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Fill in Your Cms 855R Template

The CMS 855R form is the Medicare Enrollment Application for the Reassignment of Medicare Benefits. This form is essential for healthcare providers who wish to reassign their right to bill Medicare and receive payments for services rendered to beneficiaries. Understanding how to complete this form correctly is crucial for ensuring timely and accurate payment processing.

Table of Contents

The CMS 855R form is a crucial document for healthcare providers looking to reassign their Medicare benefits. This form allows individual practitioners to transfer their rights to bill Medicare and receive payments for services rendered to beneficiaries. It is essential for those who are part of an organization or group practice, enabling these entities to submit claims on behalf of the practitioners. Completing the CMS 855R is necessary not only for establishing new reassignments but also for terminating existing ones. Both the individual practitioner and the organization must be enrolled in the Medicare program for the reassignment to take effect. The form requires specific information, including the legal business name, tax identification number, and National Provider Identifier of both the practitioner and the organization. It is important to ensure that all information is accurate and legible, as any discrepancies can delay the processing of claims. Additionally, the CMS 855R form must be submitted with original signatures and may require additional documentation if requested by the Medicare Administrative Contractor (MAC). Understanding the proper use of this form is vital for maintaining compliance and ensuring timely reimbursement for services provided to Medicare beneficiaries.

Sample - Cms 855R Form

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)

↓ Cms 855R PDF

File Specs

Fact Name	Details
Purpose	The CMS-855R form is used for reassigning Medicare benefits to an organization or group, allowing them to bill and receive payments for services rendered to Medicare beneficiaries.
Eligibility	Eligible individuals include physicians and non-physician practitioners, except for physician assistants, who can reassign their benefits after enrolling in Medicare.
Submission Process	This application must be completed and submitted by the organization or group, signed by both the individual practitioner and an authorized official.
State-Specific Law	The application must comply with federal regulations under 42 C.F.R. section 424.516 and may require additional documentation upon request by the Medicare Administrative Contractor (MAC).

Cms 855R - Usage Guidelines

Filling out the CMS-855R form is an essential step for healthcare providers who wish to reassign their Medicare benefits. This process ensures that the right organization or group receives payments for services rendered to Medicare beneficiaries. Completing the form accurately is crucial, as it helps maintain compliance with Medicare regulations and facilitates timely payment.

Obtain the most current version of the CMS-855R form from the CMS website.
Read through the instructions on the form carefully to understand the requirements.
Complete Section 1 by checking the appropriate box that indicates the reason for submitting the application.
Provide the effective date for the reassignment or termination as required in Section 1.
Fill out Section 2 with the organization/group's information that will receive the reassigned benefits, including the legal business name, Tax Identification Number (TIN), and National Provider Identifier (NPI).
In Section 3, provide the individual practitioner's information who is reassigning benefits, including their name, Social Security Number (SSN), and NPI.
If applicable, complete Section 4 to identify primary and secondary practice locations. Indicate whether you are adding, changing, or removing information.
Sign and date the certification statements in Section 6A or 6B, depending on whether you are the individual practitioner or the authorized official of the organization/group.
Make a copy of the completed form and all supporting documentation for your records.
Mail the completed application to your designated Medicare Administrative Contractor (MAC), ensuring it includes original signatures.

Your Questions, Answered

What is the purpose of the CMS-855R form?

The CMS-855R form is used to reassign Medicare benefits. If you are a healthcare provider looking to transfer your right to bill Medicare and receive payments for services rendered to Medicare beneficiaries, this form is essential. It allows eligible organizations or groups to submit claims on your behalf. Additionally, if you wish to terminate an existing reassignment, this form serves that purpose as well.

Who needs to complete the CMS-855R form?

How do I submit the CMS-855R form?

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

Common mistakes

Using an outdated version of the form: It is essential to ensure that the most current version of the CMS-855R form is being used. Submitting an outdated form can lead to delays or rejections of the application.
Inaccurate or inconsistent information: All information provided must match official documents. Discrepancies between the legal business name, tax documents, and other identifiers can result in processing issues.
Neglecting to sign the application: Both the individual practitioner and the authorized official of the organization/group must sign and date the certification statement(s). Missing signatures can lead to application rejection.
Failing to provide required documentation: The Medicare Administrative Contractor (MAC) may request additional documentation to support the application. It is the applicant's responsibility to provide this information within the specified timeframe.
Ignoring optional fields: While optional fields are not mandatory, it is advisable to complete them. Keeping this information updated can aid in future communications and processing.

Documents used along the form

The CMS 855R form is essential for healthcare providers who wish to reassign their Medicare benefits. However, several other forms and documents are often used in conjunction with this application. Each of these documents plays a critical role in the enrollment and reassignment process, ensuring compliance with Medicare regulations.

CMS-855I: This form is used by individual practitioners to enroll in the Medicare program. It collects essential information about the practitioner, including their credentials and practice details.
CMS-855B: Organizations and group practices use this form to enroll in the Medicare program. It requires details about the organization, including ownership and management structure.
CMS-855S: This form is for suppliers, such as durable medical equipment providers, who need to enroll in Medicare. It gathers information about the supplier’s business operations and service offerings.
CMS-588: The Electronic Funds Transfer (EFT) Authorization Agreement is used to set up direct deposit for Medicare payments. Providers must complete this form to ensure timely payment processing.
CMS-10114: This is the Medicare Enrollment Application for Group Practices and Organizations. It is specifically designed for groups to enroll and manage their Medicare participation.
CMS-855R Instructions: These instructions accompany the CMS-855R form and provide guidance on completing the application accurately, including details on what information is required.
National Provider Identifier (NPI) Application: Providers must obtain an NPI to participate in Medicare. This application is necessary for both individual practitioners and organizations.
W-9 Form: This form is used to provide taxpayer identification information to the IRS. It is often required for tax reporting purposes when dealing with Medicare payments.
Medicare Administrative Contractor (MAC) Correspondence: Any communication with the MAC regarding enrollment status, changes, or requests for additional documentation is crucial for maintaining compliance.

These forms and documents are integral to the Medicare enrollment and reassignment process. Proper completion and submission help ensure that healthcare providers can effectively manage their participation in the Medicare program.

Similar forms

The CMS-855I form is used by individual practitioners to enroll in the Medicare program. Similar to the CMS-855R, which focuses on the reassignment of benefits, the CMS-855I requires the practitioner to provide personal and professional information. Both forms necessitate the submission of accurate identification numbers, such as the National Provider Identifier (NPI) and Medicare Identification Number (PTAN). While the CMS-855R is specifically for reassignment, the CMS-855I serves as the initial enrollment application for practitioners, establishing their eligibility to bill Medicare directly.

The CMS-855B form is designed for organizations, clinics, and group practices to enroll in the Medicare program. Like the CMS-855R, it requires detailed information about the organization, including its legal business name and Tax Identification Number (TIN). Both forms are integral to the Medicare enrollment process, ensuring that organizations can submit claims and receive payments for services rendered. The CMS-855B focuses on the organization's enrollment, while the CMS-855R centers on the reassignment of benefits from individual practitioners to these organizations.

The CMS-855S form is used by suppliers of durable medical equipment, prosthetics, orthotics, and supplies. This form shares similarities with the CMS-855R in that it involves the enrollment process for entities seeking to bill Medicare. Both forms require detailed information about the entity, including identification numbers and practice locations. However, the CMS-855S specifically addresses the unique requirements and regulations surrounding the provision of medical supplies, while the CMS-855R focuses on the reassignment of benefits for services rendered by practitioners.

The CMS-855O form is intended for ordering and referring providers who wish to enroll in Medicare. Similar to the CMS-855R, this form is crucial for ensuring that providers can refer patients for Medicare-covered services. Both forms require the submission of identifying information and compliance with Medicare regulations. The key difference lies in the CMS-855O's focus on providers who do not bill Medicare directly but are essential for patient care coordination, whereas the CMS-855R is specifically for those reassigning their billing rights.

The CMS-855A form is used by institutional providers, such as hospitals and skilled nursing facilities, to enroll in the Medicare program. This form shares a common goal with the CMS-855R, which is to facilitate the billing process for services rendered. Both forms require detailed information about the provider, including practice locations and identification numbers. However, the CMS-855A is tailored for institutional settings, focusing on the specific needs and regulations applicable to facilities, while the CMS-855R is dedicated to individual practitioners and their benefit reassignments.

Dos and Don'ts

When filling out the CMS 855R form, attention to detail is crucial. Here are four important dos and don'ts to keep in mind:

Do ensure that all required fields are completed accurately. Missing or incorrect information can lead to delays in processing.
Do keep a copy of your completed application for your records. This can be helpful for future reference or in case of any inquiries.
Don't use pencil when filling out the form. All information should be typed or printed clearly in ink.
Don't forget to sign and date the certification statements as required. An unsigned application may be rejected.

Misconceptions

Understanding the CMS-855R form is crucial for healthcare providers who wish to reassign their Medicare benefits. However, several misconceptions can lead to confusion. Here are nine common misunderstandings about this form:

Only large organizations need to use the CMS-855R. Many believe that only large healthcare organizations are eligible to use this form. In reality, individual practitioners can also use it to reassign their benefits.
Once I submit the CMS-855R, I cannot make changes. Some assume that submitting this form locks them into a decision. However, practitioners can update their information or terminate a reassignment at any time by submitting the appropriate sections of the form.
All fields on the form must be completed. There is a misconception that every field must be filled out. In fact, only fields marked as "optional" do not need to be completed. However, it is advisable to keep optional fields updated if they are provided.
I can use the CMS-855R for employment arrangements. Many practitioners mistakenly think this form can be used to report employment arrangements. Instead, employment arrangements should be reported using the CMS-855I application.
Submitting the CMS-855R is the only step needed for reassignment. Some providers believe that submitting this form is the final step. In reality, both the individual practitioner and the organization must be enrolled in Medicare for the reassignment to take effect.
I can submit one CMS-855R for multiple organizations. It is a common belief that one form can cover multiple organizations. Each organization requires a separate CMS-855R submission for reassignments.
My benefits will be reassigned immediately after submitting the form. Many expect instant results. However, the reassignment is effective only after processing by the Medicare Administrative Contractor (MAC).
The CMS-855R is only for physicians. There is a misconception that this form is exclusive to physicians. In fact, non-physician practitioners can also use it to reassign Medicare benefits.
Once I terminate a reassignment, I cannot reassign my benefits again. Some believe that terminating a reassignment is permanent. However, individuals can reassign their benefits again in the future by submitting a new CMS-855R.

By clarifying these misconceptions, healthcare providers can better navigate the Medicare enrollment and reassignment process, ensuring they receive the payments they are entitled to for their services.

Key takeaways

Filling out the CMS-855R form is essential for healthcare providers looking to reassign their Medicare benefits. Here are key takeaways to keep in mind:

Understand the Purpose: This form is used to reassign your right to bill Medicare and receive payments for services rendered to beneficiaries.
Eligibility: Only certain practitioners, like physicians and non-physician practitioners, can complete this form.
Concurrent Enrollment: Both the individual practitioner and the organization/group must be enrolled in Medicare for the reassignment to be effective.
Use the Correct Version: Always ensure you are using the most current version of the CMS-855R form.
Single Application per Organization: A separate CMS-855R must be submitted for each organization or group where reassignment is established or terminated.
Documentation: Be prepared to provide additional documentation if requested by the Medicare Administrative Contractor (MAC).
Signature Requirements: The application must be signed by both the individual practitioner and an authorized official from the organization/group.
Keep Copies: Retain a copy of your completed application for your records.
Mailing Instructions: Send the completed form to your designated MAC, which processes enrollment applications for your state.
Privacy Protections: The information provided on this form is protected under specific privacy laws, ensuring confidentiality.

By following these guidelines, practitioners can navigate the process of reassigning Medicare benefits more effectively.