When to complete a CMS-855R
CMS-855R is to be used for Reassignment of Medicare Benefits — Complete this application if you are reassigning your right to bill the Medicare program and receive Medicare payments, or are terminating a reassignment of benefits.
Reassigning your Medicare benefits allows an eligible supplier to submit claims and receive payment for Medicare Part B services that you have provided. Such an eligible supplier may be an individual, a clinic/group practice or other organization.
Things to consider:
• Both the individual practitioner and the eligible supplier must be currently enrolled (or concurrently enrolling via submission of the CMS-855B for the eligible supplier and the CMS-855I for the practitioner) in the Medicare program before the reassignment can take effect.
• Generally, this application is completed by a supplier, signed by the individual practitioner, and submitted by the supplier.
• When terminating a current reassignment, either the supplier or the individual practitioner may submit this application with the appropriate sections completed.
• The individual or authorized/delegated official, by his/her signature, agrees to notify the Medicare fee-for service contractor of any future changes to the reassignment in accordance with 42 C.F.R. 424.516(d)(2).
• An individual will not need to reassign benefits to a corporation, limited liability company, professional association, etc., of which he/she is the sole owner. See the CMS-855I Application for Physicians and Non-Physician Practitioners for more information.
• Physician assistants: This application should not be used to report employment arrangements. Employment arrangements must be reported in Sections 2E through 2G of the CMS-855I
Download CMS-855R external pdf file
• Find step-by-step guidance to completing the CMS-855R form
• View a simulation flash file on how to avoid the No. 1 reason applications are denied
