Provider Enrollment Information
At TriSpan, we seek to protect the assets of the Medicare Trust Fund, as well as ensure the quality of health care services our beneficiaries receive. By assisting CMS in controlling who is allowed to bill Medicare, we are able to do that.
TriSpan's Provider Enrollment Unit ensures that Medicare billing privileges are granted to and retained by those individuals and organizations that have proven they are financially sound, responsible, and accountable business partners. In addition, these individuals and organizations must meet all applicable requirements and standards for their profession.
Typically, a health care provider who wants to become a Medicare Part A provider contacts TriSpan Health Services to receive an application form (CMS-855A), and other required documentation. *Note: Since an original signature must be kept on file, the CMS 855A Enrollment form cannot be faxed initially. Changes can be made at a later date through fax, if needed. Enrollees return the applications to TriSpan Health Services. You may also need to contact the state agency or the CMS regional office.
Provider Enrollment also helps providers report certain changes of information, including stock transfers or change ownership (CMS-855A), or terminate their Medicare provider number. Such activity prompts the Provider Enrollment Unit to investigate changes with the same level of scrutiny as is required with new enrollees.
You will find more information related to provider-based status and the attestation process on the CMS website. Additional "Information and Education Resources for Medicare Providers, Suppliers, and Physicians" has been developed by the Centers for Medicare and Medicaid Services to meet the Medicare business needs of Physicians and other providers.
Provider Enrollment Application Packet
We look forward to working with you as your Medicare intermediary. In order for your facility to begin billing under your new Medicare provider number we must have additional information.
Please complete these forms in the Provider Enrollment Application Packet:
Authorization Agreement for Electronic Funds Transfer (EFT) Request
To have your facility added to the Medicare payment system, please return the completed CMS-855A form, the New Provider Information Sheet, and the Projected Budget (initial rate setting information) as soon as possible. Once you are approved to be a Medicare enrolled provider, your facility will automatically be registered to receive e-mail notifications from TriSpan whenever something new is added to our site.
These forms (numbers 1-4 listed above) should be mailed or faxed
to:
(*Note: Since an original signature must be kept on file, the CMS 855A
Enrollment form cannot be faxed initially. Changes can be made at a later date
through fax, if needed.)
| AX1MC1 |
| TriSpan Health Services |
| Attn: Supervisor, Reimbursement Support |
| P.O. Box 23046 |
Jackson, MS 39225-3046 |
| Fax: (601) 664-4577 |
The Physician Referral Letter (number 5 above) is provided for your reference. Please download and familiarize yourself with it and the enrollment application packet in its entirety.
Other information for your review:
Fact Sheet: "Provider Enrollment"
Bulletin: Provider Enrollment Information and Forms (HOSP 2004-184)
Frequently Asked Questions (FAQs) at TriSpan.com or CMS website FAQs
Provider Enrollment Contact
Information
Please forward all Provider Enrollment applications and related
correspondence to the mailing address below:
AX1MC1 TriSpan Health Services P.O. Box 23046 Jackson, MS 39225-3046 Or call us toll free: Monday through Friday 8 AM to 4:30 PM CST: (877) 635-7596 Or fax: (601) 664-4577
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Provider Enrollment Process Flow
