Processing the CMS-855R Medicare 
 
Enrollment Application - Reassignment 
 
of Benefits
 
 
 
 
 
 
 
 
 
 
 
Disclaimer:  The information contained in this guide is to assist providers/suppliers in 
completing the CMS-855R application and MACs in processing the CMS-855R application.  
The procedures described in the guide, which include processing alternatives and processing 
instructions for the CMS-855R, take precedence over all other instructions in the Program 
Integrity Manual concerning the processing of CMS-855R applications.     
 
Processing the CMS-855R Medicare Enrollment Application - Reassignment of Benefits 
 
  Page 1  Table of Contents 
General Information ..................................................................................................................................... 3 
Processing the CMS-855R Application .......................................................................................................... 4 
Section 1:  Basic Information ........................................................................................................................ 5 
Reason for Submitting This Application .................................................................................................... 5 
Section 2:  Organization/Group Receiving the Reassigned Benefits ............................................................ 6 
Section 3:  Individual Practitioner Who Is Reassigning Benefits ................................................................... 8 
Section 4: Primary Practice Location ............................................................................................................ 9 
Section 5:  Contact Person ............................................................................................................................ 9 
Section 6:  Certification Statements and Signatures .................................................................................. 10 
Section 6A  Individual Practitioner ........................................................................................................ 10 
Section 6B  Delegated or Authorized Official of Group Practice/Clinic ................................................ 11 
 
 
 
 
 
 
 
 
 
 
 
 
Processing the CMS-855R Medicare Enrollment Application - Reassignment of Benefits 
 
  Page 2  General Information 
 
A. Purpose of the CMS-855R 
The CMS-855R application is used by individual physicians and non-physician practitioners 
(hereafter collectively referred to as individual 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); Medicare eligible 
professionals may also reassign their benefits to a critical access hospital (CAH) that bills 
Method II in order to participate in the Electronic Health Records (EHR) Incentive Program for 
Eligible Professionals (EPs).  In addition, the CMS-855R is used to terminate a currently 
established reassignment of benefits.   
Reassigning Medicare benefits allows an eligible individual or entity to submit claims on behalf 
of and receive payment for Medicare Part B services that the performing practitioner provides for 
the eligible billing individual or entity.  Both the individual practitioner and the eligible 
individual or entity must be currently enrolled (or concurrently enrolling via submission of the 
(1) CMS-855I/CMS-855B for the eligible individual or entity and (2) the CMS-855I for the 
individual practitioner) in the Medicare program before the reassignment can take effect.     
The Internet-based Provider Enrollment, Chain and Ownership System (PECOS) can be used to 
add or terminate a reassignment of benefits. To obtain additional information on Internet-based 
PECOS, refer to http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/MedicareProviderSupEnroll/InternetbasedPECOS.html. 
In lieu of PECOS, the most current version of the CMS-855R application shall be completed.   
To obtain the current version of the form, refer to https://www.cms.gov/Medicare/cms-
forms/cms-forms/cms-forms-list.html.  If an outdated version of the application is submitted, the 
MAC shall develop for the correct version of the form.    
B. Reassignment Packages 
A separate CMS-855R must be submitted for each individual practitioner or eligible individual 
or entity for which a reassignment is being established or terminated.  The individual practitioner 
may receive multiple Provider Transaction Access Numbers (PTANs) under a single Employer 
Identification Number (EIN), but may not reassign benefits to more than one EIN on a single 
CMS-855R application.  
In situations where an entity wants to simultaneously enroll a group practice, the individual 
practitioners therein, and to reassign benefits accordingly, the MAC shall adhere to the 
instructions contained in the scenarios below. As early in the process as possible, the MAC shall 
examine the incoming forms to see if a reassignment may be involved; also, the MAC is 
encouraged (though not required) to have the same analyst handle all applications in the package.  
 
1.  Only the CMS-855Rs are submitted - If a brand new group with new practitioners is 
attempting to enroll but submits only the CMS-855Rs for its group members (i.e., neither 
Processing the CMS-855R Medicare Enrollment Application - Reassignment of Benefits 
 
  Page 3  the initial CMS-855B nor the initial CMS-855Is were submitted), the MAC shall develop 
for the other forms. 
 
2.  Only the CMS-855R is submitted and a CMS-855A/CMS-855B and CMS-855I is 
already on file  Suppose an individual practitioner: (1) submits only the CMS-855R 
without including the CMS-855A/CMS-855B and CMS-855I, and (2) indicates on the 
CMS-855R that he/she will be reassigning all or part of his/her benefits to the CAH II.  
The MAC shall not develop for the other forms if they are already on file. The Part B 
MAC shall simply process the CMS-855R and reassign the individual practitioners 
benefits to the Part A CAH II.  
 
3.  Only the CMS-855B is submitted - If a brand new group wants to enroll but submits 
only the CMS-855B without including the CMS-855Is and CMS-855Rs for its group 
members (i.e., the CMS-855B arrives alone, without the other forms), the MAC shall 
develop for the other forms.  (Note: CMS-855R(s) may be submitted via Internet-based 
PECOS only after the group has been Approved in PECOS.  The MAC may approve an 
Internet-based PECOS CMS-855B application without receipt of a CMS-855R.) 
 
4.  Only the CMS-855I is submitted  Suppose an individual practitioner: (1) submits only 
the CMS-855I without including the CMS-855B and CMS-855R, and (2) indicates on the 
CMS-855I that he/she will be reassigning all or part of his/her benefits to the group 
practice. The MAC shall develop for the other forms. 
Suppose an individual practitioner: (1) submits only the CMS-855I, and (2) indicates on the 
CMS-855I that he/she will be reassigning all or part of his/her benefits to an existing Part A 
CAH II.  The MAC shall develop for the CMS-855R.  Upon receipt of the CMS-855R, the MAC 
shall process the application and reassign the individual practitioners benefits to the Part A 
entity. 
C.  When Not to Use the CMS-855R  
The CMS-855R shall not be used to report employment arrangements of physician assistants.  
Employment arrangements for physician assistants must be reported on the CMS-855I 
application.  In addition, a CMS-855R application is not required to be submitted with a CMS-
855B for an independent diagnostic testing facility (IDTF) that employs or contracts with 
interpreting physicians.  
The CMS-855R shall not be used to revalidate reassignments.  The individual practitioner should 
only use the CMS-855I and list his/her active reassignment information in section 4B thereof.  
The CMS-855R application is required to terminate a reassignment.  The termination cannot be 
done via the CMS-855I form (except for Internet-based PECOS applications when the 
termination is for the last PTAN on an enrollment).   
Processing the CMS-855R Application 
Note:  If a data element on the individual practitioners CMS-855R application is missing but the 
information is disclosed (1) elsewhere on the application or (2) in the supporting documentation 
Processing the CMS-855R Medicare Enrollment Application - Reassignment of Benefits 
 
  Page 4  submitted with the application, the MAC need not obtain the missing data via an updated CMS-
855R form page and a newly-signed certification statement; no further development  not even 
by telephone  is required.  However, the following information must be furnished in the 
appropriate section(s) of the CMS-855R, even if the data is identified elsewhere on the form or 
in the supporting documentation:  
 
a.  Legal business names (LBN) or legal names 
b.  Tax identification numbers (TINs), EINs or Social Security Numbers (SSNs) 
c.  NPI-legacy number combinations in sections 2 and/or 3 of the CMS-855R  
Section 1:  Basic Information 
The MAC shall ensure that the applicant completes this section of the CMS-855R with the 
submittal reason and effective date.  (Note that a separate CMS-855R is required for each new 
reassignment or termination).  The Complete All Sections column provides the sections of the 
CMS-855R that must be completed for each reason for submission.  
This section identifies the reason for the application submission.  If a submittal reason is not 
Rideenatsifoiend ,f othre  SMuAbCm sihttailnl dge Tvehloisp  Avipa pplhiocnaet ioor ns end a development letter to the individual 
practitioner/contact person to obtain the missing data. 
1.  You are enrolling or are currently enrolled in Medicare and will be reassigning your 
benefits 
 
  The individual practitioner checks this box if he/she is establishing a new 
reassignment to an eligible individual or entity.  The MAC shall ensure that an 
effective date is listed that identifies the effective date of the reassignment, and 
that all sections are completed as required.   
  If the individual practitioner is initially enrolling in Medicare and does not have a 
current CMS-855I application on file, he/she must submit a CMS-855I in addition 
to the CMS-855R.  The MAC shall develop by mail, fax, or e-mail for the CMS-
855I application if it is not currently on file.   
  If the CMS-855R is accompanied by an initial CMS-855I or if the individual 
practitioner currently has an active CMS-855I on file and is only submitting a 
CMS-855R to establish a new reassignment, the effective date of the reassignment 
shall be consistent with the 30-day rule requirements specified in the Program 
Integrity Manual, chapter 15, section 15.17 (i.e., the later of the date of filing or 
the date the practitioner first began furnishing services at the new location).  
(Note: The effective date of the reassignment shall not be prior to the effective 
dates of the enrollments of the individual practitioner and the eligible individual 
or entity to which benefits are reassigned.   
 
Processing the CMS-855R Medicare Enrollment Application - Reassignment of Benefits 
 
  Page 5  2.  You are an individual terminating a reassignment with a Sole Proprietor1 or 
Clinic/Group/Organization 
 
  The individual practitioner checks this box if he/she has a current reassignment of 
benefits arrangement with an eligible individual or entity that he/she wishes to 
terminate.  
  The MAC shall ensure that a termination date for the reassignment is listed in the 
Effective Date field and that sections 1, 2, 3, 5, and 6A of the CMS-855R 
application are completed as required.  If the termination date is not included, the 
MAC shall send a development letter by mail, fax, or e-mail to the individual 
practitioner/contact person to obtain the missing data.   
 
3.  You are a sole proprietor/clinic/group/organization terminating a reassignment with 
an individual 
 
  The eligible individual or entity checks this box if he/she/it has a current 
reassignment of benefits arrangement with an individual practitioner that he/she/it 
wishes to terminate.  
  The MAC shall ensure that a termination date for the reassignment is listed in the 
Effective Date field and that sections 1, 2, 3, 5, and 6B of the CMS-855R 
application are completed as required.  If the termination date is not included, the 
MAC shall send a development letter by mail, fax or e-mail to the contact person 
to obtain the missing data.    
  Groups that are terminating physician assistant employments should use the 
CMS-855B.  Sole proprietors and incorporated individuals who are terminating 
physician assistant employments should use the CMS-855I. 
 
Section 2:  Organization/Group Receiving the Reassigned Benefits 
The MAC shall ensure that information is populated in each field to identify the eligible 
individual or entity to whom benefits are being reassigned, or with whom the reassignment is 
being terminated.  The eligible individual or entity must be currently enrolled or enrolling 
concurrently in the Medicare program; otherwise, the reassignment cannot be processed.   
A separate CMS-855R must be submitted for each sole proprietor/clinic/group/organization for 
which a reassignment is being established or terminated.  The individual practitioner may receive 
multiple PTANs under a single EIN, but may not reassign benefits to more than one EIN on a 
single CMS-855R application.  
If a Sole Proprietor is receiving the reassigned benefits, the MAC shall ensure that the:  
                                                           
1 A business is a sole proprietorship if it meets all of the following criteria:  
 It files a Schedule C (1040) with the IRS (this form reports the businesss profits/losses);  
 One person owns all of the businesss assets; and  
 It is not incorporated.  
 
Processing the CMS-855R Medicare Enrollment Application - Reassignment of Benefits 
 
  Page 6    Legal name of the eligible individual is listed in the Organization/Group Legal 
Business Name field. 
  Eligible individuals EIN (if he or she has one) is reflected in the TIN field.   
  Eligible individuals PTAN (if he or she has one) is listed in the Medicare 
Identification Number field.  If the eligible individual is submitting an initial 
enrollment with the CMS-855R to establish a new reassignment, a PTAN need 
not be listed, as one has not been assigned; the individual can enter the word 
pending in this field or leave the field blank.   
  National Provider Identifier (NPI) of the eligible individual accepting the 
reassignment is listed in the NPI field. 
  The individual practitioner and the eligible individual or entity are currently 
enrolled or enrolling concurrently in the Medicare program; otherwise, the 
reassignment cannot be processed.  The MAC must check PECOS or its internal 
tracking systems for the CMS-855I and/or CMS-855B application(s).  
  Data elements in sections 1, 2, and 3 of the CMS-855R are completed and the 
data furnished therein is consistent with that submitted on the CMS-855I (e.g., the 
practitioners SSN matches that on his/her CMS-855I), and the data elements in 
section 6A/6B are completed and the appropriate signatures are present.  If any of 
the information is missing or there is inconsistent data, the MAC shall develop for 
the information (e.g., sending a development letter by mail, fax or e-mail). 
                  In addition: 
  The MAC shall verify the NPI against the National Plan and Provider 
Enumeration System (NPPES) or PECOS.  
  When processing the CMS-855R application, the MAC need not perform any 
verification or validation activities involving the individual practitioner or the 
eligible individual or entity (e.g., reviewing licensure, checking the Medicare 
Exclusion Database (MED)).  These validations are conducted during the CMS-
855I and CMS-855B initial enrollment and revalidation processes, and via the 
monthly License Continuous Monitoring (LCM) checks and the systematic 
monthly MED checks in PECOS.  
  If any required data elements in section 2 are not included, the MAC shall send a 
development letter by mail, fax or e-mail to the individual/entity/contact person to 
obtain the missing data.    
If a Clinic/Group/Organization/Sole Owner/CAH is receiving the reassigned benefits, the 
MAC shall ensure that the: 
  Legal business name is reported in the Organization/Group Legal Business Name 
field.  This name must exactly match the name on the entitys Internal Revenue 
Service (IRS) tax documents (CP-575), unless exceptions have been permitted 
through CMS guidance.   
  Entitys TIN (as reported to the IRS) is listed in the TIN field.   
  Entitys Medicare Identification Number (or PTAN) (if issued) is listed in the 
Medicare Identification Number field.  The MAC may use its shared systems, 
PECOS, or its provider files as a resource to determine the PTAN before 
Processing the CMS-855R Medicare Enrollment Application - Reassignment of Benefits 
 
  Page 7  contacting the entity to develop for this information.  If the entity is submitting an 
initial enrollment concurrently with the CMS-855R to establish a new 
reassignment, a PTAN need not be listed, as one has not been assigned; the entity 
may enter the word pending in this field or leave the field blank.   
  Entitys NPI is listed in the NPI field. 
              In addition: 
  The MAC shall verify the legal business name against the IRS documentation, 
NPPES, or PECOS.  
  If the entity is a CAH, the entity need not and should not complete a separate 
CMS-855B form to receive reassigned benefits.  (Note: A reassignment to a CAH 
is only permitted if the Medicare eligible professional wants to participate in the 
EHR Incentive Program for EPs.) 
  The MAC shall verify the NPI against NPPES or PECOS.  
  When processing the CMS-855R application, the MAC need not perform any 
verification or validation activities involving the individual practitioner or the 
eligible individual or entity (e.g., reviewing licensure, checking the MED).  These 
validations are conducted during the CMS-855I and CMS-855B initial enrollment 
and revalidation processes, and via the monthly LCM checks and the systematic 
monthly MED checks in PECOS.  
  The MAC shall ensure that the data elements in sections 1, 2, and 3 of the CMS-
855R are completed and the data furnished therein is consistent with that 
submitted on the CMS-855I (e.g., the practitioners SSN matches that on his/her 
CMS-855I), and the data elements in section 6A/B are completed and the 
appropriate signatures are present.  If any of the information is missing or there is 
inconsistent data, the MAC shall develop for the information (e.g., sending a 
development letter by mail, fax, or e-mail). 
  If any required data elements in section 2 are not included, the MAC shall send a 
development letter by mail, fax or e-mail to the eligible individual or entity/ 
contact person to obtain the missing data.    
 
Section 3:  Individual Practitioner Who Is Reassigning Benefits 
The information supplied in this section is for the individual practitioner who will be reassigning 
his/her benefits or who will be terminating a reassignment.  The MAC shall ensure that the: 
  Individual practitioners legal name (as reported to the Social Security 
Administration (SSA)) is listed in the First Name, Middle Initial, and Last Name 
fields. Any suffixes that may be reported to the IRS should also be included. 
  SSN (as reported to the SSA) of the individual practitioner is reflected in the 
Social Security Number field. 
  Medicare Identification Number (or PTAN) (if issued) of the individual 
practitioner is listed in the Medicare Identification Number field.  If the individual 
practitioner is submitting an initial enrollment application concurrently with the 
Processing the CMS-855R Medicare Enrollment Application - Reassignment of Benefits 
 
  Page 8  CMS-855R to establish a new reassignment, a PTAN need not be listed, as one 
has not been assigned; the individual practitioner can enter the word pending in 
this field or leave the field blank. If the reassignment is being terminated, the 
PTAN should be listed on the CMS-855R.  The MAC may use the shared 
systems, PECOS, or its provider files as a resource for determining the PTAN 
before developing for this data. 
  NPI of the individual practitioner reassigning his/her benefits is reflected in the 
National Provider Identifier field; it should match the information provided to 
NPPES. 
  If the individual practitioner is enrolled currently as an ordering and certifying 
provider, the CMS-855O enrollment must be deactivated and the MAC shall 
develop for the CMS-855I if one is not submitted.  
  When processing the CMS-855R application, the MAC need not perform any 
verification or validation activities involving the individual practitioner or the 
eligible individual or entity (e.g., reviewing licensure, checking the MED).  These 
validations are conducted during the CMS-855I and CMS-855B initial 
enrollments and revalidation processes, and via the monthly LCM checks and the 
systematic monthly MED checks in PECOS.  
  If any required data elements in section 3 are not included, the MAC shall send a 
development letter to the provider/contact person by mail, fax or e-mail to obtain 
the missing data.  
Section 4: Primary Practice Location 
The individual practitioner may identify the primary physical practice location of the eligible 
individual or entity where the individual practitioner will render services most of the time; 
however, this section is optional and not required to be completed by the practitioner.  If data is 
not populated in this section, the MAC shall take no further action.  If data is populated in this 
section, the MAC shall choose the practice location entered on the CMS-855R from the selection 
of active practice locations provided in the drop-down selection in the reassignment grid in 
PECOS.    
The practice location address must be the physical address where the practitioner sees patients.   
If the address listed is not a physical address linked to the group (i.e., section 4A of the CMS-
855B), the MAC shall proceed with processing.  Development is not required.   
Section 5:  Contact Person 
This section captures information regarding the person who should be contacted regarding this 
application.  Multiple contact persons may be listed, and the individual practitioner/contact 
person may copy this page and include it in the enrollment package sent to the MAC.  The MAC 
shall ensure that the contact person provided the required data elements, such as his/her first 
name, middle initial, and last name with any suffixes, as well as the address, city/town, state, zip 
code and telephone.  The contact persons fax number, e-mail address, and his/her relationship or 
affiliation with the eligible individual or entity is optional and not required to be submitted.     
Communications regarding the processing of the CMS-855R shall be sent to the contact person 
listed.  If multiple contact persons are listed, the MAC shall contact the first contact person listed 
Processing the CMS-855R Medicare Enrollment Application - Reassignment of Benefits 
 
  Page 9  on the application.  If he/she is not available, the MAC shall contact the other person(s) listed, 
unless the individual practitioner indicates otherwise via any means. 
If no contact person is listed in this section, the MAC shall contact the individual practitioner 
listed in section 3 or the authorized or delegated official or another contact person on file.  The 
MAC need not develop for the information in this section.  If a contact person is listed, any other 
required data for the contact person (e.g., address) can be captured via telephone.  This 
instruction applies only to section 5. 
Section 6:  Certification Statements and Signatures 
The signatures in this section authorize the reassignment of benefits to an eligible individual or 
entity or the termination of a reassignment of benefits.  Signature dates cannot be more than 120 
days prior to the receipt date. 
Providers and suppliers are able to submit their reassignment certifications either by signing 
section 6A and 6B of the paper CMS-855R application or, if completing the reassignment via 
Internet-based PECOS, by submitting signatures electronically or via downloaded paper 
certification statements (downloaded from www.cms.gov).  If the provider or supplier downloads 
the paper certification statement from the CMS website, it shall write the web tracking ID on the 
top of the certification statement. 
Providers and suppliers should not submit signatures both electronically and by paper.   
The MAC shall not begin processing new reassignment applications until all signatures are 
received from the individual practitioner and the authorized/delegated official.   This is for both 
paper and Internet-based PECOS CMS-855R applications.  The MAC is not required to compare 
signatures of individual practitioners and authorized/delegated officials to that of a signature 
already on file.  In addition, the MAC shall not request the individuals drivers license or current 
passport to verify signature.  
Applications submitted to terminate a reassignment or to update the primary practice location 
only require one signature from either the individual practitioner or the authorized/delegated 
official.  Currently, when an update to the primary practice location is submitted via Internet-
based PECOS, it is categorized as Add a New Reassignment and requires both signatures to be 
completed.  This will be addressed in a future PECOS release.   
 
Section 6A  Individual Practitioner 
The MAC shall ensure that the: 
  Individual practitioner provided his/her first name, middle initial, and last name with any 
suffixes.   
  Individual practitioner signed and dated the form in the Signature and Date Signed fields.   
Processing the CMS-855R Medicare Enrollment Application - Reassignment of Benefits 
 
  Page 10    If any required data elements in section 6A are missing, the MAC shall send a 
development letter by mail, fax, or e-mail to the individual practitioner/contact person to 
obtain the missing data.  (Note: Middle initials and suffixes are not required fields and do 
not require development if missing.)   
  When establishing a reassignment of benefits, the certification statement must be signed 
and dated by the individual practitioner and the authorized or delegated official. If the 
authorized or delegated official is not on file, the MAC shall send a development letter by 
mail, fax, or e-mail to the provider/contact person to (1) have an authorized or delegated 
official on file sign the application or (2) add the authorized or delegated official to the 
organizations enrollment via the CMS-855B application. 
  When terminating a current reassignment, the certification statement must be signed and 
dated by either the individual practitioner or the authorized or delegated official.  Both 
signatures are not required.  
 
Section 6B  Delegated or Authorized Official of Group Practice/Clinic 
The MAC shall ensure that the: 
  Eligible individual accepting the assigned benefits or the authorized or delegated official 
of the clinic/group/organization must sign in this section.  The signee must provide 
his/her first name, middle initial, and last name with any suffixes.  The 
individual/authorized/delegated official must sign and date in the Signature and Date 
Signed fields.  It is preferred that the signatures be provided in blue ink to identify a true 
original signature; however, it is not required.  
  The certification statement is signed and dated by the individual practitioner and the 
authorized or delegated official when establishing a reassignment of benefits.  If the 
authorized or delegated official is not on file, the MAC shall send a development letter by 
mail, fax, or e-mail to the provider/contact person to either have an authorized or 
delegated official on file sign the application or to add the authorized or delegated official 
to the organizations enrollment via the CMS-855B application. 
When terminating a current reassignment, the certification statement must be signed and dated 
by either the individual practitioner or the authorized/delegated official.  Both signatures are not 
required. 
If any required data elements in section 6B are missing, the MAC shall send a development letter 
by mail, fax, or e-mail to the individual practitioner/contact person to obtain the missing data. 
(Note: Middle initials and suffixes are not required fields and do not require development if 
missing.)   
  
 
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