How to Check the Status of Your Provider Enrollment Application

Providers may call the provider contact center (PCC) to obtain real time status information on provider enrollment applications. In addition to application status, the PCC is available to answer all general provider enrollment related questions.

The Provider Enrollment department has developed a list of frequently asked questions (FAQs) about the 855A application form. To view these FAQs, select the PDF file below.

1. Who should submit the Provider Enrollment 855A application?

  • Community Mental Health Centers
  • Hospitals 
  • Comprehensive Outpatient Rehabilitation Facilities
  • Indian Health Services Facilities
  • Critical Access Hospitals 
  • Organ Procurement Organizations
  • End-Stage Renal Disease Facilities
  • Outpatient Physical Therapy/Occupational Therapy
  • Federally Qualified Health Centers
  • Speech Pathology Services
  • Histocompatibility Laboratories
  • Religious Non-Medical Health Care Institutions
  • Home Health Agencies
  • Rural Health Clinics
  • Hospice Agencies
  • Skilled Nursing Facilities

2. Why should I complete the 855A application?

  • If you plan to bill Medicare for Part A medical services
  • If you plan to report a change to your existing Part A enrollment data
  • A change must be reported within 90 days of the effective date of the change
  • Changes of ownership or control must be reported within 30 days of the effective date of the change

3. Where can I obtain the most current copy of the Provider Enrollment Application?

  • To obtain the most current version of the CMS 855A application, please download the form from the CMS website

4. Should I request and obtain my National Provider Identification (NPI) number before enrolling or making changes to my Medicare enrollment information?

  • CMS requires that providers and suppliers obtain their NPI prior to enrolling or updating their enrollment record with Medicare
  • Before a provider initiates a Medicare enrollment action, they will need an active National Provider Identifier (NPI)
  • To apply for an NPI, just complete the NPI application form (PDF, 155 KB)

5. Does a copy of the NPI notification letter have to be attached to every application?

  • Yes, a copy of the NPI notification letter must be attached to every application, even if it was previously submitted with another application

6. How should I submit the 855A application?

  • Complete in ink; submissions written in pencil are not accepted
  • Report requested additional information
  • Attach all required supporting documentation
  • Keep a copy of the completed application
  • Submit the application to your MAC by mailing the application and all supporting data. The application cannot be emailed or faxed.
  • All enrollment applications/forms must be submitted via regular mail to:
    Palmetto GBA
    Part A Provider Enrollment
    Mail Code: AG-331
    P.O. Box 100144
    Columbia, SC 29202-3144
  • Note: Special mail handling can delay the delivery and processing of your application

7. How can I avoid delays with my enrollment?

  • Complete all required sections
  • The legal business name must be written on the CMS 855A application exactly as it appears on the IRS document
  • Ensure that the correspondence address shown in Section 2 is the address where the provider wishes to receive all Medicare related correspondence. Do not enter a post office box number. 
  • Ensure the practice location reported on the 855A agrees with the practice location submitted for obtaining the NPI
  • Enter your NPI in the applicable sections
  • Enter all applicable dates
  • Ensure that the correct person signs the application. The Section 15 Certification Statement must be signed and dated in ink by the Authorized Official. 
  • Include all supporting documentation

8. What is the difference between an authorized official and a delegated official?

  • An authorized official is an appointed official (e.g., chief executive officer, chief financial officer, general partner, chairman of the board or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization’s status in the Medicare program, and to commit the organization to fully abide by the statutes, regulations and program instructions of the Medicare program
  • A delegated official is an individual who is delegated by an authorized official the authority to report changes and updates to the provider’s enrollment record. A delegated official must be an individual with an ownership or control interest in, or be a W-2 managing employee of the provider. 

9. What is supporting documentation?

  • Supporting documentation includes professional licenses, business licenses, certifications, IRS form (CP 575), a Form 990, a quarterly tax coupon or other IRS correspondence that contains the applicant’s legal name and tax identification number, NPI notification and the CMS EFT authorization form
  • Note: A W-9 and SS-4 Form are not acceptable

10. Do I have to submit the Electronic Funds Transfer Agreement (EFT) (CMS- 588)?

  • All organizations must submit an EFT (CMS-588). The CMS 588 form can be downloaded from the CMS website

11. What is meant by adverse legal actions?

  • Adverse legal actions are convictions, exclusions, revocations and suspensions. All applicable adverse legal actions must be reported, regardless of whether any records were expunged or any appeals are pending.

12. What if a section does not apply, should I leave it blank?

  • If a section does not apply to your provider type, check N/A where appropriate and skip to the next section

13. If a section is not completed correctly, will you contact me?

  • Yes, and to facilitate your enrollment into the Medicare program, respond promptly and fully to any request for additional or clarifying information

14. Who do I call if I have a general provider enrollment question or want to check on the status of my enrollment application?

  • The Palmetto GBA Provider Contact Center is available to answer all Provider Enrollment related questions and to provide information regarding the status of your enrollment application 

15. How long will it take to process my enrollment application once it is submitted?

  • Initial Enrollment and Change of Ownership applications can take from 90-180 days to process
  • Changes of Information can take up to 90 to process

16. How do I report changes?

  • If an enrolled provider is adding, deleting, or changing information under its same tax identification number, the provider must submit the change on form 855A.

17. How will I know if I have successfully submitted my enrollment application?  

  • You will receive an acknowledgment email or letter informing you that Palmetto GBA has received your application. This notification will also provide your document control number (DCN) for tracking purposes.

18. What happens if my application is missing a required data element or the provider fails to submit all required data?

  • The application will be returned to you

19. How long do I (provider) have to furnish any requested information from Provider Enrollment?

  • The provider has 30 days from the date of our request to provide any missing information or make any necessary corrections to the 855

20. If Provider Enrollment has questions about the application, whom will they contact?

  • Provider Enrollment will contact the individual reported in Section 13 of the CMS Form 855A. Identify a contact person who is familiar with the application and who can obtain the necessary information and/or documentation in a timely manner.

21. What happens if I forget to sign and date the application?

  • The application will be returned without processing

22. Can a provider submit a photocopied or faxed signature page?

  • No, the signature pages must contain an original signature
  • Signatures must be in ink (blue preferable)
  • Ensure that the application is signed and dated by the authorized and/or delegated official

23. If a provider submits changes to the application, does the provider have to submit a newly signed certification page?

  • Yes, a newly signed certification page must be submitting when making changes to the application

24. What happens if I submit an outdated application?

  • These forms will be immediately rejected and returned. They cannot be processed. All applications must be the February 2008 version.

25. What if I forget to include my NPI number or NPI notification letter?

  • Providers must obtain and NPI before submitting a Medicare enrollment application. The NPI must be entered in the appropriate field on the application and the NPI notification letter must be attached.
  • A copy of the NPI notification letter must be attached to every application, even if it was previously submitted with another application

26. Should I make copies of the documentation I submit?

  • Yes, prior to mailing the documentation, please review the application to ensure all items are completed and then make copies for your file. Be sure all attachments are included.

27. What is the difference between a rejected application and a returned application?

  • An application is rejected based on the provider’s failure to respond to Provider Enrollment’s request for missing information or clarification
  • An application is subject to immediate return based on specific criteria. All resubmissions must contain a newly signed and dated certification statement page.

28. If my application is rejected, can I reapply?

  • Yes, the provider may reapply and will be required to begin a new enrollment process

29. How do I report changes?

  • If an enrolled provider is adding, deleting, or changing information under its same tax identification number, the provider must submit the change on form 855A
  • Be sure to indicate whether you are changing, adding or deleting the information and enter the effective date, especially in Sections 4, 5, 6, 15 and 16

30. Will any of the information provided on the application be shared with any other group or entity?

  • The information you provide on this application will not be shared. For more information, see the last page of the application for the Privacy Act Statement

31. Where can I find complete information about the Provider Enrollment process?

 

 

Contact Palmetto GBA JM Part HHH Medicare

Email HHH

Contact a specific JM HHH department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

Other Palmetto GBA Sites

Palmetto GBA Home

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Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

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