Helpful Tips

CMS-855B Completion Tips for Clinics/Group Practices and Other Suppliers Revalidation Application

Follow the instructions printed on the CMS-855B application and refer to this list of sections required for revalidation.

Section Required for Revalidation General Guidelines
Section 1: Basic Information 1A – Select ‘You are Revalidating your Medicare enrollment’
Section 2: Identifying Information 2A1 – Complete all fields that apply
  • The legal business name reported must match the NPPES Registry and the IRS document exactly, including any suffix, i.e., PC, PA, LLC, etc.
  • Specify the EIN/TIN
2A2 – Specify any state licenses and/or certifications that apply for the clinic/group
2A3 – Enter the clinic/group’s correspondence address and telephone number
  • Must be where the entity in 2A1 can be reached directly
  • May not report information about a billing agency and medical management company
2A4 – Enter the clinic/group’s medical record correspondence address and telephone number

2B – Specify the type of supplier
  • the specialty cannot be “Other” for revalidation
2C – Complete only if a hospital

2D – Complete only if a physical therapy or occupational therapy group

2E – Complete only if an ASC

2F – Complete to terminate employment arrangements of physician assistant(s)
Section 3: Final Adverse Legal Actions Section must be answered and only a “yes” or “no” response is acceptable
  • If there are no final adverse legal actions, convictions, exclusions, revocations, or suspensions, be sure to check the box labeled ‘No’
  • If there are any actions whether under the current or a former name or business identity, check the box labeled ‘Yes’ and list details and attach final adverse legal action documentation and/or resolutions
Section 4: Practice Location Information Copy appropriate page in each section as many times as necessary

4A – Complete this section for each practice location where the clinic/group will render services
  • this includes every office, clinic, hospital, assisted living community, SNF or any other health facility where the clinic/group will be rendering services
  • list every NPI/PTAN for each practice location (Do not report group member NPI/PTANs reassigned to the clinic/group)
4B – Enter special payment address (pay to address)

4C – Identify medical records storage location(s)

4D – Complete if rendering services in patients’ homes

4D3 – Enter any comments/special circumstances that apply

4E–4G – Complete these sections if a mobile or portable supplier
Section 5: Ownership Interest and/or Managing Control Information (Organizations) Copy appropriate page as many times as necessary

5A–5B – Complete these sections for each organization that has ownership interest or managing control
  • for each section 5A, complete a corresponding section 5B
Section 6: Ownership Interest and/or Managing Control Information (Individuals) Copy appropriate page in each section as many times as necessary

6A–6B – Complete these sections for every individual with ownership interest or managing control (i.e. manager, owner, board of trustees or other governing body, and authorized or delegated official)
  • Authorized official – at least one authorized official must be designated and reported.
    • To report an authorized official, must select ‘Authorized Official’ and an additional box indicating ‘5 Percent or Greater Direct/Indirect Owner’, ‘Partner’ and/or a ‘Director/Officer’
    • May also select Managing Employee
  • Managing Employee – at least one Managing Employee must be designated and reported
  • Delegated official
    • To report a delegated official, must select ‘Delegated Official’ and an additional box specifying an additional relationship
    • Cannot be a Contracted Managing Employee
  • All individuals currently on file need to be specified during revalidation or they will be end dated
  • For each section 6A, complete a corresponding section 6B
Section 8: Billing Agency/Agent Information Complete with billing agency information or select the box indicating that this does not apply
Section 12: Supporting Documentation Information Contains a list of supporting documentation
  • Remember to include the form CMS-588 (EFT) current version and a confirmation of account information on bank letterhead or a voided check
Supporting Documentation Required for Enrollment Revalidations
Section 13: Contact Person Information Copy appropriate page as many times as necessary
  • Complete with the contact person’s information
Section 15: Certification Statement Note: For revalidation, only one current authorized or delegated official signature and date is needed
  • 15B–New authorized official added in section 6, signature and date is required
  • 15D–New delegated official added in section 6, signature and date is required, must be cosigned and dated by an authorized official

 

Reviewed 7/29/2024