Form CMS-10457 MSI Participant Registration Information

MSI Participant Registration Information

7500 Security Boulevard
Baltimore, MD
21244

What is the MAC Satisfaction Indicator (MSI)?
The Medicare Administrative Contractor (MAC) Satisfaction Indicator is a tool that measures your satisfaction with the Medicare claims
administration contractor(s) that serve you. Each year CMS will randomly select its MSI administration sample from a list of providers
who register to become a participant.
The contractors and CMS use the results to improve the level of service offered to all Medicare Fee-For-Service (FFS) providers. If you
are a Medicare FFS provider, or represent a Medicare FFS provider, we would love to hear from you.
How do I become an MSI participant?
1. Complete and submit the form below to register to participate in this annual process.
2. If you represent more than one provider or do business with more than one MAC, feel free to submit multiple forms.
3. If you are selected to participate in the annual administration of the MSI, please be open and honest as you complete it.
We value your feedback!
Participant's Job Category: Please Select Best Choice

Participant's Name:

Participant's Email:

Provider's Individual NPI:

Provider's PTAN*:
*The PTAN must be associated with the Provider's Individual NPI

State Associated w/ NPI: 1

MAC Associated w/ NPI: Please Select MAC

What is the enrollment type of the NPI listed above? (i.e. did you use the 855A for Institutional Providers, 855S for DMEPOS suppliers, etc.)
Please Select Enrollment Type

What is the approximate number of Medicare claims this NPI submits on an annual basis? Please Select Range
Would you like to sign up for the Medicare Fee-For-Service Provider eNews, which include updates to rules & regulations, Medicare
Learning Network ® products, notices of upcoming National Provider Calls, new web postings, and more?
Yes

No

I am already signed up

Submit
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this information collection is 0938-XXXX . The time required to complete this information collection is estimated to average 1 minute per submission,
including the time to review instructions. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.