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

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’
Section 2: Identifying Information	2A1 – 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 2A2 – Specify any state licenses and/or certifications that apply for the clinic/group 2A3 – Enter the clinic/group’s correspondence address and telephone number Must be where the entity in 2A1 can be reached directly May not report information about a billing agency and medical management company 2A4 – Enter the clinic/group’s medical record correspondence address and telephone number 2B – Specify the type of supplier the specialty cannot be “Other” for revalidation 2C – Complete only if a hospital 2D – Complete only if a physical therapy or occupational therapy group 2E – Complete only if an ASC 2F – Complete to terminate employment arrangements of physician assistant(s)
Section 3: Final Adverse Legal Actions	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, 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 – Identify medical records storage location(s) 4D – Complete if rendering services in patients’ homes 4D3 – Enter any comments/special circumstances that apply 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 Managing Employee – at least one Managing Employee must be designated and reported Delegated official To report a delegated official, must select ‘Delegated Official’ and an additional box specifying an additional relationship Cannot be a Contracted Managing Employee 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/Agent Information	Complete with billing agency information or select the box indicating that this does not apply
Section 12: Supporting Documentation Information	Contains a list of supporting documentation Remember to include the form CMS-588 (EFT) current version and a confirmation of account information on bank letterhead or a voided check Supporting Documentation Required for Enrollment Revalidations
Section 13: Contact Person Information	Copy appropriate page as many times as necessary Complete with the contact person’s information
Section 15: Certification Statement	Note: For revalidation, only one current authorized or delegated official signature and date is needed 15B–New authorized official added in section 6, signature and date is required 15D–New delegated official added in section 6, signature and date is required, must be cosigned and dated by an authorized official