Completing the CMS-855A Enrollment Application

10/14/2014
Completing the CMS-855A
Enrollment Application
Presented by: Provider Outreach and Education
October 14, 2014
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Who Should Complete This
Application
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Community Mental Health
Center
Comprehensive Outpatient
Rehabilitation Facility
Critical Access Hospital
End-Stage Renal Disease
Facility
Federally Qualified Health
Center
Histocompatibility
Laboratory
Home Health Agency
Hospice
Hospital
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Indian Health Services
Facility
Organ Procurement
Organization
Outpatient Physical
Therapy/Occupational
Therapy/Speech Pathology
Services
Religious Non-Medical
Health Care Institution
Rural health Clinic
Skilled Nursing Facility
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Acronyms
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CMS – Centers for Medicare and Medicaid Services
NPI – National Provider Identifier
PTAN – Provider Transaction Access Number
NPPES – National Plan and Provider Enumeration
System
CHOW – Change of Ownership
LBN – Legal Business Name
MAC – Medicare Administrative Contractor
LLC – Limited Liability Company
DBA – Doing Business As
IRS – Internal Revenue Service
AO – Authorized Official
DO – Delegated Official
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National Provider Identifier (NPI)
• Standard unique health identifier
• Assigned by the National Plan and Provider
Enumeration System (NPPES)
• All providers, except organ procurement
organizations, must obtain an NPI prior to enrolling
in Medicare
• Apply online at https://NPPES.cms.hhs.gov
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Avoid Delays
Type or print in ink
Complete all required sections
Enter all applicable dates
Attach all required supporting documentation
Keep a copy of the application for your records
Make sure all signatures are original, stamped
signatures are NOT accepted
• Ensure that the correct person signs the application
• Include application fee, if applicable
• Utilize PECOS for faster processing
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Application Process
• Send application along with all supporting
documentation to Cahaba
• Cahaba makes a recommendation for approval or
denial to the State survey agency, with a copy to
the CMS Regional office
• Based on results, State agency makes a
recommendation for approval or denial to CMS
Regional office
• CMS Contractor conducts second review, as
needed
• CMS Regional office makes final decision
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Section 1
Basic Information
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Check the box that
corresponds to the reason
you are submitting the
application
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Complete all sections
provided in the Required
Sections box
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Key Points
• Section 1:A
o If you are voluntarily terminating your Medicare enrollment,
the effective date of termination should be the day after
the last date patients were seen
o Hospitals with subunits should list all PTANs and NPIs in this
section
• Applies to Change of Information only
• Subunits
o Subunits will have one of the following letters in the PTAN to
identify that provider type
• T – Rehab
• U-Swingbed
• S-Psych
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Section 2
Identifying Information
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Check each provider type
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If two or more provider
types, submit separate
application for each
provider type
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If hospital, check all
applicable subgroups
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Provide Legal Business
Name as reported to the IRS
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Key Points
• Section 2:B1
o Make sure that the Legal Business Name (LBN) matches
LBN on the IRS document for your facility
o LBN should also match name listed in the National Plan and
Provider Enumeration System (NPPES)
o Provide cost report end date
• If unknown, contact your Accounting department
o Identify how business is registered with IRS
• Proprietary or Non-Profit
• This information can be found on the 501(C)3
• Section 2:2C
o Be sure to provide a valid email address
• Section 2:2D
o If accredited, submit copy of accreditation
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Section 3
Adverse Legal Actions/Convictions
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Enter convictions,
exclusions, revocations and
suspensions here regardless
of whether records were
expunged or any appeals
are pending
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Attach copy of final
adverse action
documentation and
resolution
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Key Points
• This section is Required, do not leave blank
• Includes misdemeanors and felony convictions,
exclusions, revocations or suspensions
• Medicare enrollment does include a verification
process
• Include ALL documentation
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Final adverse legal action
Date
Who was the action taken by
What was the resolution
• CMS makes final decision
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Section 4
Practice Location Information
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Report all locations where
services are furnished here
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List primary practice
location first
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If more than one location,
copy and complete this
section for each
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Key Points
• Section 4:A
o If you are relocating/changing your address submit a
“delete” page for the old location and an “add” page for
the new location
o Provide an effective date for the deleted location and the
location you are adding
o Provide all NPIs and PTANs
• For Initial applications enter the word “Pending”
o For multiple locations , copy and complete this section for
each location
• Section 4:C
o Only complete if records are stored at a location other
than the locations listed in Sections 4A or 4B
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Section 5
Ownership and/or Managing Control
Information (Organizations)
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Report information for any
organization with direct or
indirect ownership of, a
partnership interest in,
and/or managing control of
the provider listed in Section
2
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Only organizations should
be reported in this section
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Key Points
• Section 5
o The Organization listed in Section 2:B1should not be listed
here unless:
• It is a government owned entity or
• Non-Profit and governed by a Board of Directors
o Board would be listed in Section 5
o Board members should be listed in Section 6
• Section 5:B
o The only time General Partnership and Limited Interest can
be selected as a Role in Section 5B is if the organizational
structure in Section 2:B1 is listed as a Partnership
o “Other” cannot be the only Role selected
• If selected, it has to be in conjunction with another Role (i.e.,
Operational/Managerial Control)
• Section 5:C
o This question must be answered
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Section 6
Ownership and/or Managing Control
Information (Individuals)
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Report information about
any individual who has
direct or indirect ownership
of, a partnership interest in,
and/or managing control of
the provider listed in Section
2
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Only individuals should be
reported in this section
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Key Points
• Section 6
o Each facility must have either a:
• W-2 or Contracted Managing Employee; or
• An individual with Operational/Managerial Control
o Other Ownership or Control/Interest cannot be the only
Role selected
• Has to be in conjunction with another Role (i.e.,
Operational/Managerial Control)
o The following officers should be listed in Section 6:
• Chain Home Office Administrator
• Authorized Official (AO)
• Delegated Official (DO)
• Section 6:B
o This question must be answered
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Section 7
Chain Home Office Information
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This section captures
information regarding chain
organizations
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The information will be used
to ensure proper
reimbursement when the
year-end cost report is filed
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Key Points
• Section 7
o The Chain Home Office listed in this section must also be
listed in Section 5
• Section 7:B
o The Chain Home Office Administrator listed in this section
must also be listed in Section 6
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Section 8
Billing Agency Information
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Complete this section if you
use a billing agency to
process and submit your
claims
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If you use a billing agency,
you are responsible for the
claims submitted on your
behalf
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Key Points
• Section 8
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If you do not use a billing agency, skip this section
Always provide an effective date
The billing agency should not be the provider
If the billing agency address matches the “special
payments” address provided in Section 4B, submit a copy
of the current Billing Agreement with the enrollment
application
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Section 12
Special Requirements for Home
Health Agencies
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All HHAs and HHA sub-units
must complete this section
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Documentation supporting
sufficient initial reserve
operating funds to operate
for the first three months in
the Medicare program
required
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Section 13
Contact Person
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If questions arise during the
processing of the
application, Cahaba will
contact the person shown in
this section
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If the contact person is an
authorized or delegated
official, indicate on the
application
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Key Points
• Section 13
o The contact person listed in this section can be contacted
by:
• Mail
• Fax
• Email
• Phone
o Multiple contacts are permissible
• Copy and complete this section for each contact person
o Make sure the telephone number and email address are valid
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Section 15
Certification Statement
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The signature provided in
this section certifies that the
information contained in the
application is true, correct
and complete
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Key Points
• Section 15
o The Authorized Official is an appointed official (i.e., CEO,
CFO, Partner)
o The Delegated Official is an individual delegated by the
authorized official
o The AO and DO should be listed in Section 6 of the
application
o Each time a correction or change is made to the
enrollment application, a newly signed and dated Section
15 is required
o Once we have received the first original signature, faxed
copies of this section are permissible
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Section 16
Delegated Officials
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Delegated officials are not
required
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If adding more than 2
delegated officials, copy
and complete this section
for each
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Key Points
• Section 16
o The individual listed as the Delegated Official in this section
should also be listed in Section 6
o When adding a Delegated Official, the Authorized Official
must also sign and date to certify that they are assigning
this delegation
o If you are changing, adding or deleting a Delegated
Official, make sure you furnish the effective date
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Section 17
Supporting Documents
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This sections lists all of the
documents that need to be
submitted with the
application
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For changes, only submit
documents that are
applicable to that change
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Key Points
• All applicable documents are required if you are
newly enrolling, reactivating or revalidating your
enrollment
o IRS document
• CP575 - Proprietary
• 501(C)3 – Non-Profit
o State License (if applicable)
o Statement in Writing
o Electronic Funds Transfer (EFT)
• Voided check
• Letter from Bank
o Articles of Incorporation (if applicable)
o Attestation Agreement (Government Owned Entities)
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Provider Enrollment Resources
• Cahaba GBA – Enrollment
o http://www.cahabagba.com/part-a/enrollment/
• CMS – Medicare Provider/Supplier Enrollment
o http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/index.html
• Medicare Program Integrity Manual, CMS Pub. 10008, Chapter 15
o http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/pim83c15.pdf
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10/14/2014
Questions
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