Blank Cms 855R Template

The CMS-855R form is a Medicare enrollment application for the reassignment of Medicare benefits. This form is necessary for healthcare providers who wish to authorize an organization or group to bill Medicare on their behalf and receive related payments. Understanding the specifics of this application is essential for ensuring proper enrollment and compliance in the Medicare program.

To start the process of filling out the CMS-855R form, click the button below.

Article Guide

The CMS 855R form serves a critical function in the world of Medicare, specifically dealing with the reassignment of Medicare benefits. Intended for use by physicians and non-physician practitioners, this form facilitates the process of reassigning the right to bill Medicare and receive payments for services rendered to beneficiaries. This means that when healthcare providers decide to work within an organization or group practice, they can allow that entity to submit claims on their behalf. It's important to note that both the individual practitioner and the organization must be properly enrolled in Medicare for the reassignment to take effect. Practitioners might fill out the CMS 855R when they wish to create or terminate a reassignment of benefits, with each application requiring careful completion and proper signatures from both parties involved. While the organization typically submits the form on behalf of the practitioner, individual circumstances may lead either party to submit the form—especially when it comes to terminating a current reassignment. Following the rules surrounding this application is vital; otherwise, one could encounter delays in payments or complications within their Medicare billing practices. Whether completing the form online through PECOS or submitting a paper version, ensure that the most up-to-date copy is used to promote efficiency and compliance in the reassignment process.

Form Sample

MEDICARE ENROLLMENT APPLICATION

REASSIGNMENT OF MEDICARE BENEFITS

CMS-855R

SEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION. SEE PAGE 2 FOR INFORMATION ON WHERE TO MAIL THIS COMPLETED APPLICATION.

TO VIEW YOUR CURRENT MEDICARE REASSIGNMENTS GO TO:

HTTPS://PECOS.CMS.HHS.GOV

	Form Approved
DEPARTMENT OF HEALTH AND HUMAN SERVICES	OMB No. 0938-1179
CENTERS FOR MEDICARE & MEDICAID SERVICES	Expires: 01/2023

WHO SHOULD COMPLETE AND SUBMIT THIS APPLICATION

Complete this application if you are reassigning your right to bill the Medicare program and receive Medicare payments for some or all of the services you render to Medicare beneficiaries, or are terminating a currently established reassignment of benefits. Reassigning your Medicare benefits allows an eligible organization/group to submit claims and receive payment for Medicare Part B services that you have provided as a member of the organization/group. Such an eligible organization/group may be an individual, a clinic/group practice or other health care organization.

Physicians and non-physician practitioners, other than physician assistants, can reassign Medicare benefits or terminate a reassignment of Medicare benefits after enrollment in the Medicare program or make a change in their reassignment of Medicare benefit information using either:

•The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or

•The paper CMS-855R application. Be sure you are using the most current version.

Both the individual practitioner and the eligible organization/group must be currently enrolled (or concurrently enrolling via submission of the CMS-855B for the eligible organization/group and the CMS-855I for the individual practitioner) in the Medicare program before the reassignment can take effect. Generally, this application is completed by the organization/group, signed by the Delegated/Authorized Official of the organization/group and the individual practitioner, and submitted by the organization/group. When terminating a current reassignment, either the organization/group or the individual practitioner may submit this application with the appropriate sections completed and signed.

NOTE: A separate CMS-855R must be submitted for each organization/group where a reassignment is being established or terminated.

The individual or delegated/authorized official, by his/her signature, agrees to notify the Medicare Administrative Contractor (MAC) of any future changes to this reassignment in accordance with 42 C.F.R. section 424.516(d)(2).

NOTE: An individual does not need to reassign their benefits to a corporation, limited liability company, professional association, etc., when he/she is the sole owner. See the CMS-855I application for Physicians and Non- Physician Practitioners for more information.

NOTE: Physician Assistants: This application should not be used to report employment arrangements. Employment arrangements must be reported using the CMS-855I application.

For additional information regarding the Medicare enrollment and reassignment process, including Internet-based PECOS and to get the current version of the CMS-855R, go to http://www.cms.gov/MedicareProviderSupEnroll.

INSTRUCTIONS FOR COMPLETING THIS APPLICATION

•All information on this form is required with the exception of those fields specifically marked as “optional.” Any field marked as optional is not required to be completed nor does it need to be updated or reported as a “change of information” as required in 42 C.F.R. section 424.516. However, it is highly recommended that if reported, these fields be kept up-to-date.

•Type or print all information so that it is legible. Do not use pencil.

•Ensure that the legal business name shown in Section 2 matches the name on the tax documents.

•Enter all NPIs in the applicable sections.

•Sign and date the certification statement(s) as appropriate.

•Keep a copy of your completed Medicare reassignment package for your own records.

CMS-855R (Rev. 01/20)

ADDITIONAL INFORMATION

When establishing a new reassignment, Section 6A must be signed by the individual practitioner and Section 6B must be signed by a delegated or authorized official of the organization/group. If the reassignment is to an individual, that person must sign Section 6B. When terminating a reassignment, either Section 6A or Section

6B can be completed. Reassigned claims for services rendered by the individual will no longer be paid to the organization/group after the effective date of the termination.

•You may visit our website to learn more about the enrollment process via the Internet-Based Provider Enrollment Chain and Ownership System (PECOS) at: https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/MedicareProviderSupEnroll/InternetbasedPECOS.html. Also, all of the CMS-855 applications are all located on the CMS webpage: https://www.cms.gov/medicare/cms-forms/cms-forms/cms-forms-list.html.

Simply enter “855” in the “Filter On:” box on this page and only the application forms will be displayed to choose from.

•The MAC may request additional documentation to support and validate information reported on this application. You are responsible for providing this documentation within 30 days of the request per 42 C.F.R. section 424.525(a)(1).

•The information you provide on this form is protected under 5 U.S.C. section 552(b)(4) and/or (b)(6), respectively. For more information, see the last page of this application to read the Privacy Act Statement.

DEFINITIONS

NOTE: For the purposes of this CMS-855R application, the following definitions apply:

Add: You are adding additional information to your existing information (e.g. practice locations).

Change: You are replacing existing information with new information (e.g. contact person) or updating existing information (e.g. change in suite #, telephone #).

Remove: You are removing existing information.

WHERE TO MAIL YOUR APPLICATION

Send this completed application with original signatures and all required documentation to your designated MAC. The MAC that services your State is responsible for processing your enrollment application. To locate the mailing address for your designated MAC, go to www.cms.gov/MedicareProviderSupEnroll.

CMS-855R (Rev. 01/20)

SECTION 1: BASIC INFORMATION

ALL APPLICANTS MUST COMPLETE THIS SECTION

Reason for Submitting this Application

Check the applicable box and complete the required sections.

You are enrolling or are currently enrolled in	Effective Date (mm/dd/yyyy):	Complete all sections
Medicare and will be reassigning your benefits

You are an individual practitioner/organization	Effective Date (mm/dd/yyyy):	Complete sections 1, 2 or
changing information on a currently existing		3, as applicable, sections 4
reassignment		and/or 5, as applicable,
		and section 6A or 6B, as
		applicable

You are an individual practitioner terminating a	Effective Date (mm/dd/yyyy):	Complete sections 1, 2, 3,
reassignment with an organization/group		5, and 6A

You are the organization/group terminating a	Effective Date (mm/dd/yyyy):	Complete sections 1, 2, 3,
reassignment with an individual		5, and 6B

SECTION 2: ORGANIZATION/GROUP RECEIVING THE REASSIGNED BENEFITS

A. Organization/Group Identification

Provide the information below for the organization/group to whom benefits are being reassigned, or a reassignment is being terminated. If the organization/group’s initial enrollment application is being submitted concurrently with this reassignment application, write “pending” in the Medicare identification number block. The organization/group’s name as reported to the IRS must be the same as reported on the organization/group’s CMS-855B when it enrolled.

Organization/Group Legal Business Name (as Reported to the Internal Revenue Service)

Tax Identification Number (TIN)

Medicare Identification Number (PTAN) (if issued)

National Provider Identifier (NPI)

B. Individual Practitioner Identification

Provide the information below for the individual to whom benefits are being reassigned, or a reassignment is being terminated. If the individual’s initial enrollment application is being submitted concurrently with this reassignment application, write “pending” in the Medicare identification number block. The individual’s name as reported to the Social Security Administration must be the same as reported on the individual’s CMS-855I when the individual enrolled. If the individual is a sole proprietor with an Employee Identification Number (EIN), check the appropriate box and report the EIN.

First Name (Print)	Middle Initial	Last Name (Print)		Jr., Sr., M.D., etc.

Social Security Number (SSN) (List number below if applicable)			Employer Identification Number (EIN) (List number below if applicable)

Medicare Identification Number (PTAN) (if issued)			National Provider Identifier (NPI)

CMS-855R (Rev. 01/20)

SECTION 3: INDIVIDUAL PRACTITIONER WHO IS REASSIGNING BENEFITS

Individual Practitioner Identification

Provide the information below for the individual practitioner who will be reassigning his/her benefits, or who will be terminating a reassignment. If the individual’s initial enrollment application is being submitted concurrently with this reassignment application, write “pending” in the Medicare identification number field.

First Name (Print)	Middle Initial	Last Name (Print)		Jr., Sr., M.D., etc.

Social Security Number (SSN)	Medicare Identification Number (PTAN) (if issued)		National Provider Identifier (NPI)

SECTION 4: PRIMARY PRACTICE LOCATION(S) (Optional)

A. Primary Practice Location

Identify the primary practice location of the organization/group where the individual practitioner will render services most of the time. This practice location must be currently enrolled or enrolling in Medicare.

If you are changing information about a currently reported primary practice location or adding or removing primary practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section.

Change	Add	Remove	Effective Date (mm/dd/yyyy):

Practice Location Name (“Doing Business As” Name)

Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)

Practice Location Address Line 2 (Suite, Room, Apt. #, etc.)

City/Town				State		ZIP Code +4

Medicare Identification Number for this location – PTAN (if issued)					National Provider Identifier (NPI)

B. Secondary Practice Location

Identify additional practice location.

If you are changing information about a currently reported an additional practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section.

Change	Add	Remove	Effective Date (mm/dd/yyyy):

Practice Location Name (“Doing Business As” Name)

Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)

Practice Location Address Line 2 (Suite, Room, Apt. #, etc.)

City/Town				State		ZIP Code +4

Medicare Identification Number for this location – PTAN (if issued)					National Provider Identifier (NPI)

CMS-855R (Rev. 01/20)

SECTION 5: CONTACT PERSON INFORMATION (Optional)

If questions arise during the processing of this reassignment, the designated MAC will contact the individual indicated below. If a contact person is not furnished, the MAC will contact the individual practitioner is Section 3.

If you are changing information about a currently reported contact person or adding or removing a contact person, check the applicable box, furnish the effective date, and complete the appropriate fields in this section.

Change	Add	Remove		Effective Date (mm/dd/yyyy):

First Name				Middle Initial	Last Name				Jr., Sr., M.D., etc.

Contact Person Address Line 1		(Street Name And Number)

Contact Person Address Line 2		(Suite, Room, Apt. #, etc.)

City/Town						State		ZIP Code +4

Telephone Number			Fax Number (if applicable)				Email Address (if applicable)

Relationship or Affiliation to Individual or Organization/Group (Spouse, Secretary, Attorney, Billing Agent, etc.)

NOTE: The Contact Person listed in this section will only be authorized to discuss issues concerning this or any other enrollment application. Your designated MAC will not discuss any other Medicare issues about you with the above Contact Person.

CMS-855R (Rev. 01/20)

SECTION 6: CERTIFICATION STATEMENTS AND SIGNATURES

Title XVIII of the Social Security Act prohibits payment for services provided by an individual practitioner to be paid to another individual or organization/group unless the individual practitioner who provided the services specifically authorizes another individual or organization/group to receive said payments in accordance with

42 C.F.R. section 424.73 and 42 C.F.R. section 424.80. All individual practitioners who allow another individual or organization/ group to receive payment for their services must sign the Reassignment of Medicare Benefits Statement below. By signing this Reassignment of Medicare Benefits Statement, you are authorizing the organization/group or individual identified in Section 2 to receive Medicare payments on your behalf.

The signature(s) below authorize the reassignment of benefits, or the termination of a reassignment of benefits, between the individual practitioner shown in Section 3 and the organization/group or individual shown in Section 2. The employment of, or contract between, the individual practitioner and organization/group or individual must be in compliance with CMS regulations and applicable Medicare program safeguard standards described in 42 C.F.R. section 424.80. These signatures also serve as an attestation and acknowledgment to the compliance with all laws and regulations pertaining to the reassignment of Medicare benefits.

A. Individual Practitioner Certification Statement and Signature

Under penalty of perjury, I, the undersigned, certify that the above information is true, accurate and complete. I understand that any misrepresentation or concealment of any information requested in this application may subject me to liability under civil and criminal laws.

Individual Practitioner First Name (Print)

Middle Initial

Last Name (Print)

Jr., Sr., M.D., etc.

Individual Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)

Date Signed (mm/dd/yyyy)

In order to process this application it MUST be signed and dated.

B. Delegated or Authorized Official of Organization/Group Certification Statement and Signature

Delegated or Authorized Official’s First Name (Print)

Middle Initial

Last Name (Print)

Jr., Sr., M.D., etc.

Delegated or Authorized Official’s Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)

Date Signed (mm/dd/yyyy)

In order to process this application it MUST be signed and dated.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1179 (Expires: 01/2023). The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please visit http://www.cms.gov/MedicareProviderSupEnroll.

CMS-855R (Rev. 01/20)

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

MEDICARE SUPPLIER ENROLLMENT APPLICATION PRIVACY ACT STATEMENT

The Authority for maintenance of the system is given under provisions of sections 1102(a) (Title 42 U.S.C. 1302(a)), 1128 (42 U.S.C. 1320a–7), 1814(a)) (42 U.S.C. 1395f (a)(1), 1815(a) (42 U.S.C. 1395g(a)), 1833(e) (42 U.S.C. 1395I(3)),1871 (42 U.S.C. 1395hh), and 1886(d)(5)(F), (42 U.S.C. 1395ww(d)(5)(F) of the Social Security Act; 1842(r) (42 U.S.C.1395u(r)); section 1124(a)(1) (42 U.S.C. 1320a–3(a)(1), and 1124A (42 U.S.C. 1320a–3a), section 4313, as amended, of the BBA of 1997; and section 31001(i) (31 U.S.C. 7701) of the DCIA (Pub. L. 04–134), as amended.

The information collected here will be entered into the Provider Enrollment, Chain and Ownership System (PECOS).

PECOS will collect information provided by an applicant related to identity, qualifications, practice locations, ownership, billing agency information, reassignment of benefits, electronic funds transfer, the NPI and related organizations. PECOS will also maintain information on business owners, chain home offices and provider/chain associations, managing/ directing employees, partners, authorized and delegated officials, supervising physicians of the supplier, ambulance vehicle information, and/or interpreting physicians and related technicians. This system of records will contain the names, social security numbers (SSN), date of birth (DOB), and employer identification numbers (EIN) and NPI’s for each disclosing entity, owners with 5 percent or more ownership or control interest, as well as managing/directing employees. Managing/directing employees include general manager, business managers, administrators, directors, and other individuals who exercise operational or managerial control over the provider/ supplier. The system will also contain Medicare identification numbers (i.e., CCN, PTAN and the NPI), demographic data, professional data, past and present history as well as information regarding any adverse legal actions such as exclusions, sanctions, and felonious behavior.

The Privacy Act permits CMS to disclose information without an individual’s consent if the information is to be used for a purpose that is compatible with the purpose(s) for which the information was collected. Any such disclosure of data is known as a “routine use.” The CMS will only release PECOS information that can be associated with an individual as provided for under Section III “Proposed Routine Use Disclosures of Data in the System.” Both identifiable and non-identifiable data may be disclosed under a routine use. CMS will only collect the minimum personal data necessary to achieve the purpose of PECOS. Below is an abbreviated summary of the six routine uses. To view the routine uses in their entirety go to: https://www.cms.gov/Research-Statistics-Data- and-Systems/Computer-Data-and-Systems/Privacy/Downloads/0532-PECOS.pdf.

1.To support CMS contractors, consultants, or grantees, who have been engaged by CMS to assist in the performance of a service related to this collection and who need to have access to the records in order to perform the activity.

2.To assist another Federal or state agency, agency of a state government or its fiscal agent to:

a.Contribute to the accuracy of CMS’s proper payment of Medicare benefits,

b.Enable such agency to administer a Federal health benefits program that implements a health benefits program funded in whole or in part with federal funds, and/or

c.Evaluate and monitor the quality of home health care and contribute to the accuracy of health insurance operations.

3.To assist an individual or organization for research, evaluation or epidemiological projects related to the prevention of disease or disability, or the restoration or maintenance of health, and for payment related projects.

4.To support the Department of Justice (DOJ), court or adjudicatory body when:

a.The agency or any component thereof, or

b.Any employee of the agency in his or her official capacity, or

c.Any employee of the agency in his or her individual capacity where the DOJ has agreed to represent the employee, or

d.The United States Government, is a party to litigation and that the use of such records by the DOJ, court or adjudicatory body is compatible with the purpose for which CMS collected the records.

5.To assist a CMS contractor that assists in the administration of a CMS administered health benefits program, or to combat fraud, waste, or abuse in such program.

6.To assist another Federal agency to investigate potential fraud, waste, or abuse in, a health benefits program funded in whole or in part by Federal funds.

The applicant should be aware that the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-

503)amended the Privacy Act, 5 U.S.C. section 552a, to permit the government to verify information through computer matching.

CMS-855R (Rev. 01/20)

⇩ PDF

Document Specifications

Fact Name	Description
Purpose	The CMS 855R form allows practitioners to reassign their Medicare billing rights to an organization or terminate a current reassignment.
Who Uses It	This form is completed by individual practitioners, clinics, group practices, or other eligible healthcare organizations.
Submission Requirement	Both the individual practitioner and the organization must be enrolled in the Medicare program for the reassignment to take effect.
Current Version	Ensure you are using the most current version of the CMS 855R form, which can be found on the CMS website.
Documentation	The Medicare Administrative Contractor (MAC) may request additional documentation within 30 days after submission of this form.
State-specific Law	This form is governed by federal law, specifically outlined in 42 C.F.R. section 424.516(d)(2) and section 424.525(a)(1).

Steps to Filling Out Cms 855R

Filling out the CMS 855R form is an essential process for those looking to reassign their Medicare benefits. After completion, the form must be submitted to the appropriate Medicare Administrative Contractor (MAC), which will process the request. Ensure all required sections are accurately filled out before submission to avoid delays.

Obtain the CMS 855R form, ensuring it is the latest version.
Read the application instructions carefully to understand the requirements.
In Section 1: Basic Information, check the appropriate box that describes your reason for submitting the application. Fill in all required fields, including effective dates.
Complete Section 2: Organization/Group Receiving the Reassigned Benefits. Provide the legal business name, Tax Identification Number (TIN), and any Medicare or National Provider Identifier (NPI) numbers for the organization/group.
In Section 3: Individual Practitioner Who is Reassigning Benefits, fill in the individual practitioner's details including name, Social Security Number (SSN), Medicare ID, and NPI.
If applicable, complete Section 4: Primary and Secondary Practice Locations. Indicate if you are adding, changing, or removing practice locations and provide the necessary addresses and identifiers.
Sign and date the certification statements in Section 6A or Section 6B, depending on whether you are the individual practitioner or the organization/group.
Make a copy of the completed form for your records before submission.
Mail the completed application with all original signatures and required documentation to the designated MAC for your state.

More About Cms 855R

What is the CMS-855R form used for?

The CMS-855R form is a Medicare enrollment application specifically for reassigning benefits. It allows healthcare providers to authorize an organization or group to bill Medicare for services they provide. This form can also be used to terminate an existing reassignment of benefits. Essentially, it’s the official way to ensure payments go to the right place when multiple healthcare professionals are involved.

Who needs to fill out the CMS-855R form?

If you’re a physician or a non-physician practitioner and want to reassign your Medicare billing rights, you need to complete this form. This could be for either a new reassignment or to terminate an existing one. Both individual practitioners and the organizations to which benefits are being assigned must be enrolled in Medicare for the reassignment to be valid. Therefore, check current enrollments before applying.

What information is required on the CMS-855R form?

Complete sections related to your basic information, organization/group identification, and practice locations. While all required fields must be filled out, optional sections can be left blank if not relevant. It is crucial that all information is accurate, especially the legal business name, as errors could delay processing.

How do I submit the CMS-855R form?

After completing the form, send it with original signatures and any required documentation to your designated Medicare Administrative Contractor (MAC). The mailing address can be found on the CMS website. Make sure that you don't forget to keep copies of everything for your records.

What if I need to make changes after submitting the CMS-855R form?

If any changes occur after your reassignment is submitted, you must notify your MAC within a specific timeframe. The signature on your form indicates that you agree to these responsibilities. Remember, changes could affect payment processes, so it’s important to keep everything up-to-date.

Can I use the CMS-855R for employment arrangements?

No, the CMS-855R is not intended for reporting employment arrangements, such as hiring physicians or support staff. If you need to report employment details, use the CMS-855I application designed for physicians and non-physician practitioners.

How do I know if I'm using the latest version of the CMS-855R form?

Always ensure you’re using the most current version of the form. You can download the latest version directly from the CMS website. Using out-of-date forms can lead to complications in processing your application, so it's worth taking the time to verify.

Common mistakes

Using an outdated form: Many individuals mistakenly utilize an earlier version of the CMS 855R form. It's vital to ensure that the most current version is being used, as older forms may not be accepted.
Incomplete information: Failing to fill out all required fields is a common error. Every field marked as required must be completed; missing information can lead to delays in processing.
Signature errors: Not signing the appropriate certification statement(s) can render the application invalid. Both the individual practitioner and a delegated or authorized official from the organization/group must sign where required.
Mismatched names: Individuals often overlook ensuring that names on the application match those on tax documents. The legal business name must correspond correctly with IRS records for the application to be processed successfully.
Improper submission: Submitting the application to the wrong Medicare Administrative Contractor (MAC) can result in significant delays. It is essential to verify and mail the application to the designated MAC for your state.

Documents used along the form

The CMS 855R form is essential for reassigning Medicare benefits between individual practitioners and eligible organizations or groups. When navigating the Medicare system, it's important to be aware of other documents that may accompany the CMS 855R to ensure comprehensive compliance and facilitate the reassignment process. Below is a list of common forms and documents that are often used alongside the CMS 855R.

CMS 855I: This form is used by individual practitioners to enroll in the Medicare program. It collects necessary information about the practitioner’s qualifications, practice locations, and other vital details.
CMS 855B: Intended for organizations and groups, this form serves to enroll healthcare entities into Medicare. It requires extensive organizational information to verify eligibility.
CMS 855A: This form is designed for institutional providers such as hospitals and skilled nursing facilities. It covers the enrollment process for those larger healthcare entities.
National Provider Identifier (NPI) Application: This document is mandatory for healthcare providers to obtain a unique identification number necessary for billing Medicare and other insurers.
Tax Identification Number (TIN) Document: Practitioners or organizations must provide a TIN for tax reporting purposes. This number is essential for the IRS and links the organization to its tax obligations.
W-9 Form: This IRS form collects the correct name and TIN of a business or individual to ensure proper tax documentation. It is often requested by organizations before processing payments.
Documentation of Practices and Affiliations: Additional supporting documents may be needed to confirm affiliations and practice locations, which help Medicare Administrative Contractors verify credentialing details.

By understanding these accompanying forms and documents, practitioners can better navigate the complexities of Medicare enrollment and reassignments. Ensuring all necessary paperwork is prepared and submitted will streamline the process and alleviate potential delays in billing and payments.

Similar forms

The CMS-855B form is an enrollment application specifically designed for organizations and group practices seeking to participate in the Medicare program. It allows entities such as clinics, hospitals, and other healthcare organizations to enroll by providing necessary information like their legal business name, tax identification number, and details regarding their practice locations. While the CMS-855R focuses on the reassignment of benefits from a practitioner to an organization, the CMS-855B facilitates the enrollment itself. Thus, both forms are interconnected, with the CMS-855B being essential for organizations that plan to receive the reassignments protected under the terms of the CMS-855R.

Similarly, the CMS-855I form serves as the application for individual practitioners, such as physicians and non-physician providers, seeking to enroll in Medicare. This form requires applicants to provide personal identification information, including their social security number and National Provider Identifier. Practitioners complete this form when they first enroll in the Medicare program and it’s a prerequisite for submitting the CMS-855R application. Therefore, while the CMS-855I outlines the enrollment process for individual practitioners, the CMS-855R deals specifically with the reassignment of payments, making both forms critical components of the Medicare enrollment framework.

Another document worth mentioning is the CMS-588 form, known as the Electronic Funds Transfer (EFT) Authorization Agreement. This form allows Medicare providers and suppliers to authorize Medicare to deposit payments directly into their bank accounts. While it serves a different purpose, its objective is still intertwined with the electronic management of billing and payment systems in the Medicare program. Providers submitting the CMS-855R must often ensure they have filled out the CMS-588 form to facilitate the receipt of payments resulting from their reassigned benefits, thus ensuring a smooth and timely transaction process.

The CMS-10114 form, also known as the Provider Enrollment Application, is another document similar to the CMS-855R in that it involves the registration of healthcare providers in Medicare, but it specifically focuses on specific categories of providers. It might not be as widely known as the CMS-855 forms but is relevant for certain provider types. Those utilizing the CMS-10114 typically need to reassess or reinforce their participation in Medicare, which can include aspects akin to those covered by the CMS-855R. Both the CMS-855R and CMS-10114 address the enrollment and billing frameworks but target different operational needs within Medicare’s structure.

Dos and Don'ts

When filling out the CMS-855R form, it's essential to adhere to best practices to ensure a smooth submission process. Here is a list of ten things to do and avoid:

Do use the most current version of the CMS-855R application. Check the CMS website for updates.
Don’t leave any required fields blank. All information must be completed unless marked as "optional."
Do type or print all information clearly; illegible forms may delay processing.
Don’t use pencil to fill out the form; only a pen should be used for signatures as well.
Do ensure that the legal business name matches the name on tax documents.
Don’t forget to sign and date all necessary certification statements on the form.
Do keep a copy of the completed application for your records.
Don’t submit the form without ensuring all sections applicable to your situation are completed.
Do respond promptly to any requests from the Medicare Administrative Contractor for additional documentation.
Don’t mix up the sections for reassigning and terminating benefits; fill out only the relevant sections for your action.

Misconceptions

Below are 10 common misconceptions regarding the CMS 855R form, along with clarifications to address each issue:

Only Physicians Can Complete This Form: A common misunderstanding is that only physicians can file the CMS 855R. In fact, non-physician practitioners, such as nurse practitioners or therapists, can also use this form to reassign benefits.
CMS 855R Is Only for New Enrollments: Some people think the CMS 855R is solely for new enrollments. However, it also facilitates changes to existing reassignments and the termination of current reassignments.
Completion Is Optional: There is a belief that completing all sections of the form is optional. In reality, all required fields must be filled out to ensure completeness and accuracy for processing.
You Can Only Submit This Form Online: While many prefer online submissions through PECOS, this form can also be submitted in paper format. Both methods are valid.
Signature from the Organization Is Not Necessary: Some assume that only the individual practitioner’s signature is needed. However, both the delegated official of the organization and the practitioner must sign the application when establishing a new reassignment.
All Information on the Form Is Confidential: There is a misconception that the information remains completely confidential. While it is protected under privacy laws, certain details may still be disclosed as part of regulatory processes.
There Is No Need to Notify MAC After Submission: Some individuals believe submitting the form is sufficient. However, it is essential to inform the Medicare Administrative Contractor (MAC) of any future changes related to the reassignment.
Any Changes Can Be Made on the CMS 855R: It is falsely believed that all types of changes can be made using this form. Only reassignments and terminations are covered; employment arrangements require the CMS-855I form.
One Form Can Cover Multiple Organizations: A significant misconception is that a single CMS 855R can be used for multiple organizations. A separate form is needed for each organization where reassignment is involved.
There Is No Deadline for Submitting Additional Documentation: It is a common mistake to think there is no urgency once the application is submitted. This is incorrect; additional documentation requested by the MAC must be supplied within 30 days.

Key takeaways

Eligibility: Complete the CMS-855R form if you are reassigning your right to bill Medicare or terminating an existing reassignment. Both the practitioner and the organization must be enrolled in Medicare for the reassignment to be effective.
Submission Requirements: A separate CMS-855R is necessary for each organization or group where a reassignment is established or terminated. All information must be typed or printed clearly and signed appropriately.
Documentation: Retain a copy of the completed application for your records. The Medicare Administrative Contractor (MAC) may request additional documentation to validate the information provided.
Important Fields: Pay close attention to ensure that the legal business name matches IRS documents. Enter all required identifiers, including Tax Identification Number, National Provider Identifier, and Medicare Identification Number.