Medicare Revalidation Application 855i 2011-2025 Form

What is the CMS 855I?

The CMS 855I form, also known as the Medicare revalidation application 855I, is a critical document used by healthcare providers to enroll or revalidate their enrollment in the Medicare program. This form is specifically designed for individual practitioners and is essential for maintaining compliance with Medicare regulations. It collects necessary information about the provider's qualifications, practice location, and any affiliations that may impact their eligibility for Medicare reimbursement.

Steps to Complete the CMS 855I

Completing the CMS 855I form involves several key steps to ensure accuracy and compliance. Follow these steps for a successful submission:

1. Gather necessary information, including your National Provider Identifier (NPI), tax identification number, and practice details.
2. Access the CMS 855I form, which can be found in a PDF format for easy download and printing.
3. Carefully fill out each section of the form, ensuring all information is accurate and complete.
4. Review the form for any errors or omissions before submission.
5. Submit the completed form either electronically through the PECOS system or by mailing it to the appropriate Medicare Administrative Contractor (MAC).

Legal Use of the CMS 855I

The CMS 855I form is legally binding when filled out correctly and submitted according to Medicare guidelines. It is essential for providers to understand that any misrepresentation or omission of information can lead to serious consequences, including penalties or denial of Medicare payments. Utilizing a secure platform for electronic submission can enhance the legal standing of the document, ensuring compliance with relevant eSignature laws.

Required Documents

To complete the CMS 855I form successfully, certain documents must be provided. These may include:

• Proof of identity, such as a driver's license or passport.
• National Provider Identifier (NPI) confirmation.
• Tax identification information, including a W-9 form.
• Documentation of any previous Medicare enrollments or revalidations.

Form Submission Methods

The CMS 855I form can be submitted through various methods, providing flexibility for healthcare providers. The primary submission methods include:

• Online: Providers can submit the form electronically via the PECOS (Provider Enrollment, Chain, and Ownership System) portal.
• Mail: The completed form can be printed and mailed to the designated Medicare Administrative Contractor (MAC).
• In-Person: Some providers may choose to submit the form in person at their local MAC office, although this option may vary by location.

Eligibility Criteria

To be eligible to submit the CMS 855I form, healthcare providers must meet specific criteria. These include:

• Possession of a valid National Provider Identifier (NPI).
• Compliance with all Medicare regulations and guidelines.
• Provision of services that are covered under the Medicare program.