CMS-855I/CMS-855R Consolidated Enrollment Applications
The consolidated CMS-855I/CMS-855R enrollment applications provide a streamlined process for physicians and non-physician practitioners to reassign Medicare benefits. This document explains how to enroll, report changes, and terminate reassignments. It includes step-by-step instructions for both paper and PECOS submissions.
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How do I fill this out?
To fill out this form, start by identifying whether you are a new enrollee or reporting a change. Follow the detailed instructions provided for each scenario. Make sure all required sections are completed and signed.
How to fill out the CMS-855I/CMS-855R Consolidated Enrollment Applications?
1
Check the appropriate box in Section 1A.
2
Complete all applicable sections of the form.
3
Report a new reassignment or change in Section 4F.
4
Provide effective dates and additional information as required.
5
Ensure all signatures are collected and submit the form.
Who needs the CMS-855I/CMS-855R Consolidated Enrollment Applications?
1
Physicians who need to reassign Medicare benefits.
2
Non-physician practitioners requiring reassignment of Medicare benefits.
3
Organizations/groups accepting reassignment of Medicare benefits.
4
Practitioners reporting changes in reassignment information.
5
Healthcare providers terminating existing reassignments.
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What are the instructions for submitting this form?
Submit the completed CMS-855I form to your Medicare Administrative Contractor (MAC) using their provided methods, such as mailing to their physical address, faxing, or through their online submission portal. For physical submissions, refer to MAC contact information: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Medicare-Administrative-Contractors/Downloads/MACs-by-State-and-Specialty.pdf. Advice: Ensure all sections are accurately completed and signed before submission to avoid delays.
What are the important dates for this form in 2024 and 2025?
From September 1, 2023, Medicare Administrative Contractors (MACs) will accept the revised CMS-855I. MACs will continue accepting previous versions until October 30, 2023. As of November 1, 2023, any newly submitted applications using outdated forms will be returned.
What is the purpose of this form?
The CMS-855I/CMS-855R enrollment applications serve a critical role in the Medicare program by facilitating the reassignment of benefits to eligible healthcare providers and organizations. By merging these applications, Medicare aims to simplify the process for practitioners and ensure accurate reporting and disbursement of Part B payments. This form also allows healthcare providers to report changes or terminate reassignment arrangements efficiently, maintaining up-to-date information with the Medicare system.
Tell me about this form and its components and fields line-by-line.
- 1. Section 1A: Identifies whether the applicant is a new enrollee or reporting changes.
- 2. Section 1B: Specifies the nature of changes being reported, such as reassignment of benefit information.
- 3. Section 4F: Details the reassignment information, including adding, changing, or terminating reassignments.
- 4. Section 15: Includes certification and signature fields for practitioners and authorized officials.
- 5. Sections 2A, 3, 12, and 13: Collect additional pertinent information required for completing the form.
What happens if I fail to submit this form?
Failing to submit the CMS-855I form can result in delays or denials of Medicare payments. Practitioners and organizations must ensure timely submission to avoid disruptions in service and payment.
- Payment Delays: Medicare payments may be delayed if the form is not submitted on time.
- Service Disruptions: Interruptions in Medicare-covered services may occur for patients if reassignment information is not updated.
- Denial of Claims: Claims may be denied if accurate reassignment information is not on file with Medicare.
How do I know when to use this form?
- 1. New Enrollment: Use when enrolling as a new Medicare practitioner or organization.
- 2. Reassignment Reporting: Use to report new reassignment of benefits to an organization.
- 3. Change of Information: Use to update existing reassignment details.
- 4. Termination of Reassignment: Use to terminate an existing reassignment of benefits.
- 5. Organizational Changes: Use when there are changes in the primary or secondary location of service delivery.
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