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CMS-855B Revalidation Completion Tips for Clinics/Group Practices and Suppliers

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

Section Required for Revalidation General Guidelines
Section 1: Basic Information 1A – Select ‘You are Revalidating your Medicare enrollment’
  • Specify the group or supplier’s PTAN and NPI here
Section 2: Identifying Information 2A – Specify the type of supplier
  • the specialty cannot be “Other” for revalidation

2B1 – Complete all fields that apply

  • The legal business name reported must match the NPPES Registry and the IRS document exactly, including any suffix, i.e., PC, PA, LLC, etc.
  • Specify the EIN/TIN

2B2 – Specify any state licenses and/or certifications that apply for the clinic/group
2B3 – Enter the clinic/group’s correspondence address and telephone number

  • Must be where the entity in 2B1 can be reached directly
  • May not report a billing agency’s address/phone number

2C – Complete only if a hospital
2D – Enter any comments/special circumstances that apply
2E – Complete only if a physical therapy or occupational therapy group
2F – Complete only if an ambulatory surgical center (ASC)
2H – Complete only if a group will bill for advanced diagnostic imaging (ADI) services

Section 3:  Adverse Legal Action/Convictions 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: Practice Location Information   Copy appropriate page in each section as many times as necessary

4A – Complete this section for each practice location where the clinic/group will render services
  • this includes every office, clinic, hospital, assisted living community, skilled nursing facility (SNF) or any other health facility where the clinic/group will be rendering services
  • list every NPI/PTAN for each practice location (Do not report group member NPI/PTANs reassigned to the clinic/group)
4B – Enter special payment address (pay to address)
4C – Enter medical records location(s) if different than 4A or 4E
4D – Complete if rendering services in patients’ homes
4E–4G – Complete these sections if a mobile or portable supplier
Section 5: Ownership Interest and/or Managing Control Information (Organizations) Copy appropriate page as many times as necessary

5A–5B – Complete these sections for each organization that has ownership interest or managing control 
  • for each section 5A, complete a corresponding section 5B
Section 6: Ownership Interest and/or Managing Control Information (Individuals) Copy appropriate page in each section as many times as necessary

6A–6B – Complete these sections for every individual with ownership interest or managing control (i.e. manager, owner, board of trustees or other governing body, and authorized or delegated official)
  • Authorized official – at least one authorized official must be designated and reported. 
    • To report an authorized official, must select ‘Authorized Official’ and an additional box indicating ‘5 Percent or Greater Direct/Indirect Owner’, ‘Partner’ and/or a ‘Director/Officer’  
    • may also select Managing Employee (W-2)
  • Managing Employee (W-2) – at least one Managing Employee (W-2) must be designated and reported
  • Delegated official – is optional
    • To report a delegated official, must select ‘Delegated Official’ and an additional box specifying an additional relationship
  • All individuals currently on file need to be specified during revalidation or they will be end dated
  • For each section 6A, complete a corresponding section 6B
Section 8: Billing Agency Information
  • Complete with billing agency information or select the box indicating that this does not apply
Section 13: Contact Information Copy appropriate page as many times as necessary
  • Complete with the contact person’s information
Section 15: Certification Statement 15B and 15C – For revalidation, only one current authorized official signature is needed (remember to sign and date)
Section 16: Delegated Official 16A – This section does not need to be completed for revalidation unless enrolling a new delegated official, then this section must be completed and cosigned by an authorized official
Section 17: Supporting Documentation Contains a list of supporting documentation
  • Remember to include the form CMS-588 (EFT) version (01/17) and a confirmation of account information on bank letterhead or a voided check
CMS-855B Revalidation Completion Tips for Clinics/Group Practices and Suppliers
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