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Providers in AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs

Revalidation Helpful Hints / Reminders

Based on historical trends, we have found providers/suppliers often require additional assistance with certain topics related to revalidation. Please see below for supplemental education related to those topics:

Tips for Completing the Revalidation CMS-855I Application for Physicians and Non-Physician Practitioners

Section 1A

Provide ALL active PTANs (Provider Transaction Access Numbers) even if all active PTANs are not disclosed on the revalidation notification letter. Do not submit a separate application for each PTAN.
Provide the physician/non-physician’s Type 1 NPI (National Provider Identifier).

Section 2A

Provide, at a minimum, the physician/non-physician practitioner’s Last/First name, Former Name (if applicable), Date of Birth, SSN (Social Security Number) and valid/active state license information.

Section 3

Complete this section. If adverse action exists, supporting documentation must also be submitted.

Section 4A

This section is completed only if the applicant is a Sole Owner Incorporation. Refer to our Revalidation FAQs for the definition of a Sole Owner Incorporation.
If applicable, provide the Incorporation’s Type 2 NPI. If a Type 2 NPI has not yet been assigned, access the NPES (National Plan and Provider Enumeration System) to request one be assigned.

Section 4B

Provide ALL active reassignment information in this section (i.e., a group(s) bills for and receives payments for the physician / non-physician practitioner’s services).

Section 4C

This section must be completed for physicians/non-physician practitioners who are:
In private practice
Sole Proprietors
Sole Owner Incorporations
Don’t forget to provide the date the first Medicare patient was seen at the practice location (mm/dd/yy) and provide all active PTANs and NPIs.
Verify and provide the +4 segment of the zip code.

Section 8

Complete only if the applicant contracts with a billing agency.

Section 13

Provide the person(s) we can contact if we have questions related to the application. This is the only person(s), other than the physician/non-physician practitioner, we are permitted to communicate with related to processing the application.

Section 15

Only the physician/non-physician practitioner may sign and date the certification page.
If corrections to the application are requested, a newly signed and dated certification statement will be required

Supporting Documentation

Certified Providers required to submit a copy of their diploma with their application:
CRNA (Certified Registered Nurse Anesthetists)
NP (Nurse Practitioners)
CNS (Certified Nurse Specialists)
CNM (Certified Nurse Midwives)
CP (Clinical Psychologists)
CPs must submit a copy of their diploma to prove their doctoral degree is in Psychology. If the diploma states ‘Doctor of Philosophy’, ‘Doctorate in Psychology’ or ‘Doctor of Education’ followed by a specific area of Psychology, no further documentation is needed. However, if the diploma does not clearly indicate that the degree was in Psychology, transcripts must also be submitted.

Tax documentation

Although tax documents are not typically required, if there is an enrollment record structure change (i.e. changing from an individual in private practice to a sole proprietorship), it is generally a good idea to include a copy of the tax document (i.e. CP575) that was issued to you when you filed the change with the IRS.


If the Legal Business Name is required on the CMS-855, that name must exactly match the way the name is established with the IRS (Internal Revenue Service).
If you receive a request for additional/clarifying information (i.e., development), please review the request carefully to ensure the information you submit in response the request is the information requested. Submitting incorrect information will cause delays in processing.
In most cases, development responses can be faxed; however, be sure to double check your development request letter since some information must be mailed back to us.
The majority of requests for development, whether faxed, emailed, or mailed to customers will include a Cover Sheet that is pre-populated with key identifiers utilized to electronically route development responses to the correct area/person. The Cover Sheet improves the timeframe associated with delivery of development responses and lessens the likelihood of misplaced documents. If your development request includes a Cover Sheet, please be sure to include it when responding to the request for additional/clarifying information.
Institutional providers revalidating their enrollment information and submitting either a CMS-855A or CMS-855B application must submit an application fee in an amount prescribed by CMS and/or a request for a hardship exception to the application fee with their application. 
Note: You DO NOT need to submit an application fee if you are one of the following provider/supplier types:
Non-physician practitioner
Physician group practice
Non-physician group practice
Don’t forget to pay the application fee, if required, to avoid delays in processing.
Ensure the email address listed on the application is correct and that the SPAM filter is turned off for items coming from ‘medenroll’, as requests for corrections are often sent via email.

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Last modified:  02/23/2018