slide 38

Section 4: Practice Location Information (Cont.)

Section 4C For initial enrollment for a professional corporation, professional association, limited liability company, etc., the NPI should be the individual (Type 1).

For an established professional corporation, professional association, limited liability company, etc., that is submitting the application for a change, the NPI should be the organization (Type 2).

Page 16

Slide 39

Section 4: Practice Location Information (Cont.)

Section 4C
If making a change to an existing application, enter the practice location name (DBA name if different from the legal business name), complete address, telephone number, fax number and e-mail address. Check the appropriate box and enter the date the change, addition or deletion will be effective. This same date should be on the date you saw your first Medicare patient. If provider has multiple addresses, do not check change. This would be either a delete or an add. If deleting one address and adding another address, make copies of this section and complete one for the add and one for the delete. This only applies if the provider has multiple addresses. Enter the providers NPI number and the date the provider first saw the Medicare patient at this location. Identify the providers type of practice location. Enter the CLIA number and FDA number, if applicable. Page 16

Slide 40

Section 4: Practice Location Information (Cont.)

Section 4D
If services are provided in patients homes, complete Section 4D. If the service is provided to an entire state, enter the state. There is no need to list each city/town separately. If services are only provided in a city or town, enter the city or towns name and the state. The ZIP code is only required if not servicing the entire city/town. If services are not rendered in patients homes, skip Section 4D.
Slide 41

Page 17

Section 4: Practice Location Information (Cont.)

Section 4E This section is used to identify where remittance notices or special payments should be sent. New enrollees do not use this area. If making a change to an existing profile, check the appropriate box and enter the effective date of the change, addition or deletion. If the address is the same as the practice location in Section 4C and only one address is listed, check the indicated box and skip to Section 4F. If the address is different from the practice location in Section 4C or multiple locations are listed, check the indicated box and furnish the address where notices and special payments should be sent.
Page 18

Slide 42

Section 4: Practice Location Information (Cont.)

Section 4F This section is used when a sole proprietor wants Medicare payments reported under an EIN. Example: John Q. Public, MD, has obtained an EIN from the IRS, and the legal business name on the IRS notice (CP575) is John Q. Public, MD. The three bulleted requirements listed on the form must be met. Enter the EIN.
Page 18

Slide 43

Section 4: Practice Location Information (Cont.)

Section 4G If patients medical records are stored at a location other than the location listed in Section 4C, complete Section 4G with the name and address of the storage location. New enrollees do not use this area. Section 4H Explain any unique circumstances concerning the practice locations in Section 4H. Section 5 Skip.
Page 19

Slide 44

Section 6: Individuals Having Managing Control

Section 6A
This section must be completed by sole proprietors. Section 6A is for individuals who will exercise operational or managerial control over the practice. If there is more than one individual who needs to be reported, copy and complete this section for each individual. New enrollees do not use this area. If making a change to an existing profile, check the appropriate box and enter the date the change, addition or deletion will be effective. Adverse legal actions must be completed for each individual reported. Yes or No must be checked in response to question 1 in Section 6B. Section 7 Skip.
Page 20

Slide 45

Section 8: Billing Agency

Section 8
This section captures information about any individual or entity with whom the provider has contracted to prepare and submit claims for the business. New enrollees do not use this area. If making a change to an existing application, check the appropriate box and enter the date the change, addition or deletion will be effective. A billing agency may perform other services for the provider, but claims completion and/or submission is included in the contract. If a billing agency is not used, indicate this by checking the first box. Sections 912: Skip.
Page 21

Slide 46

Section 13: Contact Person

Section 13 The contact person should be someone who can answer questions about the information on the application. Medicare will not list the contact person on the Medicare providers record. If no one is listed, Medicare will contact the provider directly.

Page 22

Slide 47

Section 14: Penalties for Falsifying Information

Section 14 This section outlines the penalties for falsifying information and should be read by the provider listed in Section 2. This section does not have an area to be completed.

Page 23

Slide 48

Section 15: Certification Statement

Section 15 Only the individual practitioner has the authority to sign this application. The individual practitioner must read and understand page 25.

Page 25

Slide 49

Section 15: Certification Statement (Cont.)

Section 15 All signatures must be original and signed in ink. Applications with signatures deemed not original will not be processed. Stamped, faxed or copied signatures will not be accepted. To indicate an original signature, the practitioner should sign in blue ink. Section 16 Skip.

Page 26

Slide 50

Section 17: Supporting Documents

Section 17 This section indicates what is attached to the application. Check the corresponding boxes for all information being attached to the application. Dont forget: Tax documents (IRS CP575, tax coupon or IRS letter). CMS-588 (EFT authorization). If applicable, copies of CLIA, FDA and/or diabetes program certifications. Copy of attestation for government and tribal organizations.
Page 26

Slide 51

Medicare Supplier Enrollment Application Privacy Act Statement

The Privacy Act Statement includes important information relating to Medicares authorization, use and disclosure of specific provider information.

Page 27

Slide 52

CMS-588: Electronic Funds Transfer

CMS mandates all providers filing a CMS-855 form must receive all Medicare reimbursements electronically. This is a way for Medicare to pay providers with a money transfer directly into a bank account. The Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588), along with a voided check, deposit slip or bank letter, must be included with the enrollment form. The CMS-588 is located at: http://www.cms.gov/cmsforms/downloads/CMS588.pdf For providers, EFT eliminates waiting for a check to be mailed!
Slide 53

CMS-460: Participating Provider/Supplier Agreement

Medicare fee schedule amounts for professional services, services and supplies provided incident to physicians professional services, outpatient physical and occupational therapy services, diagnostic tests or radiology services are 5 percent higher if you participate. Also, providers receive direct and timely reimbursement from Medicare. https://www.cms.gov/cmsforms/downloads/cms 460.pdf
Slide 54

Prescreening
All enrollment applications are prescreened to ensure providers submit a complete enrollment application and all required supporting documentation. Did you know? The online PECOS application is scenario-driven and screens the application during entry. This process helps ensure the online application is complete!
Slide 55

Prescreening Missing Information

If an application is received that contains at least one missing required data element or the provider fails to submit all required supporting documentation:
TrailBlazer will send a letter to the provider (when appropriate, the letter can be sent via e-mail or fax) that documents and requests the missing information. The letter is sent to the provider during the 15-day prescreening period. TrailBlazer is not required to make any additional requests for the missing data elements or documentation after the initial letter.
Slide 56

Prescreening Missing Information (Cont.)

The provider must furnish all missing information within 30 calendar days of the request or the application will be denied. The provider will be notified by letter with the reasons for denial and how to reapply. If the provider wishes to reapply, he will be required to begin a new process.

Slide 57

Denied Versus Returned

Denied An application is denied based on the providers failure to respond to TrailBlazers request for missing information or clarification. Returned An application is subject to immediate return based on specific criteria. All resubmissions must contain a newly signed and dated certification statement page.
Slide 58

Criteria for Returning Applications

No signature on application. Old version of application submitted. (Effective November 1, 2011, the only 855 application that will be accepted is the 07/11 version.) Copied or stamped signature. Applicant failed to submit all forms needed to process a reassignment package. Completed application in pencil. Wrong application submitted. Web-generated application submitted but does not appear to have been downloaded off CMS Web site. Application not mailed (i.e., it was faxed or e-mailed).

Slide 59

Criteria for Returning Applications (Cont.)

Application received more than 30 days prior to the effective date listed on the application. (This does not apply to certified providers, Ambulatory Surgical Centers (ASCs) or portable X-ray suppliers.) Provider submitted new enrollment application prior to expiration of time in which provider is entitled to appeal the denial of its previously submitted application. Submitted CMS-855 for sole purpose of enrolling in Medicaid. CMS-855 not needed for the transaction in question. CMS-588 sent in as a stand-alone change of information request (i.e., it was not accompanied by a CMS-855) but was unsigned, undated or contained a copied, stamped or faxed signature.
Slide 60

Criteria for Returning Applications (Cont.)

TrailBlazer is allowed to return applications for missing information. The top reasons for returns in Provider Enrollment are:
Missing CMS-588 Authorization Agreement for Electronic Funds Transfer. Failure to document the reason for application submittal. Application was not signed or dated. IRS tax identification (e.g., IRS CP575) or supporting documentation was not received.
Slide 61

Reminder
If you have submitted an 855 application and it has been returned for additional information:
Ensure the missing/incomplete information has been included in the appropriate section(s). Complete a new certification page (Section 15) and sign and date to reflect the new information being sent back to Medicare.

Slide 62

Application Processing
Once it is determined that the application will not be returned, it will begin the various phases of verification, validation and final processing. If additional information is needed during these phases, the provider could receive an e-mail, fax or a letter requesting information. This contact will be directed to the person listed as the contact person in Section 13 of the CMS-855I form.
Slide 63

Application Processing (Cont.)

Once the application has been screened and begins the enrollment process, the provider will receive an acknowledgment letter. This letter will have a tracking number to allow the provider to track the various phases of the application. Providers are encouraged to periodically monitor the progress of the pending application and act accordingly if there are any requests for additional information during the processing phases.
Slide 64

Enrollment Status Inquiry Tool

Slide 65

Reminders
1. Request and obtain an NPI before enrolling or making a change. 2. Be sure the CMS-855I application is complete. A CMS-855I application must be completed by all individuals who will be billing Medicare carriers for medical services furnished to Medicare beneficiaries and by individuals who are already enrolled in Medicare but have a new tax ID. If you are reporting a change to your tax ID, you must complete a new application. 3. Include the CP575, if needed. A CP575 must be submitted with the CMS855I and the CMS-855B application any time a tax ID number is used. The CP575 is the official letter from the IRS confirming the tax ID number with the legal business name. If the CP575 is not available, we will also accept a copy of the quarterly tax payment coupon or any official letter from the IRS that lists the legal business name and tax ID number. 4. Include all necessary supporting documentation. This supporting documentation includes the CP575 and the CMS-588 authorization form for EFT.
Slide 66

Reminders (Cont.)
5. Identify a contact person. Once your application has passed CMS prescreening guidelines, a Provider Enrollment analyst will conduct research and validation of the enrollment application. Identifying a contact person who is familiar with the application and who has access to the physician, practitioner or administrator will help TrailBlazer obtain the necessary information and/or documentation in a timely manner. 6. Sign and date the application. In accordance with CMS regulations, any unsigned CMS-855 applications will be returned to the applicant. Any changes requested must include the effective date of the change. 7. Utilize all training materials and job aids on the Web site to assist in completion of the application. Incomplete applications can cause serious delays!

Slide 67

Mailing Address
Mail the provider enrollment form to:
TrailBlazer Health Enterprises, LLC Medicare Part B Provider Enrollment
Colorado P.O. Box 650710 Dallas, TX 75265-0710 New Mexico P.O. Box 650709 Dallas, TX 75265-0709 Oklahoma P.O. Box 650711 Dallas, TX 75265-0626 Texas/IHS P.O. Box 650544 Dallas, TX 75265-0544

Physical address: TrailBlazer Health Enterprises, LLC Medicare Part B Provider Enrollment Executive Center III 8330 LBJ Freeway Dallas, TX 75243-1756
Slide 68

Provider Enrollment Hotline

If you have any questions, contact the Provider Enrollment department: Colorado, New Mexico, Oklahoma and Texas: (866) 539-5596 Indian Health Facilities: (866) 448-5894
Slide 69

Provider Enrollment Outgoing Calls

CMS requires Medicare contractors to call and verify that the provider can be reached at the phone number listed in Section 2B of the application. The phone number listed in this section must be one where the provider can actually be reached. If Medicare calls the number on the initial call and has to leave a message, the provider must make a return call to Medicare and either speak with the enrollment analyst or leave a message to validate the number. A second outgoing call can be made by Medicare to the contact person listed in Section 13 if no callback is received from the initial outgoing call. If no response has been received after 30 days, the application will be denied.
Slide 70

Application Completion
Congratulations! This completes the 855I application. Prior to mailing the form, review the information to ensure all items are completed, if appropriate, and copies of all attachments are included.

Slide 71

TrailBlazer Health Enterprises

Education Makes the Difference

How to Complete the Paper CMS-855I Enrollment Application

Thank you for participating.