Medicare Participating Physician or Supplier Agreement (CMS-460)

On a quarterly basis beginning on October 1, 2006, Medicare will routinely deactivate the billing privileges of those providers who fail to bill the Medicare program for four consecutive quarters. Each billing account is considered separately for the deactivation criteria. This means that a provider who is affiliated with a group may be deactivated under his individual Medicare billing account, yet the group member Medicare billing account remains active. Notification will not be done prior to deactivation.

To reactivate your individual and/or group billing privileges, please review the following information.

• If an individual provider billing account is deactivated, the provider is required to submit a completed CMS-855I (04/06 or 06/06), Medicare Enrollment Application Physicians and Nonphysician Practitioners .

Note: Sole proprietors who are incorporated must complete the CMS-855B, Medicare Enrollment Application Clinic/Group Practices and Certain Other Suppliers , CMS-855R, Medicare Enrollment Application Reassignment of Medicare Benefits , along with the CMS-855I

• If the group member billing account is deactivated, the group is required to submit a completed CMS-855R (04/06 or 06/06), Medicare Enrollment Application Reassignment of Medicare Benefits
• If the group billing account is deactivated, the group is required to submit a completed CMS-855B (04/06 or 06/06), Medicare Enrollment Application Clinic/Group Practices and Certain Other Suppliers and a completed CMS-855R (04/06 or 06/06), Medicare Enrollment Application Reassignment of Medicare Benefits