Most Frequently Asked Questions--Provider Enrollment--Legacy
Which enrollment application form(s) should I complete?
- CMS-855B: This form is used by groups and organizations that are enrolling in Medicare for the first time in a given state, or that are reporting a change to previously reported enrollment information. (Individuals who are the sole owner of a professional corporation, professional association, or limited liability company and who bill through that entity may complete just the CMS 855I and are not required to complete the CMS- 855B.)
- CMS-855I: This form is used by individual physicians and practitioners who are enrolling in Medicare for the first time in a given state or who are reporting changes to their enrollment. This includes individuals who are unincorporated sole proprietors, reporting their income to the Internal Revenue Service with either their Social Security Number or their employer identification number. It also includes individuals who are the sole owner of a professional corporation, professional association, or limited liability company and who will bill Medicare through that business entity.
- CMS-855R: This form is used by individual physicians/practitioners who are reassigning Medicare benefits to an enrolled group, organization, or individual or who are making a change to a previously established reassignment. (Physician assistants do not complete the CMS-855R; they complete only the CMS-855I.)
Note: Only one reason may be checked for submittal of an application. Separate applications must be submitted, for example, to report a new enrollment and a change of information to an established record, such as a voluntary termination. Termination of a reassignment of benefits may be reported only on Form CMS-855R. Termination of one reassignment and the addition of a new reassignment must be reported on separate CMS- 855R forms.
Where should completed applications and other provider enrollment documents be sent?
Illinois, Michigan, and Wisconsin enrollment applications should be sent to the following address:
Wisconsin Physicians ServiceIf you are sending the application via courier, please use the following address:
Medicare Part B
Provider Enrollment Department
P.O. Box 8248
Madison, WI 53708-8248
1707 W BroadwayMinnesota enrollment applications should be sent to the following address:
Madison, WI 53713-1834
Wisconsin Physicians ServiceMay provider enrollment applications be submitted electronically?
Medicare Part B
Provider Enrollment Department
8120 Penn Avenue South, Suite 200
Bloomington, MN 55431-1394
Physicians, non-physician practitioners, and provider and supplier organizations may submit their applications electronically via Internet-Based PECOS. The application is completed and reviewed on-line and is then submitted electronically. The original signed and dated certification statement and all required supporting documentation must be mailed to the WPS Medicare Provider Enrollment Department at the appropriate address. The certification statement and all required supporting documentation must be mailed in promptly or the application could be subject to rejection. Note: Providers are encouraged to submit applications via Internet-Based PECOS but are not currently required to do so.
Am I required to receive Medicare payment via electronic funds transfer (EFT)?
All applications for initial enrollment require that Form CMS-588, "Electronic Funds Transfer (EFT) Authorization Agreement," be included with the application. Established providers who are not already receiving payment via EFT, and who are reporting any change to their enrollment information, must submit Form CMS-588 to initiate payment via EFT.
Providers already receiving payments via EFT are not required to complete Form CMS-588 when reporting a change of information. If, however, there is a change in banking information (e.g., bank name or account number), the provider must complete a new Form CMS-588 form.
When EFT information is being changed, a complete CMS-855I or CMS-855B may also be required to update the provider's enrollment information. If the required CMS 855I or CMS-855B is not submitted within 60 days of the request, the change in EFT information will not be processed, and the provider's Medicare enrollment will be subject to revalidation requirements per 42 CFR § 424.515.
Note: Established entities not receiving payment via EFT are not required to complete Form CMS-588 when they submit Form CMS-855R, Reassignment of Medicare Benefits, to report the addition or termination of members to their group Practice
What action may be taken by a provider who disagrees with a determination on a provider enrollment application?
Providers who disagree with a determination on a provider enrollment application may submit a Corrective Action Plan (CAP) or a request for reconsideration.
Corrective Action Plan: If a provider believes that the deficiencies cited can be corrected to establish eligibility to participate in the Medicare program, a CAP can be submitted within 30 calendar days of the postmark date of our notification letter. The CAP must be submitted by letter, which must be signed and dated by the provider, or by the authorized or delegated official. It may not be signed by a contact person or other staff member. The CAP must provide evidence that the provider is in compliance with Medicare requirements.
CAPs for providers in Illinois, Michigan, and Wisconsin should be mailed to:
Wisconsin Physicians ServiceThey may also be faxed to 608-301-2740.
Medicare Part B
Attention: Provider Enrollment
PO Box 8248
Madison, WI 53708-8248.
CAPs for providers in Minnesota should be mailed to:
Wisconsin Physicians ServiceRequest for Reconsideration: Providers who believe the determination on an application was incorrect may also request a reconsideration before a contractor hearing officer. The reconsideration is an independent review and is conducted by a person who was not involved in the initial determination. Reconsiderations must be requested in writing within 60 calendar days of the postmark date of our notification letter.
Medicare Part B
8120 Penn Avenue South, Suite 200
Bloomington, MN 55431-1394.
They may also be faxed to 952-885-2814.
Additional information that may have a bearing on the decision may be submitted with the reconsideration request. Failure to request a reconsideration within the specified period is deemed a waiver of all rights to further administrative review. The request for reconsideration must state the issues, or the findings of fact with which the provider disagrees, and the reasons for disagreement.
Requests for reconsideration must be submitted in writing and mailed to:
Wisconsin Physicians ServiceNote: If the issue can be addressed via CAP, e.g., the submission of information that was missing from the application and not provided on request, a CAP will expedite the enrollment process and result in a faster determination than a request for reconsideration.
Medicare Part B
Attention: Provider Enrollment Reconsideration Requests
PO Box 4433, Marion, IL 62959.
Page Last Updated: Friday, 06-Nov-2009 14:16:20 CST
