CMS-855R Medicare Enrollment Application

The CMS-855R is a Medicare Enrollment Application for physicians and non-physician practitioners who are reassigning their Medicare benefits to a group or an organization. This form is used when a physician or non-physician practitioner is joining or leaving a group or an organization that is already enrolled in Medicare.

The CMS-855R consists of several parts, including:

• Provider Information: This section includes general information about the provider, such as their name, address, and contact information.
• Practice Location Information: This section includes information about the practice location, including the address and phone number.
• Reassignment of Medicare Benefits: This section is used to indicate that the provider is reassigning their Medicare benefits to a group or an organization.
• Electronic Funds Transfer (EFT) Information: This section is used to provide banking information for electronic payment of Medicare services.
• Signature and Certification: This section is used to certify that the information provided on the form is accurate and complete.

The most important fields on the CMS-855R are the provider's name, address, and contact information, as well as the information regarding the reassignment of Medicare benefits.

This form is compiled when a physician or non-physician practitioner is joining or leaving a group or an organization that is already enrolled in Medicare. The parties involved in this document are the physician or non-physician practitioner and the group or organization that is already enrolled in Medicare.

When compiling the CMS-855R, it is important to ensure that all information provided is accurate and complete. Failure to provide accurate information can result in delays in processing the application or even rejection of the application.

The advantages of the CMS-855R form include the ability for physicians and non-physician practitioners to reassign their Medicare benefits to a group or an organization, which can help streamline billing and payment processes.

One potential problem when filling out the CMS-855R form is ensuring that all information provided is accurate and complete. This can be a time-consuming process, and errors can result in delays or rejection of the application.

Related forms to the CMS-855R include the CMS-855I (Medicare Enrollment Application for Physicians and Non-Physician Practitioners), CMS-855B (Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers), and CMS-855A (Medicare Enrollment Application for Institutional Providers). These forms are used for different types of Medicare enrollment.

The CMS-855R form can be submitted electronically through the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) or by mail to the appropriate Medicare Administrative Contractor (MAC). Completed forms are stored in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and can be accessed by authorized Medicare staff.