One of Pinnacle Medicare Services’ goals is to ensure that only qualified, eligible individuals and entities are enrolled in the Medicare program and that reimbursements received for services furnished to beneficiaries are correct. Any individual, group or organization which provides covered services to beneficiaries must enroll in the Medicare program and remain enrolled in the program as a condition of being reimbursed for those services. The Medicare Enrollment Application (Form 855) is the form issued by CMS and approved by the Office of Management and Budget, for use in collecting information and documentation that must be verified to assure that the applicant is qualified and eligible to enroll in the Medicare program.

There are 3 types of applications: CMS 855I, CMS 855B and CMS 855R. These applications must be used by all providers of Medicare services within our jurisdiction, such as physicians, non-physician practitioners, ambulance companies, Independent Diagnostic Testing Facilities, and other organizations.

The CMS 855 Enrollment applications were revised by CMS in 2006. We will no longer accept applications with the revision date of 11/2001. Any applications received with this revision date will be returned to the applicant along with instructions on how to access the latest version of the CMS 855 enrollment application.

• CMS 855 Medicare Enrollment Applications
• Downloading the Enrollment Applications
• Mailing Address

Effective June 2006, Electronic Funds Transfer (EFT) is mandatory. All newly enrolling providers and existing providers who are making a change to their file must complete and submit with their application the Electronic Funds Transfer Form 588. A pre-printed voided check with the name of the provider shown must be submitted with the CMS Form 588; deposit tickets and joint bank accounts are not acceptable. This form must be signed by the individual applicant if submitting the CMS 855I and the Authorized Representative of the group/organization on file with your local Medicare Carrier if you are submitting the CMS 855B. For existing providers who are already receiving funds electronically, you do not need to submit this form unless there has been a change in bank information since you signed up for Electronic Funds Transfer. Do not submit this form if you are completing the CMS 855R application.

Although the NPI is captured on the application, a copy of the NPI Confirmation letter, email or fax received from the NPI Enumerator must be included with your application. Failure to include this form with your application will cause a delay in the processing of the application you submitted.

If you wish to participate in the Medicare Program as a Participating Physician or Supplier, you must complete the CMS Form 460 (Medicare Participating Physician or Supplier Agreement) and submit it with your CMS 855 application. If this form is not included with your application, you as an individual or group/organization provider will be setup as NONPARTICIPATING.

The CMS 855I application is for individual practitioners. This form is for both physicians and non-physician practitioners who render medical services to Medicare beneficiaries. Individuals can use this form for new enrollments, reactivations, changes to previously submitted information, or voluntary deactivation of a billing number. You will be required to complete a CMS 855I for each state where you render services to Medicare beneficiaries.

The CMS 855B application is for health care suppliers that will bill for services rendered to Medicare beneficiaries. This form is for suppliers such as ambulance companies, Independent Diagnostic Testing Facilities, labs, etc. It can also by used to enroll groups/clinic or an individual whose business is incorporated. This form can be used for new enrollments, reactivations, changes to previously submitted information, or voluntary deactivation of a billing number. It can also be used for Change of Ownership (CHOW) for Hospitals rendering Part B services, Portable X-ray and Ambulatory Surgical Centers.

All applicants must disclose their SSNs/EINs, as well as those for any managing/directing employees or person with an ownership or control interest of at least 5% or more. For each CMS 855B a CMS 855R must also be completed and submitted for each individual provider this is reassigning benefits to that organization/supplier.

The CMS 855R application is for individual practitioners who chose to reassign their benefits to an entity which is eligible to receive benefits. This form can be used for new reassignments or to terminate a current reassignment. The CMS-855R is not applicable to Ambulatory Surgery Centers, Portable X-Ray Suppliers and IDTFs who are only billing the technical part of the service.

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• (Form CMS-460) Medicare Participating Physician or Supplier Agreement
• (Form CMS - 588) Authorization Agreement for Electronic Funds Transfer (EFT) 
• (Form CMS-855A) Application for Health Care Providers that will Bill Medicare Fiscal Intermediaries
  This application is to be completed by a provider (e.g., hospital) that will furnish medical services to Medicare beneficiaries and bill fiscal intermediaries.
• (Form CMS-855B) Application for Health Care Suppliers that will Bill Medicare Carriers
  This application is to be completed by a supplier (e.g., ambulance company, physician groups) that will bill Medicare carriers for medical services furnished to Medicare beneficiaries. It is not to be used to enroll individuals.
• (Form CMS-855I) Application for Individual Health Care Practitioners
  A physician or non-physician practitioner who renders medical services to Medicare beneficiaries must complete this application. This form is processed through the Medicare carrier.
• (Form CMS-855R) Individual Reassignment of Benefits
  An individual who renders services and seeks to reassign his/her benefits to an eligible entity must complete the Form CMS-855R for each entity eligible to receive reassigned benefits. The person must be enrolled in the Medicare program as an individual before reassigning his/her benefits. The Form CMS-855R may be submitted concurrently with the Form CMS-855.
• (Form CMS-855S) DMEPOS Supplier Application
  A supplier that wishes to enroll in the Medicare program and provide Medicare beneficiaries with durable medical equipment, prosthetics, orthotics, or supplies (DMEPOS) must complete the Form CMS-855S. The National Supplier Clearinghouse (NSC) is responsible for processing the application.

Once you have completed the appropriate enrollment form(s) and attached all required documentation, please mail it to us at the following address:

Faxed applications are not acceptable. Original signatures are required all on CMS 855 applications. If you have any questions, please feel free to contact us at 1-866-794-0466 Monday through Friday between the hours of 9:00 a.m. - 3:00 p.m. (Central Standard Time)

For additional information on Provider Enrollment, please visit the CMS Provider Enrollment web site.