If the provider is a new enrollee, complete the entire application to add the reassignment.
To add, terminate, or change a reassignment, the individual or group would complete the following sections. Indicate on the CMS-855I a change of information, the reason of the submission, and follow the instructions.
Section 1A: REASON FOR SUBMITTING THIS APPLICATION
Section 1B: WHAT INFORMATION IS CHANGING?
Clarification for Section 15 (CERTIFICATION STATEMENT AND SIGNATURE)
If adding a reassignment both the individual provider(15B) and the authorized/delegated official of the group (15C) need to sign and date.
- If a Physician Assistant is adding an employment arrangement no 15C is needed.
If terminating/changing a reassignment either the individual provider(15B) OR the authorized/delegated official of the group (15C) need to sign and date.
Section 15: CERTIFICATION STATEMENT AND SIGNATURE
If adding a reassignment both the individual provider(15B) and the authorized/delegated official of the group (15C) need to sign and date.
- If a Physician Assistant is adding an employment arrangement no 15C is needed.
If terminating/changing a reassignment either the individual provider(15B) OR the authorized/delegated official of the group (15C) need to sign and date.
Institutional providers or suppliers when initially enrolling, revalidating or adding a new practice location. For more information see Determine/Pay Application Fee.
Institutional providers or suppliers when initially enrolling, revalidating or adding a new practice location. For more information see Determine/Pay Application Fee.
On our website, select Resources> Tools & Calculators> Check Provider Enrollment Application Status Tool.
On PECOS, you can find the status of the application from the home page under Helpful Links> Application Status, follow the prompts according to an individual or an organization enrollment.
On our website, select Resources> Tools & Calculators> Check Provider Enrollment Application Status Tool.
On PECOS, you can find the status of the application from the home page under Helpful Links> Application Status, follow the prompts according to an individual or an organization enrollment.
Contact Provider Enrollment Customer Service. On our website: select Resources > Contact Us > (scroll down) Provider Enrollment for a telephone number to call. Only the contacts identified on the enrollment or individuals identified as authorized or delegated officials under section 6 of the enrollment information can request a copy.
Contact Provider Enrollment Customer Service. On our website: select Resources > Contact Us > (scroll down) Provider Enrollment for a telephone number to call. Only the contacts identified on the enrollment or individuals identified as authorized or delegated officials under section 6 of the enrollment information can request a copy.
A CMS-2007 Provider tie in notification will be issued to the contact person on the submitted application from the state agency or CMS RO by email or mail as well as to the MAC, when completed.
More Information: Understanding the Approval Recommendation Process for Certified Providers.
A CMS-2007 Provider tie in notification will be issued to the contact person on the submitted application from the state agency or CMS RO by email or mail as well as to the MAC, when completed.
More Information: Understanding the Approval Recommendation Process for Certified Providers.
The first contact person on the submitted application will receive the approval letter via email, fax or mail. In the event another copy is needed, only the contacts identified on the enrollment or individuals identified as authorized or delegated officials under section 6 of the enrollment information can request a copy.
The first contact person on the submitted application will receive the approval letter via email, fax or mail. In the event another copy is needed, only the contacts identified on the enrollment or individuals identified as authorized or delegated officials under section 6 of the enrollment information can request a copy.
Section 6401(a) of the Affordable Care Act informs application fee amount will adjust each calendar year by a percentage change in consumer price index. For calendar year 2024 the amount is $709. Visit Determine/Pay Application Fee for more information.
Section 6401(a) of the Affordable Care Act informs application fee amount will adjust each calendar year by a percentage change in consumer price index. For calendar year 2024, the amount is $709. Visit Determine/Pay Application Fee for more information.
The approval recommendation letter received will have the state agency or CMS regional office contact information so you can contact if you have any questions. You can also view State Survey Agency Directory or Survey and Certification (S&C) Regional and Central Office Management for contact information.
More Information: Understanding the Approval Recommendation Process for Certified Providers
The approval recommendation letter received will have the state agency or CMS regional office contact information so you can contact if you have any questions. You can also view State Survey Agency Directory or Survey and Certification (S&C) Regional and Central Office Management for contact information.
More Information: Understanding the Approval Recommendation Process for Certified Providers
The email will instruct two methods to e-sign an application:
- Log into PECOS > on the welcome page scroll under Manage Signature > select “View and Sign” button for each application requiring your signature > review and follow the prompts.
- Select E-signature website link on email to populate identifying information as well as the PIN on the email > “log in” > select “View and Sign” button for each application requiring your signature > review and follow prompts.
The email will instruct two methods to e-sign an application:
- Log into PECOS > on the welcome page scroll under Manage Signature > select “View and Sign” button for each application requiring your signature > review and follow the prompts.
- Select E-signature website link on email to populate identifying information as well as the PIN on the email > “log in” > select “View and Sign” button for each application requiring your signature > review and follow prompts.
Find your enrollment in PECOS to verify the signatures are complete or still pending.
On our website under Enrollment > Step 5 Submit Enrollment Application > use the dropdown “Enroll Using PECOS” to select “Verify and Manage Signatures” for instructions.
Find your enrollment in PECOS to verify the signatures are complete or still pending.
On our website under Enrollment > Step 3 Submit Enrollment Application > select “Verify and Manage Signatures” for instructions.
To view an enrollment record report: log into PECOS, > select “My Associates” > under Existing Associates, select the “View Enrollment” button beside the providers name > under Existing Enrollment select “View Approved Enrollment Record”. Once the report opens, you can view, print or download. If the provider is not listed under the “Existing Associates”, go to the I&A System to gain access to that record. (Link to Quick Reference Guide, page 31 or 40)
More Information: View an Existing Medicare ID (PTAN) in PECOS and Effective/End Dates for Reassignment and PECOS Starter Guide.
On our website select Enrollment > “Step 5-Submit Enrollment Application” > use the dropdown “Enroll Using PECOS” for multiple articles on submitting the application. On Enrollment home page, you can find similar instructions under “Step 5-Submit Enrollment Application” for “Change Existing Provider Enrollment Information” & “Revalidating Your Enrollment”.
More Information: Learn About PECOS Web and PECOS Starter Guide.
To view an enrollment record report: log into PECOS, > select “My Associates” > under Existing Associates, select the “View Enrollment” button beside the providers name > under Existing Enrollment select “View Approved Enrollment Record”. Once the report opens, you can view, print or download. If the provider is not listed under the “Existing Associates”, go to the I&A System to gain access to that record. (Link to Quick Reference Guide, page 31 or 40)
More Information: View an Existing Medicare ID (PTAN) in PECOS and Effective/End Dates for Reassignment and PECOS Starter Guide.
On our website, select Enrollment > “Step 3-Submit Enrollment Application” for multiple articles on submitting the application. On Enrollment home page, you can find similar instructions under “Change Existing Provider Enrollment Information” & “Revalidating Your Enrollment”.
More Information: Learn About PECOS Web and PECOS Starter Guide.
To submit an application for a new provider, new to Medicare or new to the state, log into PECOS select “My Associates” button > “Create Initial Enrollment Application” button > select provider from list. If the provider is not listed, you will need to go to the I&A system to gain access to that providers record. (Link to Quick Reference Guide, page 31 or 40)
To submit a change or revalidation application for a provider, that is actively enrolled in Medicare in the state, log into PECOS > select “My Associates” button > under Existing Associates select the “View Enrollment” button beside the providers name > scroll under Existing Enrollments for the appropriate enrollment record. If the provider is not listed, you will need to go to the I&A system to gain access to that providers record. (Link to Quick Reference Guide, page 31 or 40).
More Information: Learn About PECOS Web and PECOS Starter Guide.
To submit an application for a new provider, new to Medicare or new to the state, log into PECOS> select “My Associates” button > “Create Initial Enrollment Application” button > select provider from list. If the provider is not listed, you will need to go to the I&A system to gain access to that providers record. (Link to Quick Reference Guide, page 31 or 40)
To submit a change or revalidation application for a provider, that is actively enrolled in Medicare in the state, log into PECOS > select “My Associates” button > under Existing Associates select the “View Enrollment” button beside the providers name > scroll under Existing Enrollments for the appropriate enrollment record. If the provider is not listed, you will need to go to the I&A system to gain access to that providers record. (Link to Quick Reference Guide, page 31 or 40).
More Information: Learn About PECOS Web and PECOS Starter Guide
Read the request carefully. Log into PECOS, find the submitted enrollment (IF a reassignment, first click View/Manage Reassignment)> select correct and resubmit button > make updates or upload supporting documents. If clarification needed, contact the provider enrollment representative processing the application. The name and phone number will be listed on the request.
Tips:
- To change the physician primary or secondary specialty, select Practitioner Specialty topic.
- To change the nonphysician specialty, submit an initial enrollment to establish a new specialty.
- To change from a physician to a nonphysician specialty or vice versa, submit an initial enrollment to establish a new specialty.
- To process the reassignment application when provider is new to Medicare or new to the group’s state, submit an initial enrollment for the individual.
On our website, select Enrollment > “Hot Topics” > select article PECOS Correct and Resubmit Application Instructions.
More information: PECOS Starter Guide
Read the request carefully. Log into PECOS, find the submitted enrollment (IF a reassignment, first click View/Manage Reassignment) > select correct and resubmit button > make updates or upload supporting documents. If clarification needed, contact the provider enrollment representative processing the application. The name and phone number will be listed on the request.
Tips:
- To change the physician primary or secondary specialty, select Practitioner Specialty topic.
- To change the nonphysician specialty, submit an initial enrollment to establish a new specialty.
- To change from a physician to a nonphysician specialty or vice versa, submit an initial enrollment to establish a new specialty.
- To process the reassignment application when provider is new to Medicare or new to the group’s state, submit an initial enrollment for the individual.
On our website, select Enrollment > “Step 5-What to Expect After Submission” > select article PECOS Correct and Resubmit Application Instructions.
More Information: PECOS Starter Guide
Yes, you need to revalidate if you received a notice and have been assigned a revalidation due date.
In accordance with Section 6401 (a) of the Patient Protection and Affordable Care Act, all new and existing providers must be reevaluated under the new screening guidelines. Medicare requires all enrolled providers and suppliers to revalidate their enrollment information every five years (reference 42 CFR Section 424.515). To ensure compliance with these requirements, existing regulations at CFR 42 Section 424.515(d) provide that the CMS is permitted to conduct off-cycle revalidations for certain program integrity purposes.
Read the article: How to Search on the Medicare Revalidation List Tool for Due Date to look up if the enrollment has a due date.
Yes, you need to revalidate if you received a notice and have been assigned a revalidation due date.
In accordance with Section 6401 (a) of the Patient Protection and Affordable Care Act, all new and existing providers must be reevaluated under the new screening guidelines. Medicare requires all enrolled providers and suppliers to revalidate their enrollment information every five years (reference 42 CFR Section 424.515). To ensure compliance with these requirements, existing regulations at CFR 42 Section 424.515(d) provide that the CMS is permitted to conduct off-cycle revalidations for certain program integrity purposes.
Read the article: How to Search on the Medicare Revalidation List Tool for Due Date to look up if the enrollment has a due date.
Revalidation due dates can be located on the Medicare Revalidation List Tool. Revalidation notification letter will be sent about three months prior to the determined due date from the MAC. Visit How to Search on the Medicare Revalidation List Tool for Due Date for more information.
Revalidation due dates can be located on the Medicare Revalidation List Tool. Revalidation notification letter will be sent about three months prior to the determined due date from the MAC. Visit How to Search on the Medicare Revalidation List Tool for Due Date for more information.
NGS will send a revalidation notification request letter to the correspondence address and special payment address identified in the enrollment record. Visit Revalidating Your Enrollment for more information.
NGS will send a revalidation notification request letter to the correspondence address and special payment address identified in the enrollment record. Visit Familiarize Yourself with Enrollment Revalidation for more information.
Authorized and/or delegated officials identified in the individual control section of the application are the only individuals that can sign the CMS applications and forms for an entity.
For more information refer to the Understanding Authorized Official and Delegated Official Roles.
Authorized and/or delegated officials identified in the individual control section of the application are the only individuals that can sign the CMS applications and forms for an entity.
For more information refer to the Understanding Authorized Official and Delegated Official Roles.
Only the individual provider (applicant) can sign section 15B of this application, the authority to sign cannot be delegated to any other person. Section 15C (if applicable) is signed by an authorized/delegated official of the reassignment.
Authorized and/or delegated officials identified in the individual control section of the application are the only individuals that can sign the CMS applications and forms for an entity.
For more information refer to the Understanding Authorized Official and Delegated Official Roles.