CMS 855I Instructions

Section 1: Basic Information

Entities and Providers must have an NPI before they can enroll with Medicare Carriers. Please indicate your personal NPI number in section 1.

Reason for Application Who Should Complete This Section
"You are a new enrollee in Medicare" Applicants who have never enrolled with the Medicare program in any state, or who are changing specialty types (not MD's or DO's) will mark this box
"You are enrolling with another fee-for-service contractor" Applicants who have enrolled with other contractors, but are now enrolling with Noridian will mark this box.
"You are reactivating your Medicare enrollment" Applicants will mark this box if they were previously enrolled in Medicare, but their number(s) was (were) deactivated.
"You are voluntarily terminating your Medicare enrollment" Applicants choosing to close their number will check this box. Indicate the effective date of termination, the provider number, and the NPI.
"You are changing your Medicare Information" Check the appropriate boxes on page 5 identifying what information is changing. List applicant's Medicare Identification Number, known as a Provider Transaction Access PTAN, if one has been issued. If you are not already using Electronic Funds Transfer (EFT), you must submit the CMS-588 EFT form along with your change application.
"You are revalidating your Medicare enrollment" Revalidation Cycle 2 began March 1st, 2016. All unsolicited revalidation applications submitted more than 6 months in advance of your due date will be returned. Click this link to find out more: CMS Revalidation Information


Section 2: Identifying Information

Section A Personal Information:

List applicant's name as it appears with the Social Security Agency (SSA). Name changes must be updated with the SSA before submitting an initial Medicare enrollment or submitting a change on your CMS-855I. The SSN must be in this section.

Section B Correspondence Address:

This must be the address (such as a home address) where the carrier can contact the provider directly. The address cannot be a billing agency's address.

Physician Assistants must complete Section 2e to establish employment arrangement(s) or Section 2f to terminate the employment arrangement(s).

Section D Medical Specialties:

Be sure to enter a P for Primary in the box next to your specialty. If you have a second specialty, enter an S in the box next to your secondary specialty. Refer to our Medical Specialties list on our website for all specialties that can enroll with Medicare Part B.

Section 3: Adverse Legal Actions/Convictions

  • Marking "N/A" anywhere on this page is not accepted.
  • Question 1 must be answered.
  • If the answer is YES, complete question 2 and attach documentation and information about the resolution for each adverse legal action.

Section 4: Practice Location Information

Section 4A:

If this section applies to you, be sure the legal business name is listed as it appears with the IRS.

Section 4E:

Where do you want remittance notices or special payments sent? All new enrollees must receive Medicare payments via Electronic Funds Transfer (EFT). Be sure to include the CMS-588 form (Authorization Agreement for Electronic Funds Transfer) with your application.

Section 6: Individuals Having Managing Control

  • Complete this section for any managing employees
  • Complete Section 6b for the person listed in section 6a

Section 8: Billing Agency

If this section is not applicable, make sure to check the box after "CHECK HERE" before the sentence "If this section does not apply and skip to Section 13."

Section 13: Contact Person(s)

This section should be completed (for initial Enrollments and Change Applications). Reaching the contact is extremely important, especially if enrollment has any questions regarding the submitted information. If there are multiple contacts for this application, copy this section and complete it for each contact.

Section 15: Certification Statement

The applicant must sign and date this section. The signature must be an original signature and cannot be a photocopy or stamp.

Supporting Documents

Some supporting documentation requirements may change due to the laws in your state. This is a list of supporting documents which are often missed.

  • Participation Agreements on initial enrollments. (If the individual does not want to be in a participating status with Medicare, they should submit a letter stating they wish to be Nonparticipating).
  • Sole proprietors must complete the CMS-588EFT. If the provider is submitting a change of information application and is currently receiving electronic payments, the 588 is not required.
  • Sole proprietors using a Federal Tax ID need to submit a copy of the CP575 form or another type of IRS-generated document.

 

Last Updated Feb 01, 2018