A. Does the enrollee want to be classified as a participating supplier with Medicare Part B and accept assignment on all beneficiary claims? (Medicare providers have the choice to be classified as participating or non-participating.)
Note: CMS now requires all providers enrolling or making an update to their file to include the NPI on the CMS 855 forms. Submit a copy of the NPI notification letter from the NPI Enumerator (NPI) https://nppes.cms.hhs.gov
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Complete form 855B sections 1-6, 8, 13, 15 16 (optional), and 17
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CMS 855B form (CMS Web site)
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Section 15 (Certification Statement) of the 855B must be signed and dated by the 'authorized official' for initial enrollment. Faxed, photocopied, or stamped signatures will not be accepted.
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Include the following documents:
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Participating Agreement: CMS 460 form (CMS Web site)
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IRS documentation (e.g., CP575, quarterly tax coupon) confirming the tax identification number and legal business name of the enrollee.
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State Business License
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CLIA certificate (Mandatory for Independent Clinical Laboratory)
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Electronic Funds Transfer (EFT)
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EFT CMS 588 form (CMS Web site)
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A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter.
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Submitting Claims Electronically - Electronic Data Interchange (EDI)
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There are many advantages to submitting claims electronically. In most cases, submitting electronically is required due to ASCA (Administrative Simplification Compliance Act).
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New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form. To access the Enrollment Forms go to: http://www.PalmettoGBA.com/jmb/edi, select Enrollment from left margin.
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Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:
|
JM Mailing Address |
JJ Mailing Address |
|
Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100190
Columbia, SC 29202-3190
Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728
|
Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100306
Columbia, SC 29202-3306
Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728
|
Be sure to:
-
Complete all required information, including any boxes to indicate “not applicable.”
-
Include effective date in all appropriate sections, for example, section 4b, “Practice Information.”
-
Provide information required for Electronic Fund Transfer.
-
Sign your application in BLUE ink.
-
Date your application.
-
Submit copies of all appropriate licenses, agreements and tax documents.
Important Information:
-
Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.
-
Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.
-
Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.
Note: CMS now requires all providers enrolling or making an update to their file to include the NPI on the CMS 855 forms. Submit a copy of the NPI notification letter from the NPI Enumerator (NPI) https://nppes.cms.hhs.gov
-
Complete form 855B sections 1-6, 8, 13, 15 16 (optional), and 17
-
CMS 855B form (CMS Web site)
-
Section 15 (Certification Statement) of the 855B must be signed and dated by the 'authorized official' for initial enrollment. Faxed, photocopied, or stamped signatures will not be accepted.
-
Include the following documents:
-
IRS documentation (e.g., CP575, quarterly tax coupon) confirming the tax identification number and legal business name of the enrollee.
-
State Business License
-
CLIA certificate (Mandatory for Independent Clinical Laboratory)
-
Electronic Funds Transfer (EFT)
-
EFT CMS 588 form (CMS Web site)
-
A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter.
-
Submitting Claims Electronically - Electronic Data Interchange (EDI)
-
There are many advantages to submitting claims electronically. In most cases, submitting electronically is required due to ASCA (Administrative Simplification Compliance Act).
-
New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form. To access the Enrollment Forms go to: http://www.PalmettoGBA.com/jmb/edi, select Enrollment from left margin.
-
Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:
|
JM Mailing Address |
JJ Mailing Address |
|
Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100190
Columbia, SC 29202-3190
Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728
|
Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100306
Columbia, SC 29202-3306
Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728
|
Be sure to:
-
Complete all required information, including any boxes to indicate “not applicable.”
-
Include effective date in all appropriate sections, for example, section 4b, “Practice Information.”
-
Provide information required for Electronic Fund Transfer.
-
Sign your application in BLUE ink.
-
Date your application.
-
Submit copies of all appropriate licenses, agreements and tax documents.
Important Information:
-
Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.
-
Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.
-
Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.