Helpful Tips

CMS-855I Completion Tips for Physicians and NPPs that Reassign All Benefits Revalidation Application

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

Sections Required for Revalidation General Guidelines
Section 1: Basic Information 1A – Select ‘You are Revalidating your Medicare enrollment’

1B – Check all that apply (optional during revalidation)
Section 2: Personal Identifying Information 2A – Enter all personal information
  • The full legal name reported must match the social security record and NPPES Registry exactly including any initials, credentials and suffixes.
2B – Check the box not applicable or supply the active license/certification/registration information

2C – Indicate if accepting new patients (optional)

2D ‒ Indicate an address where correspondence will be sent directly to physician or nonphysician practitioner
  • Can be a home address, but cannot be a billing agency or medical management company
2E – Indicate an address where medical records correspondence will be sent directly to physician or nonphysician practitioner
  • Cannot be a billing agency or medical management company information
2G – Specify physician specialty (select all that apply)
  • Use ‘P’ for Primary and ‘S’ for all Secondary
2H ‒ Specify nonphysician practitioner specialty

2I1 - Identify doctoral psychology degree

2I2 - Psychologists billing independently (in private practice)

2J ‒ Physical/Occupational Therapists (in private practice)

2K ‒ If a nurse practitioner or certified clinical nurse specialist answers “yes,” furnish SNF information
Section 3: Final Adverse Legal Action 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: Business Information Check the box “If you do not have a private practice but reassign all of your benefits to an entity, check this box and only complete section 4F.”

4F – Complete for every group or organization where benefits have been reassigned
  • Specify each group/organization’s name, PTAN and NPI
  • Be sure to address all reassignments specified in the revalidation request letter
Section 12: Supporting Documentation Information
Section 13: Contact Person Information (optional)
  • Complete with the contact person’s information
Section 15: Certification Statement and Signature
  • Complete with individual physician or nonphysician practitioner’s name as indicated in section 2A for section 15B
  • The individual physician or nonphysician practitioner must sign and date
  • If adding a new reassignment, the authorized/delegated official must sign and date section 15C.

 

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Revised 10/4/2023