When to use a CMS-855B form and tips to avoid error

CMS-855B is to be used by Clinics/group practices and certain other suppliers -- Complete this application if you are an organization/group that plans to bill Medicare and you are:

• A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, portable x-ray suppliers).

• A hospital or other medical practice or clinic that may bill for Medicare Part A services but will also bill for Medicare Part B practitioner services or provide purchased laboratory tests to other entities that bill Medicare Part B.

• Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor’s jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another Medicare fee-for-service contractor).

• Currently enrolled in Medicare and need to make changes to your enrollment data (e.g., you have added or changed a practice location).

The following suppliers must complete this application to initiate the enrollment process:
• Ambulance Service Supplier
• Ambulatory Surgical Center
• Clinic/Group Practice
• Independent Clinical Laboratory
• Independent Diagnostic Testing Facility (IDTF)
• Intensive Cardiac Rehabilitation Supplier
• Mammography Center
• Mass Immunization (Roster Biller Only)
• Part B Drug Vendor
• Portable X-ray Supplier
• Radiation Therapy Center
• Pharmacy

Note: Are you a supplier looking for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) enrollment? Please visit CGS Medicare external link, the DMEPOS Medicare Administrative Contractor (MAC) for Florida, Puerto Rico, and the U.S. Virgin Islands.

Download CMS-855B external pdf file

• View how to avoid the errors flash file that result in the CMS-855B form not being processed, specifically missing signatures or dates in Section 15B and Section 16A.

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