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

1. 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.
2. Include the following documents:
   • Participating Agreement: CMS 460 form (CMS Web site)
   • 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)
3. 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.
4. 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.
5. 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

1. 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.
2. 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)
3. 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.
4. 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.
5. 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.