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Revised CMS-855 Medicare Enrollment Applications 

The Office of Management and Budget recently approved changes to the Medicare Enrollment Applications (CMS-855).  The Centers for Medicare & Medicaid Services (CMS) has placed the revised enrollment applications on their website.  You may access these forms via Highmark Medicare Services’ website at www.highmarkmedicareservices.com. 

With the exception of specialty hospitals who are required to use the revised application immediately, Highmark Medicare Services will accept the 2006 version of the CMS-855 for all providers and suppliers through June 2008.  However, we encourage you to submit the revised version of the application.  Please review MLN Matters Number SE0810 for more details on the new forms.

When to Submit a CMS-855 Form

It has come to our attention that providers and suppliers are being advised by various sources (i.e., Software Vendors, Clearinghouses, Billing Agencies, NPPES Registry, and Specialty Societies) that they should proactively submit a CMS 855 Enrollment Application to their Medicare contractor for purpose of revalidation or to register their NPI number(s).  We want to make you aware that this is not necessary.

Please do not proactively submit a CMS-855 form unless you meet one of the following criteria:

• You are a newly enrolling provider/supplier
• You are joining a new group
• You are leaving the Medicare program (i.e., retirement)
• A change needs to be made to the information previously supplied on a CMS 855 Enrollment Application
• A specific request is made by Highmark Medicare Services for a CMS-855 form in order to complete an update to your file.

Following these guidelines will assist us in processing valid applications in a timely fashion.  This will also prevent you from completing unnecessary paperwork.

If at any time you are unsure whether a CMS-855 form should be submitted in a given situation, please call our Customer Service line at 1-866-488-0549 for further guidance.

FORM NAME	PDF VERSION
CMS-855B - Clinics/Group Practices and Certain Other Suppliers	Click Here
CMS-855I - Physicians and Non-Physician Practitioners	Click Here
CMS-855R - Reassignment of Medicare Benefits	Click Here
CMS-460 - Medicare Participating Physician Or Supplier Agreement	Click Here
CMS-588 Authorization Agreement for Electronic Funds Transfer (EFT)	Click Here