License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association website.
Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.

Print | Bookmark | Font Size: + | –

December 2017 Top Development Reasons for Part B CMS 855 Paper Applications

CGS has identified the top development reasons for CMS paper applications. As you are completing the enrollment applications, please review to ensure you are completing the forms correctly and submitting the necessary supporting documents to avoid any delays in processing your request.

Choose from the application-specific topics below to expand and collapse the development reason details.

CMS 855I Application

Section 4B - Practice Location Information - Individual Affiliations	Practitioners who want to reassign their right to receive Medicare payments to another eligible individual or entity (i.e., sole proprietorship/clinic/group practice/other health care organization) must complete Section 4B with the eligible individual's or entity's name, Medicare Identification Number (PTAN) and NPI. This is required for initial enrollment, reactivation and revalidation.
	If you are submitting an 855I to initially enroll and reassigning your benefits, you must also complete the CMS 855R Application.
Section 4C - Practice Location Information	For sole proprietors and sole owners, Section 4C is required to be completed with your practice location information (address, phone number, start date, etc.), regardless if there haven't been any changes to the practice information.
Section 4E – Special Payments Address	Medicare will issue payments via electronic funds transfer (EFT). Since payment will be made by EFT, the "Special Payments" address will indicate where all other payment information (e.g., remittance notices, special payments) are sent. For sole proprietors and sole owners, furnish the address where remittance notices and special payments should be sent for services rendered at the practice location(s). This is required regardless if there haven't been any changes to the practice information.
CMS 588 – EFT Agreement	Medicare will issue payments via electronic funds transfer (EFT). Therefore, if you are a Sole Proprietor or Sole Owner, initialing enrolling or revalidating your enrollment information, you must complete and submit the CMS 588 Electronic Funds Transfer (EFT) Agreement.

CMS 855B Application

Section 6A and 6B - Ownership Interest and/or Managing Control Information –Individuals	For initial enrollment, reactivation and revalidation, ensure that Sections 6A and 6B are completed for: All persons who have a 5 percent or greater direct or indirect ownership interest in the supplier; If (and only if) the supplier is a corporation (whether for-profit or non-profit), all officers and directors of the supplier; All managing employees of the supplier; All individuals with a partnership interest in the supplier, regardless of the percentage of ownership the partner has; and All Authorized and delegated officials.
	If you have identified a delegated official in Section 16 and this individual is not yet an approved Delegated Official with your group/organization enrollment, Section 6 must be completed for the new delegated official.
Attachment 1 – Ambulance Vehicle Information	For initial enrollment, reactivation and revalidation, vehicle information is required to be completed in Attachment 1. This includes the vehicle identification number (VIN), make, model and type. If the application is being submitted for revalidation, this is required, regardless if there haven't been any changes to the vehicle information. A copy of the vehicle registration must also be submitted with the CMS 855B Application.
CMS 588 Electronic Funds Transfer (EFT) Agreement	If you are submitting the CMS 588, Electronic Funds Transfer (EFT) Agreement with the CMS 855B, a voided check or written letter from the bank verifying the bank account information is required to be submitted.

Top

CMS 855O Application

CMS 855R Application

Section 1 - Reason for Submitting this Application Effective Date	Provide the effective date in Section 1 of the CMS 855R. This is the date in which the practitioner began providing services to Medicare beneficiaries. Please ensure you provide the month, day and year.
Section 2 –Organization/Group Receiving the Reassigned Benefits	Provide the correct NPI for the group/organization in which you are reassigning your benefits to or terminating your benefits from.
Section 6 - Certification Statements and Signatures	Please remember when submitting the CMS 855R, Section 6 must contain the following for all signatories: Both a signature from the individual practitioner and the authorized/delegated official If you are terminating your reassignment of benefits, only one signature is required. Original Signature(s) (not photocopied or stamped) Signature dates cannot be more than 120 days prior to the receipt date Signature for the Authorized/Delegated Official Please ensure that the authorized/delegated official signing Section 6B of the CMS 855R Application is currently approved as an authorized or delegated official for the current group/organization enrollment record. If the official is not established, you must submit a change of information to add the individual as an authorized/delegated official for your group/organization.
Supporting Application(s) – CMS 855I Application	Before you submit an 855R Reassignment of Benefits application, take a moment to verify you have an approved enrollment record in PECOS with CGS Administrators LLC. If you do not have an approved PECOS enrollment record, you must complete and submit the CMS 855I application along with the CMS 855R application. If the CMS 855I is not submitted, this will delay the processing of the CMS 855R. Here are tips to confirm your enrollment status: If you have access to Internet Based PECOS: Login. View My Associates. Click View Enrollments. Look for your enrollment, with CGS Administrators LLC, in the applicable state and in a status of Approved. If you don't see an approved enrollment record, you will need to submit an 855I application, either via Internet Based PECOS by clicking on More Options to continue or submitting the paper CMS 855I application to our office. If you don't have access to Internet Based PECOS, please call the J15 Contact Center at 866.276.9558, option 3. A representative can confirm your PECOS enrollment status.

Top