Provider Enrollment Interactive Help Tool — Certified Registered Nurse Anesthetist
1. Does the enrollee have an active Medicare Provider Transaction Access Number (PTAN) within CGS's jurisdiction?
Yes No
2. Is the organization/group to whom benefits are being reassigned enrolled with an active Medicare PTAN/Legacy Number within CGS' jurisdiction?
Yes No
Certified Registered Nurse Anesthetist:
- Complete form 855I
sections 1, 2A, 4F, 12, 13, and 15. - Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:
Mailing Address – Jurisdiction 15
CGS Administrators LLC
J15 Part B Provider Enrollment
P.O. Box 20017
Nashville, TN 37202Overnight, UPS, Fed Ex address:
CGS Administrators LLC
J15 Part B Provider Enrollment
26 Century Blvd, Suite NT600
Nashville, TN 37214
Be sure to:
- Complete all required information, including any boxes to indicate "not applicable."
- Sign your application and date your application.
Important Information:
- Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.
- Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.
- Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.
Certified Registered Nurse Anesthetist:
- Complete form 855I sections 1, 2A, 4F, 12, 13, and 15.
- Complete form 855B sections 1-6, 8, 13, 15, and 16
- CMS 855B Form
- Section 15 (Certification Statement) of the 855B must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.
- CMS 855B Form
- Complete the following forms:
- Participation Agreement (CMS 460 Form)
Note: The provider has from the approval of its initial enrollment, 90 days to submit a participation agreement. The participation effective date is based on the receipt date of the agreement.
- Electronic Funds Transfer form (EFT CMS 588 Form)
Note: A copy of a voided pre-printed check OR bank letter verifying the information on the EFT form)
- Participation Agreement (CMS 460 Form
- Include the following additional documentation:
- CP575 or other pre-printed IRS documentation that identifies the Legal Business Name and Tax Identification Number of the group.
- Submitting Electronic Claims Electronic Data Interchange (EDI)
- a. New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form
- Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:
Mailing Address – Jurisdiction 15
CGS Administrators LLC
J15 Part B Provider Enrollment
P.O. Box 20017
Nashville, TN 37202Overnight, UPS, Fed Ex address:
CGS Administrators LLC
J15 Part B Provider Enrollment
26 Century Blvd, Suite NT600
Nashville, TN 37214
Be sure to:
- Complete all required information, including any boxes to indicate "not applicable."
- Sign your application and date your application.
Important Information:
- Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.
- Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.
- Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.
2. Is the organization/group to whom benefits are being reassigned enrolled with an active Medicare PTAN/Legacy Number within CGS' jurisdiction?
Yes No
Certified Registered Nurse Anesthetist:
- Complete form 855I (sections 1, 2A 2B, 2C, 2D, 2E, 2H, 3, 4F, 13, 15)
- CMS 855I Form
- Section 15 (Certification Statement) of the 855I must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.
- CMS 855I Form
- Include the following documents:
- Copy of state CRNA license or state APRN license (with designation as CRNA, KY only)
- Copy of CRNA certification, or proof of graduation from an accredited CRNA program that will meet certification requirements within 2 years of graduation
- Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:
Mailing Address – Jurisdiction 15
CGS Administrators LLC
J15 Part B Provider Enrollment
P.O. Box 20017
Nashville, TN 37202Overnight, UPS, Fed Ex address:
CGS Administrators LLC
J15 Part B Provider Enrollment
26 Century Blvd, Suite NT600
Nashville, TN 37214
Be sure to:
- Complete all required information, including any boxes to indicate "not applicable."
- Sign your application and date your application.
Important Information:
- Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.
- Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.
- Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.
Certified Registered Nurse Anesthetist:
- Complete form 855I (sections 1, 2A, 2B, 2C, 2D, 2E, 2H, 3, 4F, 13, 15)
- CMS 855I Form
- Section 15 (Certification Statement) of the 855I must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.
- CMS 855I Form
- Include the following documents:
- Copy of state CRNA license or state APRN license (with designation as CRNA, KY only)
- Copy of CRNA certification, or proof of graduation from an accredited CRNA program that will meet certification requirements within 2 years of graduation
- Complete form 855B sections 1-6, 8, 13, 15, and 16
- CMS 855B Form
- Section 15 (Certification Statement) of the 855B must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.
- CMS 855B Form
- Complete the following forms:
- Participation Agreement (CMS 460 Form)
Note: The provider has from the approval of its initial enrollment, 90 days to submit a participation agreement. The participation effective date is based on the receipt date of the agreement.
- Electronic Funds Transfer form (EFT CMS 588 Form)
Note: A copy of a voided pre-printed check OR bank letter verifying the information on the EFT form)
- Participation Agreement (CMS 460 Form
- Include the following additional documentation:
- CP575 or other pre-printed IRS documentation that identifies the Legal Business Name and Tax Identification Number of the group.
- Submitting Electronic Claims Electronic Data Interchange (EDI)
- New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form
- New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form
- Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:
Mailing Address – Jurisdiction 15
CGS Administrators LLC
J15 Part B Provider Enrollment
P.O. Box 20017
Nashville, TN 37202Overnight, UPS, Fed Ex address:
CGS Administrators LLC
J15 Part B Provider Enrollment
26 Century Blvd, Suite NT600
Nashville, TN 37214
Be sure to:
- Complete all required information, including any boxes to indicate "not applicable."
- Sign your application and date your application.
Important Information:
- Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.
- Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.
- Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.
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