MEDICARE ENROLLMENT APPLICATION INSTITUTIONAL PROVIDERS CMS-855A SEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION SEE PAGE 3 FOR INFORMATION ON WHERE TO MAIL THIS APPLICATION. SEE PAGE 52 TO FIND A LIST OF THE SUPPORTING DOCUMENTATION THAT MUST BE SUBMITTED WITH THIS APPLICATION. American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0685 Expires: 08/19 WHO SHOULD COMPLETE THIS APPLICATION Institutional providers can apply for enrollment in the Medicare program or make a change in their enrollment information using either: · The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or · The paper enrollment application process (e.g., CMS 855A). For additional information regarding the Medicare enrollment process, including Internet-based PECOS, go to www.cms.gov/MedicareProviderSupEnroll. Institutional providers who are enrolled in the Medicare program, but have not submitted the CMS 855A since 2003, are required to submit a Medicare enrollment application (i.e., Internet-based PECOS or the CMS855A)asaninitialapplicationwhenreportingachangeforthefirsttime. The following health care organizations must complete this application to initiate the enrollment process: · Community Mental Health Center · Hospital · Comprehensive Outpatient Rehabilitation Facility · Indian Health Services Facility · Critical Access Hospital · Organ Procurement Organization · End-Stage Renal Disease Facility · Outpatient Physical Therapy/Occupational Therapy /Speech Pathology Services · FederallyQualifiedHealthCenter · Religious Non-Medical Health Care Institution · Histocompatibility Laboratory · Rural Health Clinic · Home Health Agency · Skilled Nursing Facility · Hospice If your provider type is not listed above, contact your designated fee-for-service contractor before you submit this application. Complete this application if you are a health care organization and you: · Plan to bill Medicare for Part A medical services, or · Would like to report a change to your existing Part A enrollment data. A change must be reported within 90 days of the effective date of the change; per 42 C.F.R. 424.516(e), changes of ownership or control must be reported within 30 days of the effective date of the change. BILLING NUMBER INFORMATION The National Provider Identifier (NPI) is the standard unique health identifier for health care providers and is assigned by the National Plan and Provider Enumeration System (NPPES). Medicare healthcare providers, except organ procurement organizations, must obtain an NPI prior to enrolling in Medicare or before submitting a change to your existing Medicare enrollment information. Applying for an NPI is a process separate from Medicare enrollment. To obtain an NPI, you may apply online at https://NPPES.cms.hhs.gov. As an organizational health care provider, it is your responsibility to determine if you have "subparts." A subpart is a component of an organization that furnishes healthcare and is not itself a legal entity. If you do have subparts, you must determine if they should obtain their own unique NPIs. Before you complete this enrollment application, you need to make those determinations and obtain NPI(s) accordingly. IMPORTANT: For NPI purposes, sole proprietors and sole proprietorships are considered to be "Type 1" providers. Organizations (e.g., corporations, partnerships) are treated as "Type 2" entities. When reporting the NPI of a sole proprietor on this application, therefore, the individual's Type 1 NPI should be reported; for organizations, the Type 2 NPI should be furnished. For more information about subparts, visit www.cms.gov/NationalProvIdentStand to view the "Medicare Expectations Subparts Paper." The Medicare Identification Number, often referred to as the CMS Certification Number (CCN) or Medicare "legacy" number, is a generic term for any number other than the NPI that is used to identify a Medicare provider. CMS-855A (07/11) American LegalNet, Inc. www.FormsWorkFlow.com 1 INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION · Type or print all information so that it is legible. Do not use pencil. · Report additional information within a section by copying and completing that section for each additional entry. · Attach all required supporting documentation. · Keep a copy of your completed Medicare enrollment package for your records. · Send the completed application with original signatures and all required documentation to your designated Medicare fee-for-service contractor. AVOID DELAYS IN YOUR ENROLLMENT To avoid delays in the enrollment process, you should: · Complete all required sections. · Ensure that the legal business name shown in Section 2 matches the name on the tax documents. · Ensure that the correspondence address shown in Section 2 is the provider's address. · Enter your NPI in the applicable sections. · Enter all applicable dates. · Ensure that the correct person signs the application. · Send your application and all supporting documentation to the designated fee-for-service contractor. OBTAINING MEDICARE APPROVAL The usual process for becoming a certified Medicare provider is as follows: 1. The applicant completes and submits a CMS-855A enrollment application and all supporting documentation to its fee-for-service contractor. 2. The fee-for-service contractor reviews the application and makes a recommendation for approval or denial to the State survey agency, with a copy to the CMS Regional Office. 3. The State agency or approved accreditation organization conducts a survey. Based on the survey results, the State agency makes a recommendation for approval or denial (a certification of compliance or noncompliance) to the CMS Regional Office. Certain provider types may elect voluntary accreditation by a CMS-recognized accrediting organization in lieu of a State survey. 4. A CMS contractor conducts a second contractor review, as needed, to verify that a provider continues to meet the enrollment requirements prior to granting Medicare billing privileges. 5. The CMS Regional Office makes the final decision regarding program eligibility. The CMS Regional Office also works with the Office of Civil Rights to obtain necessary Civil Rights clearances. If approved, the provider must typically sign a provider agreement. American LegalNet, Inc. www.FormsWorkFlow.com CMS-855A (07/11) 2 ADDITIONAL INFORMATION