Riverbend

Process Details

Current Enrollment Process Details:

• New Provider Enrollment Applications were released in April 2006 and minor revisions occurred in June and July 2006. To obtain the most current versions of the CMS-855A application, please download the form from the CMS website at: http://www.cms.hhs.gov/CMSForms/downloads/CMS855A.pdf.
  
  
• RGBA is required to develop for any missing information in any required field and for any missing supporting documentation. Ensure that all mandatory supporting documents listed on Page 41 of the CMS Form 855A are included with the submission of the application.
  
  
• All new enrollments, changes of ownership or changes to existing provider information must include the facility’s National Provider Identifier (NPI) in Section 4 of the application.
  
  
• At the time of initial enrollment or when reporting a change of ownership or a change to existing provider information, an Electronic Funds Transfer Authorization Agreement (CMS-588) must be submitted. The CMS-588 form can be downloaded at: http://www.cms.hhs.gov/CMSForms/downloads/CMS588.pdf
  
  
• You must submit IRS documentation to support the legal business name and the tax identification number reported on the CMS Form 855A. The legal business name must be written on the CMS-855A application exactly as it appears on the IRS document. Acceptable documentation includes a CP575 (a computer-generated letter), a Form 990, a quarterly tax coupon or other IRS correspondence that contains the applicant's legal name and tax identification number pre-printed by the IRS. A W-2, W-9 and SS-4 Form are not acceptable.