Get Medical Office Provider Enrollment Form

When to complete a CMS-855I. CMS-855I is to be used by Physicians and non-physician practitioners (including clinical psychologists) -- Complete this application if you are an individual practitioner who plans to bill Medicare and you are: An individual practitioner who will provide services in a private setting.

If you have any questions, please contact the Provider Hotline at 1-800-686-1516.

While medical credentialing is an essential process to certify a provider's qualifications, payer enrollment is the process of requesting participation in a health insurance network as a medical provider.

What is the 855A? ❖ The Medicare Enrollment Application for Institutional Providers. ❖ This form is also used to submit changes to your enrollment data.

CMS 855A. Form Title. Medicare Enrollment Application - Institutional Providers.

What is the 855B? ❖ The CMS form used for the enrollment of Clinic/Group practices and Certain Other Suppliers. This form is also used to submit changes to your enrollment data.

Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change in their enrollment information using either: The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or • The paper CMS-855I enrollment application.

Assigning Medicaid IDs to administer PNM module accounts – Call the Ohio Medicaid Integrated Help Desk at 1-800-686-1516 and select option 2, and then select option 3 to speak to a live agent. Call representatives will confirm provider credentials prior to updating the system. A call-back option is available.