CMS 855 Fiscal Intermediary Form

To: Medicare Applicants

Effective November 1, 2001, the fiscal intermediaries and carriers are responsible for distribution of the CMS 855 form, MEDICARE PROVIDER/SUPPLIER Enrollment Application. Therefore, you must contact the appropriate intermediary or carrier to receive a CMS 855 form if you are an initial Medicare applicant or if you are buying an existing Medicare provider/supplier.

In accordance with the policy established by the Centers for Medicare and Medicaid Services, the Minnesota Department of Health will not conduct an initial Medicare survey until we receive notification that the intermediary or carrier has approved the completed 855 form for your organization.

All Medicare application forms other than the CMS 855 should be returned to the Minnesota Department of Health, P.O. Box 64900, St. Paul, Minnesota 55164-0900.

The most common intermediaries/carriers utilized in Minnesota are listed below.

Noridian Government Services
Contact person: Nikki Tingum - (888) 608-8816

Intermediary for Hospitals, Skilled Nursing Facilities, Rehabilitation Agencies, End Stage Renal Disease Suppliers and Provider-Based Rural Health Clinics

National Government Services
Contact person: Chris Troesch- (414) 459-6950

Intermediary for Home Health Agencies and Hospices

Wisconsin Physicians Services
Contact person: Irene Michel - (952) 885-2809

Intermediary for Portable X-Ray Suppliers and Ambulatory Surgical Centers.

Please contact the Minnesota Department of Health, Compliance Monitoring Division, Licensing and Certification Section at 651-201-4101 with questions.

Updated Monday, May 09, 2011 at 11:41AM