Institutional Providers: Revised CMS-855A Medicare Enrollment Paper Application Required 12/17/2023

If you don’t use PECOS, use the revised CMS-855A (Medicare Enrollment Application -Institutional Providers) to enroll or update your information. MACs will accept current and revised versions of the form through 12/16/2023. Starting 12/17/2023, you must use the revised form CMS-855A (09/23).

Form updates:​

• Section 2 – Medical Record Correspondence Address
• Section 4 – Practice Location
  • Primary Practice Location checkbox
  • Date you saw or will see your first Medicare patient field
  • Hospitals only (Identify type of practice location) – Select PBD site option and type
  • Medical Record Electronic Storage
• Section 5 and 6 – Ownership and Managerial Information
  • Ownership changes attach the legal document that governed the transaction
  • Report all limited partnership
  • Indirect owner checkbox, if organization owned by another organization/individual
  • Report all HH+H and SNF Medical Directors and Administrators
• Section 10 – OTP Supplier Information
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• Events: Join Provider Enrollment and PECOS sessions

Posted 12/7/2023