Submit an Initial Enrollment Application
Step 1: Determine You are in the Right Place
The enrollment process for submitting an initial organization enrollment application has a number of steps as well as documents required for submission. You first need to know that you are in the right place.
To submit the initial organization enrollment application you need to be at least one of the following:
- A health care organization and a new enrollee in Medicare
- Undergoing a change of ownership and not accepting assignment of the Medicare assets/liabilities of the former owner
- Currently enrolled in Medicare but do not have a PECOS record
Step 2: Choose the Right Applications
Once you are sure that this is the right enrollment for your business, you need to complete the correct applications for submission. The two applications for this initial enrollment process are the Medicare Enrollment Application form for Institutional Providers (CMS-855A) and the EFT Authorization Agreement (CMS-588).
You can complete the Enrollment Application either electronically or on paper. Submitting the claim electronically will result in a faster response than submitting by mail.
- To submit your application electronically, you will access PECOS. Here you will be able to become a registered user and complete the application. Select the “My Enrollments” button then select the “New Application” button and the system will guide you through the process and ensure that you complete the required application forms.
- To submit your application by mail, you will fill out form CMS-855A (instructions for completion are on the form) and follow the instructions regarding where to mail the application. You will complete sections 1A and 1B of the CMS-855A application to determine required sections. Refer to the Medicare Fee-for-Service Provider Enrollment Contact List to locate the mailing address for your State's MAC.
You must next complete the EFT Authorization Agreement. This application can also be completed either electronically or on paper (to be mailed to your State’s Medicare administrative contractor). Submitting the claim electronically will result in a faster response than submitting by mail.
- This application can also be completed through PECOS and the system will walk you through the steps you need to take to complete the application.
- To submit this application by mail, you will fill out form CMS-588 and mail it to the same mailing address for your State’s MAC. This form can be submitted along with the Enrollment Application.
Step 3: Submit the Correct Documentation
It is very important to submit the correct documentation along with your enrollment and EFT applications. Supporting documents can be submitted electronically or by mail along with the applications.
- PECOS will generate a list of required supporting documentation that you can attach and submit along with the applications. You will be able to upload the supporting documentation prior to submitting the completed application.
- If you are mailing your applications in, form CMS-855A, section 17 will help you determine the documentation required for your application. You must include your supporting documentation along with your applications to avoid any unnecessary delays in processing.
Best Practices for Submitting an Initial Enrollment Application:
- Take advantage of PECOS to complete your Enrollment Application.
- If you choose not to e-sign, remember to mail the signed and dated certification statements.
- Be sure to pay the application fee or submit a hardship request.
- If you are mailing in your application, verify that you are using the correct version of the CMS-855 (07/11).
- If you are mailing in your application, verify that you are using the correct version of the CMS-588 (05/10).
- Ensure that your application is completed, signed and that all supporting documentation is included.
- Ensure that the Legal Business Name entered in section 2 matches the name located on your IRS tax documentation.
- Respond quickly to any request for additional information or changes required to process your application.
Last Modified: 1/22/15