Completing the Medicare 855R application form is a crucial step for healthcare providers who want to reassign their Medicare benefits to another entity. The form is used to reassign benefits from one provider to another, and it requires careful attention to detail to avoid errors or delays in the process. In this article, we will guide you through the 5 steps to complete the Medicare 855R application form successfully.
Understanding the Medicare 855R Application Form
Before we dive into the steps to complete the form, let's understand what the Medicare 855R application form is and why it's essential for healthcare providers. The Medicare 855R form is used to reassign Medicare benefits from one provider to another. This form is typically used when a healthcare provider wants to sell their practice or retire and transfer their Medicare benefits to another entity.
Step 1: Gather Required Documents and Information
Before starting the application process, it's essential to gather all the required documents and information. This includes:
- Your Medicare Provider Enrollment, Chain, and Ownership System (PECOS) login credentials
- Your National Provider Identifier (NPI) number
- Your Taxpayer Identification Number (TIN)
- The name and address of the entity to which you want to reassign your Medicare benefits
- The date of the reassignment
Step 2: Complete Section 1-3 of the Form
Once you have gathered all the required documents and information, start completing the form. Sections 1-3 of the form require you to provide your personal and professional information, including your name, address, and NPI number.
- Section 1: Provider Information
- Provide your name, address, and NPI number
- Indicate your provider type (e.g., physician, nurse practitioner, etc.)
- Section 2: Reassignment Information
- Provide the name and address of the entity to which you want to reassign your Medicare benefits
- Indicate the date of the reassignment
- Section 3: Certification
- Certify that you are authorized to sign the application on behalf of the provider
Step 3: Complete Section 4-6 of the Form
Sections 4-6 of the form require you to provide additional information about the reassignment, including the reason for the reassignment and the effective date of the reassignment.
- Section 4: Reassignment Reason
- Indicate the reason for the reassignment (e.g., sale of practice, retirement, etc.)
- Section 5: Effective Date
- Indicate the effective date of the reassignment
- Section 6: Supporting Documentation
- Attach supporting documentation, such as a copy of the sales agreement or a letter from the provider explaining the reason for the reassignment
Step 4: Review and Sign the Form
Once you have completed the form, review it carefully to ensure that all the information is accurate and complete. Sign the form in the designated area, and make sure to date it.
Step 5: Submit the Form
Finally, submit the completed form to the Medicare Administrative Contractor (MAC) via mail or electronically through the PECOS system. Make sure to keep a copy of the form for your records.
Gallery of Medicare 855R Application Form
FAQs
What is the Medicare 855R application form used for?
+The Medicare 855R application form is used to reassign Medicare benefits from one provider to another.
Who needs to complete the Medicare 855R application form?
+Healthcare providers who want to reassign their Medicare benefits to another entity need to complete the Medicare 855R application form.
How do I submit the Medicare 855R application form?
+You can submit the Medicare 855R application form via mail or electronically through the PECOS system.
By following these 5 steps, you can complete the Medicare 855R application form successfully and reassign your Medicare benefits to another entity. Remember to review the form carefully and submit it to the Medicare Administrative Contractor (MAC) via mail or electronically through the PECOS system.