| Reformatting of CMS 855B - Mapping Guide |
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| Current Section Location |
Current Section Header/Subheader/Information |
New Section Location |
New Section Header/Subheader/Information |
| Intro. Pages |
Who Should Complete This Application |
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Who Should Complete and Submit This Application |
| Intro. Pages |
Billing Number Information |
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Billing Number and National Provider Identifier Information |
| Intro. Pages |
Instructions For Completing And Submitting This Application |
stet |
Instructions for Completing This Application |
| Intro. Pages |
Avoid Delays In Your Enrollment |
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Tips To Avoid Delays In Your Enrollment |
| Intro. Pages |
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Important Information About Individual Verses Organizational NPIs |
| Intro. Pages |
Additional Information |
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stet |
| Intro. Pages |
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Acronyms Commonly Used In This Application |
| Intro. Pages |
Mail Your Application |
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Where To Mail Your Application |
| 1 |
Basic Information |
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stet |
| 1A |
Check one box and complete the required sections. |
1A |
Reason For Submitting This Application |
| 1B |
Check all that apply and complete the required sections. |
1B |
What Information Is Changing? |
| 2 |
Identifying Information |
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stet |
| 2A |
Type of Supplier |
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| 2B |
Supplier Identification Information |
2B |
Business Identification Information |
| 2B1 |
Business Information |
2C |
Business Structure Information |
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2D |
Internal Revenue Service Registration |
| 2B2 |
State License Information/Certification Information |
5A |
License/Certification/Accreditation Information |
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5A1 |
License Information |
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5A2 |
Certification Information |
| 2B3 |
Correspondence Address |
4A |
Correspondence Mailing Address |
| 2C |
Hospitals Only |
5C |
stet |
| 2C1 |
Are you going to: (billing checkboxes) |
n/a |
deleted |
| 2C2 |
List the hospital departments for which you plan to bill separately: |
n/a |
deleted |
| 2D |
Comments/Special Circumstances |
5E |
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| 2E |
Physical Therapy (PT) and Occupational Therapy (OT) Groups Only |
5B |
stet |
| 2F |
Accreditation for Ambulatory Surgical Centers (ASCs) Only |
5A3 |
stet |
| 2G |
Termination of Physician Assistants (Only) |
5D |
Termination of Physician Assistants Only |
| 2H |
Advanced Diagnostic Imaging (ADI) Suppliers Only |
n/a |
deleted |
| 3 |
Final Adverse Legal Actions/Convictions |
8 |
Final Adverse Legal Actions |
| 4 |
Practice Location Information |
3 |
stet |
| 4A |
Practice Location Information |
4 |
Important Address Information |
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4B |
Revalidation Request Package Mailing Address |
| 4B |
Where Do You Want Remittance Notices or Special Payments Sent? |
4C |
Remittance Notices/Special Payments Mailing Address |
| 4C |
Where Do You Keep Patients’ Medical Records? |
4D |
Medicare Beneficiary Medical Records Storage Address |
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4D1 |
Paper Storage |
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4D2 |
Electronic Storage |
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5 |
Supplier Specific Information |
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5A4 |
Director of Independent Clinical Laboratories Only |
| 4D |
Rendering Services In Patients’ Homes |
6 |
In-Home Services Information |
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7 |
Mobile and/or Portable Services Information |
| 4E |
Base of Operations Address for Mobile or Portable Suppliers (Location of Business Office or Dispatcher/Scheduler) |
7A |
Base of Operations Address for Mobile or Portable Suppliers |
| 4F |
Vehicle information |
7B |
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| 4G |
Geographic Location for Mobile Or Portable Suppliers Where The Base Of Operations and/or Vehicle Renders Services |
7C |
Geographic Area Covered by the Mobile and/or Portable Service |
| 5 |
Ownership Interest and/or Managing Control Information (Organizations) |
9 |
stet |
| 5A |
Organization with Ownership Interest and/or Managing Control—Identification Information |
9A |
Organization Identification Information (Ownership and/or Managing Control) |
| 5B |
Final Adverse Legal Action History |
9B |
stet |
| 6 |
Ownership Interest and/or Managing Control Information (Individuals) |
10 |
stet |
| 6A |
Individuals with Ownership Interest and/or Managing Control—Identification Information |
10A |
Individual Identification Information (Ownership and/or Managing Control) |
| 6B |
Final Adverse Legal Action History |
10B |
stet |
| 7 |
For Future Use |
n/a |
delete |
| 8 |
Billing Agency Information |
13 |
stet |
| 9 |
For Future Use |
n/a |
delete |
| 10 |
For Future Use |
n/a |
delete |
| 11 |
For Future Use |
n/a |
delete |
| 12 |
For Future Use |
n/a |
delete |
| 13 |
Contact Person |
14 |
Contact Person Information |
| 14 |
Penalties For Falsifying Information |
16 |
Penalties For Falsifying Information On This Application |
| 15 |
Certification Statement |
18 |
Authorized Official Certification Statement And Signature |
| 15A |
Additional Requirements for Medicare Enrollment |
18A |
Certification Statement |
| 15B |
1st Authorized Official Signature |
18B |
Signature(s) |
| 15C |
2nd Authorized Official Signature |
n/a |
deleted |
| 16 |
Delegated Official (Optional) |
17 |
Assignment of Delegated Official(s) (Optional) |
| 16A |
1st Delegated Official Signature |
n/a |
deleted |
| 16B |
2nd Delegated Official Signature |
n/a |
deleted |
| 17 |
Supporting Documents |
15 |
Supporting Documentation Information |
| Attachment 1 |
Ambulance Service Suppliers |
11 |
Ambulance Service Suppliers Only |
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11A |
Geographic Area |
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11B |
State License Information |
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11C |
Paramedic Intercept Services Information |
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11D |
Vehicle Information |
| Attachment 2 |
Independent Diagnostic Testing Facilities |
12 |
Independent Diagnostic Testing Facilities (IDTFs) Only |
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12A |
Date IDTF Met Standards Qualifications |
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12B |
Comprehensive Liability Insurance Information |
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12C |
CPT-4 and HCPCS Codes |
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12D |
Interpreting Physician Information |
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12E |
Technicians Who Perform Tests |
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12F |
Supervising Physicians |
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12F 1-5 |
Supervising Physical Detail/Duties and Signature (re: 12F) |
| last page |
Medicare Supplier Enrollment Privacy Act Statement |
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Medicare Supplier Enrollment Application Privacy Act Statement |