CMS-855I Completion Tips for Physicians and NPPs that Reassign All Benefits Revalidation Application

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

Sections Required for Revalidation	General Guidelines
Section 1: Basic Information	1A – Select ‘You are Revalidating your Medicare enrollment’ 1B – Check all that apply (optional during revalidation)
Section 2: Personal Identifying Information	2A – Enter all personal information The full legal name reported must match the social security record and NPPES Registry exactly including any initials, credentials and suffixes. 2B – Check the box not applicable or supply the active license/certification/registration information 2C – Indicate if accepting new patients (optional) 2D ‒ Indicate an address where correspondence will be sent directly to physician or nonphysician practitioner Can be a home address, but cannot be a billing agency or medical management company 2E – Indicate an address where medical records correspondence will be sent directly to physician or nonphysician practitioner Cannot be a billing agency or medical management company information 2G – Specify physician specialty (select all that apply) Use ‘P’ for Primary and ‘S’ for all Secondary 2H ‒ Specify nonphysician practitioner specialty 2I1 - Identify doctoral psychology degree 2I2 - Psychologists billing independently (in private practice) 2J ‒ Physical/Occupational Therapists (in private practice) 2K ‒ If a nurse practitioner or certified clinical nurse specialist answers “yes,” furnish SNF information
Section 3: Final Adverse Legal Action	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: Business Information	Check the box “If you do not have a private practice but reassign all of your benefits to an entity, check this box and only complete section 4F.” 4F – Complete for every group or organization where benefits have been reassigned Specify each group/organization’s name, PTAN and NPI Be sure to address all reassignments specified in the revalidation request letter
Section 12: Supporting Documentation Information	Contains a list of supporting documentation National Certifications and diploma for nonphysician practitioners are required
Section 13: Contact Person Information (optional)	Complete with the contact person’s information
Section 15: Certification Statement and Signature	Complete with individual physician or nonphysician practitioner’s name as indicated in section 2A for section 15B The individual physician or nonphysician practitioner must sign and date If adding a new reassignment, the authorized/delegated official must sign and date section 15C.

CMS-855I Completion Tips for Physicians and NPPs that Reassign All Benefits Revalidation Application

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