Provider Enrollment Packet

Cahaba’s “Provider Enrollment Packet” offers assistance in completing an accurate CMS-855A. The CMS-855A Medicare enrollment application must be completed when enrollment information needs to be added, deleted, or changed. This includes:

Changing Existing Medicare Information—Currently Enrolled Providers
- Additions, Deletions, and Changes of Address
- Managing/Directing Employee Change
- Authorized/Delegated Official Change
- Transfer of Stock
- Note that in conjunction with any change submitted on the CMS-855A or 588 form, a full CMS-855A may be required if the provider has not submitted an application since implementation of the Provider Enrollment Chain and Ownership System (PECOS) on July 29, 2002
Initial Enrollment Resulting in Issuance of a Medicare Provider Number
Home Health Agency Capitalization Requirements
Voluntary Termination
Changes of Ownership (old and new owner)
Acquisitions and Mergers (acquiring and acquired owners)
Consolidations (consolidating owners and newly created provider)
Revalidation (contractor requested or voluntary)
Reactivation of previously deactivated provider number

Access the following:

CMS-855A application and instructions — Available on the Centers for Medicare & Medicaid Services (CMS) Web site and can be completed on-line or can be downloaded to complete manually.
CMS-855A Provider Enrollment Process Checklist — Ensures all steps in the process have been completed (applicable to all types of submissions).
CMS-855A Provider Enrollment Submission Checklist — A checklist with step-by-step instructions for completing the application (applicable for only home health and hospice providers).
Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588) Form — Allows Medicare to transfer payments to your facility’s financial institution. Must be completed for new enrollments. For enrolled providers, if not already receiving EFT, the CMS-588 EFT form must be completed when requesting an enrollment change. The CMS-588 EFT form must be submitted with the CMS-855A application. Refer to Cahaba’s Electronic Funds Transfer (EFT) Web page for additional information.
Provider Enrollment Review Process — Refer to this Web page for an explanation of the process used to review the CMS-855A enrollment application.