Provider Enrollment

Provider Enrollment:
Completing the CMS
855-O, 855-R, & 588 Forms
June 24, 2015
Presented by:
Part B Provider Outreach and Education
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•
•
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2
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3
Disclaimer
This presentation was current at the time it was published. Medicare policies change
frequently so links to the source documents have been provided within the document
for your reference. This presentation was prepared as a service to the public and is not
intended to grant rights or impose obligations.
This presentation may contain references or links to statutes, regulations, or other
policy materials. The information provided is only intended to be a general summary.
Use of this material is voluntary. Inclusion of a link does not constitute Cahaba nor
CMS endorsement of the material. We encourage providers to review the specific
statutes, regulations, and other interpretive materials for a full and accurate
statement of their contents.
4
Agenda
•
•
•
•
•
Acronyms
Part B Provider Enrollment Series
Friendly Reminder to Enrolling Providers
Order & Referring
Completing CMS-855O Application
•
•
•
Opting-Out
Reassigning Medicare Benefits
Completing CMS-855R Application
•
•
Electronic Funds Transfer (EFT)
Completing CMS-588 Application
•
Announcements & Resources
– Most Common Developmental Delays
– Most Common Developmental Delays
– Most Common Developmental Delays
5
Acronyms
Helpful Medicare Enrollment Terms
AO
Authorized Official
CMS
Centers for Medicare and Medicaid Services
DBA
Doing Business As
LLC
Limited Liability Company
MAC
Medicare Administrative Contractor
NPI
National Provider Identifier
NPPES
National Plan & Provider Enumeration System
PECOS
Provider Enrollment Chain and Ownership System
PTAN
Provider Transaction Access Number
TIN
Tax Identification Number
MLN Commonly Used Acronyms
http://cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads
/Acronyms-Educational-Tool-ICN908999.pdf
6
Provider Enrollment Series
• Did you have an opportunity to attend:
– Part I: Submitting the CMS 855B – June 10, 2015
– Part II: Submitting the CMS 855I – June 17, 2015
https://www.cahabagba.com/part-b/education/cahaba-u-18370/
7
Eligible to Enroll using 855 Applications
Part B Providers/Suppliers who can apply to Medicare Program
Physicians
Clinical Social Workers
Speech-Language
Pathologists
Mammography Centers
Anesthesiology
Assistants
Mass Immunization Roster
Billers - Individuals
Ambulance Service
Suppliers
Mass Immunization Roster
Billers - Entities
Audiologists
Nurse Practitioners
Ambulatory Surgical
Centers (ASCs)
Physical/Occupational
Therapy Group in Private
Practice
Certified NurseMidwives
Physical/Occupational
Therapists in private practice
Clinics/Group Practices
Portable X-ray Suppliers
Certified Registered
Nurse Anesthetists
Physician Assistants
Independent Clinical
Laboratories
Radiation Therapy Centers
Clinical Nurse
Specialists
Psychologists practicing
independently
Independent Diagnostic
Testing Facilities (IDTFs)
DMEPOS Suppliers
Clinical Psychologists
Registered Dietitians or
Nutrition Professionals
Intensive Cardiac
Rehabilitation Suppliers
8
Not Eligible to Enroll using 855 Applications
Acupuncturist
Hearing Aid Center/Dealer
Master of Social Work
Assisted Living Facility
Licensed Alcoholic and Drug
Counselor
National Certified Counselor
Birthing Center
Licensed Massage Therapist
Registered Nurse
Certified Alcohol and Drug
Counselor
Licensed Practical Nurse
Speech and Hearing Center
Certified Social Worker
Licensed Professional Counselor
Substance Abuse Facility
Drug and Alcohol
Rehabilitation Counselor
Marriage Family Therapist
Medicare Program Integrity Manual 100-08, Chapter 15-Medicare Enrollment
9
Ordering and Referring
•
The Affordable Care Act, Section 6405, requires physicians or
eligible professionals who order items or services for Medicare
beneficiaries to be Medicare to be enrolled in the Medicare
program or have a valid record of opting-out
•
CMS phased implementation of Ordering/Referring Edits
– Phase 1: Effective October 5, 2009
• remittance informational message
– Phase 2: Effective January 6, 2014
• Full implementation of O & R edits
• Denial of items or services provided by clinical lab, imaging, DME
and HHA claims missing eligible ordering/referring provider information
MLN SE1305
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Dow
nloads/se1305.pdf
10
CMS 4159-F2
• Medicare Program – Contract Year 2016 Policy and Technical
Changes to the Medicare Advantage and Medicare Prescription
Drug Benefit Programs
– Requires physician and other eligible professional who write
prescriptions for Part D drugs to be enrolled in an approved status or
to have valid opt-out affidavit
•
•
•
•
CMS-855I Form (for reimbursement); or,
CMS-855O Form (order, refer or prescribe Part D drugs)
Submit enrollment or affidavit by January 1, 2016
Requirement will become effective June 1, 2016
MLN SE1434 Revised
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downl
oads/SE1434.pdf
11
Ordering/Referring Defined
• Ordering/Referring Provider – a person who ordered, referred, or
certified an item or service reported in a Medicare claims
1. A provider “orders” non-physician items or services such as:
• Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
(DMEPOS)
• Clinical Laboratory Services
• Imaging Services
• Prescribe Part D Medication
2. A provider “certifies” home health services for a beneficiary
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Eligible to Order and Refer
Part B Providers who can Order/Refer Items, Services, or DMEPOS
Doctors of Medicine
Doctors of Podiatric Medicine
Clinical Psychologists
Fellows
Doctors of Osteopathy
Doctors of Optometry
Clinical Social Workers
Nurse Practitioners
Doctors of Dental
Medicine
Certified Nurse-Midwives
Interns*
Optometrists *
Doctors of Dental
Surgery
Clinical Nurse Specialists
Residents*
Physician Assistants
Part B Providers who can Order/Refer Part A Home Health Agency
Doctors of Medicine
Doctors of Osteopathy
Doctors of Podiatric Medicine
*MLN Ordering/Referring Enrollment Fact Sheet
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/
MedEnroll_OrderReferProv_FactSheet_ICN906223.pdf
13
Completing the CMS-855O
CMS 855 Form
• Type or print all information legibly
• Report additional information within a section by copying and
completing for each additional entry
• Attach all required supporting documentation
• Keep a copy for your records
• Make sure a completed application with original signatures is sent
to Cahaba
14
Application Submission Options
1.
Online - Internet web based PECOS at:
https://pecos.cms.hhs.gov/pecos/login.do#headingLv1
2.
Paper Application – CMS-855O Form
** All 855 enrollment applications are maintained by the Centers of Medicare
and Medicaid Services (CMS)
15
Locating the 855 Application Forms
http://www.cahabagba.com/
16
855O
Before Completing the CMS-855O:
• Review the form from beginning to end
• Instructions are located on cover page and
throughout the form
• All information on this form is required with
the exception of those fields marked as
“optional”
• Do not include this sheet when submitting
your completed application
17
855O - Instructions
Instructions for Completing the Application:
• Determine if the provider is eligible to
complete the CMS-855O
• Decide if this is the most appropriate
application for the provider
• National Provider Identifier (NPI) must be
obtained prior to applying to be a Medicare
Supplier
• Know where to mail your completed
paper application
• Sign/Date application using blue ink
• Do not include this sheet when submitting
your completed application
18
855O – Section 1
A
B
Item A
• Indicate application
submission reason
Select one option:
 new application
 update existing
 withdrawal to order
and refer only
• Complete application
section requirements
listed based on your
choice
Part B
• Select one reason you are registering to order and refer
19
855O – Section 1 Developments
Item B
• Providers who select
Non-Licensed need to
provide documentation
on the educational
program in which they
are currently enrolled to
avoid developmental
delays
20
855O – Section 2
• Complete in its entirety:
A
B
 Item A – Personal
Information
 Item B – Educational
Information
 Item C – License/
Certification/Registration
Information
1.
2.
3.
C
License
Certification
Drug Enforcement
Agency (DEA)
Registration
21
855O – Section 2 Developments
Item C
• If entering licensing/
certification/registration
information please provide
documentation (copies) of
credentials to avoid
development delays
• Alert
The effective date entry
in 2 (Certification) &
3 (DEA Registration) may
not print in the correct
XX/XX/XXXX format
22
855O – Section 3A & 3B
• Read in its entirety:
A
 Item A – Convictions
Information
 Item B – Exclusions,
Revocations or
Suspensions
B
23
855O – Section 3C
Item C
• Indicate:
 If there is a change in the
providers status and list
the effective date
 Check YES or NO, in
response to if provider has
ever had a final adverse
legal action imposed
 IF YES –
• List action(s) and attach
copy of the relevant
legal document(s)
 IF NO –
• Go to Section 4
24
855O – Section 3 Developments
Item C-1
• A selection of either Yes or
No must be chosen to
avoid developmental delays
25
855O – Section 4A
Item A
• If you are a physician,
only select one physician
specialty
– Primary Specialty
26
855O – Section 4B
Item B
• If you are a non-physician
practitioner, only select one
specialty type that indicates
your field of professional
concentration
27
855O – Section 4 Developments
Item A & Item B
• Both – Physicians and Non-Physician
Practitioners must be eligible to order and
refer services to avoid development and/or
application denial
 Example – Acupuncturist and Licensed
Practical Nurse are not eligible to order
and/or refer services
 See slide 13 for a list of eligible
providers
*MLN Ordering/Referring Enrollment Fact Sheet
http://www.cms.gov/Outreach-and-Education/Medi
care-Learning-Network-MLN/MLNProducts/Downlo
ads/MedEnroll_OrderReferProv_FactSheet_ICN9062
23.pdf
28
855O – Section 5
• Complete correspondence
mailing address in its
entirety
 Attention section is
optional
29
855O – Section 6
• Complete the contact
person information to
provide an alternative
contact person
30
855O – Section 7
• Read in its entirety the penalties for
falsifying information
• Do not include this sheet when
submitting your completed application
31
855O – Section 8A
Item A
• Read the certification statement
A
 Understand to receive reimbursement must
complete 855I
 Contents of application are true correct and
complete
 Authorize MAC/Cahaba to verify information
contain in application
 Notify of changes within 90 days of the
effect date of change
 Misrepresentation on application may be
punished by criminal, civil and/or
administrative penalties
 Agree to abide by all Medicare regulations
 Will not knowing order/refer items and/or
services that allow a false or fraudulent claim
to be presented to Medicare
32
855O – Section 8B
B
Item B
• Application must be signed by the individual practitioner
• Signature included in the application must be original and signed in
blue ink
• Stamped, faxed or copied signatures will not be accepted
• Date the application
33
855O – Section 8 Developments
LaTrelle M. White, M.D.
06/24/2015
Item B
• The individual practitioner must sign and date the application, using
blue ink to avoid developmental delays
34
855O – Privacy Statement
• Read the Privacy Act Statement carefully
 Information will be entered into and
maintained on PECOS
 Permits CMS to disclose information to
support contractors, consultants, Federal/
State agencies and the Department of
Justice (DOJ) as it relates to the Medicare
program and its protection
• Do not include this sheet when
submitting your completed application
35
Submitting 855-O Application
• Retain a copy of the completed
application and any submitted
documentation for your records
• If submitting your application
for a Part B provider on or after
July 1, 2015 be sure to verify
mailing address due to possible
Jurisdiction J changes
36
Opting Out of Medicare
• Physician/Practitioner does not wish to enroll in Medicare
• Physician/Practitioner must file a written affidavit
•
•
•
Opt out affidavits are only valid for 2 years
A private contract must be in place between the physician/practitioner and
the Medicare beneficiary*
Submit affidavit at least 30 days prior to selected calendar quarter
• Physician/Practitioner/Beneficiary agree not to submit claims or
receive reimbursement from Medicare
• Beneficiary is financially responsible for payment of all services
*MLN SE1311
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downl
oads/SE1311.pdf
37
Opting Out of Medicare
Part B Enrollment Webpage
38
CMS Ordering & Referring
• Locate providers approved to Order & Refer
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Medicar
eProviderSupEnroll/MedicareOrderingandReferring.html
39
Data.CMS.gov
• Locate providers in approved Opt-Out status
https://data.cms.gov/dataset/Medicare-Individual-Provider-List/u8u9-2upx
40
Reassigning Medicare Benefits
• Reassigning Medicare benefits allows an eligible organization or
group to submit claims and receive payment for Medicare Part B
services you have provided as a member of the
organization/group or terminating an established reassignment
• Separate 855R applications must be submitted for each
organization/group where reassignment is being established or
terminated
*Physician Assistants should not use the 855R
41
Reassignment Eligibility
• Individual practitioner should
be currently enrolled or in the
enrollment process with the
855I application
• Group/Organization should
be currently enrolled or in the
enrollment process with the
855B application
42
Reassignment Eligibility
Individuals can reassign Medicare benefits to:
Clinic
Group Practice
Individual
Other Healthcare Organization
• An individual does not need to reassign their benefits if they are the Sole
Owner of a:
– Corporation
– Limited Liability Company
– Professional Association
43
Completing the CMS-855R
CMS 855 Form
•
•
•
•
•
Type or print all information legibly
Do not use pencil – blue ink is preferred
Enter all NPIs in the appropriate sections (group/individual)
Keep a copy for your records
Make sure a completed application with original signatures is sent
to Cahaba
44
Application Submission Options
1.
Online - Internet web based PECOS at:
https://pecos.cms.hhs.gov/pecos/login.do#headingLv1
2.
Paper Application – CMS-855R Form
** All 855 enrollment applications are maintained by the Centers of Medicare
and Medicaid Services (CMS)
45
855R
Before Completing the CMS-855R:
• Review the form from beginning to end
• Instructions are located on cover page and
throughout the form
• Do not include this sheet when submitting
your completed application
46
855R - Instructions
Instructions for Completing the Application:
• Determine if the provider is eligible to
complete the CMS-855R
• Decide if this is the most appropriate
application for the provider
• National Provider Identifier (NPI) must be
obtained prior to applying to be a Medicare
Supplier
• Know where to mail your completed
paper application
• Sign/Date application using blue ink
• Do not include this sheet when submitting
your completed application
47
855R – Section 1
• Indicate application
submission reason
Select one option:
 Reassigning benefits
 Individual terminating
reassignment with
group
 Group terminating
reassignment with
individual
• Complete application
section requirements
listed based on your
choice
48
855R – Section 1 Developments
• An effective date must
be entered for chosen
option to avoid
developmental delays
49
855R – Section 2
• Identify the Organization/
Group to whom benefits
are being assigned or
terminated
Include:
 Legal Business Name as
reported to the IRS
 Tax Identification Number
for organization/group
 PTAN if issued
 If initial group/organization
enrollment has been
submitted write “Pending”
in the Medicare ID/PTAN
block
 Organization/Group NPI 50
855R – Section 2 Developments
Example
LBN/File Taxes to IRS as:
Primary Care Medicare Group of Florence Empire, Inc.
DBA/Marketed/Advertised as:
Florence Primary Care
• The legal business name
should reflect the name of
the business in which you
file your taxes under – not
the DBA name
• Cross reference Tax ID and
PTAN with legal business
name entry for the
organization – may have
more than one number
• Check for possible
transposed numbers
Review all to avoid
developmental delays
51
855R – Section 3
• Identify the Individual who
is reassigning or
terminating his/her benefits
Include:
 Provider Name
 Social Security Number
 PTAN if issued
 Individual NPI
52
855R – Section 3 Developments
• Check for possible
transposed numbers to
avoid developmental delays
53
855R – Section 4
• Complete the primary
practice location
information – where the
provider will render
services most of the time
List DBA Name
Practice Address
If location rendering
services has a
different PTAN/NPI
than reported in
Section 2
54
855R – Section 5
• Complete the contact
person information –
gives authorization to
discuss issues concerning
reassignment
55
855R – Section 6
• Read the Certification Statement
Notice of authorization or
termination of payment to
Organization/Group
Item A
• Signature of Individual Practitioner
A
B
 Signature date
 Use blue ink
Item B
• Signature of the Delegated or
Authorized Official of the
Organization/Group as indicated on
the 855B
 Signature date
 Use blue ink
56
855R – Section 6 Developments
LaTrelle M. White, M.D.
Renea M. Cloud
• The Delegated or Authorized
Official must be on file
• If the DO/AO has changed,
the 855B must be updated
• Application must be signed
and dated
• Submit this application
within 120 days of the
signature dates
Review all to avoid
developmental delays
57
855R – Privacy Statement
• Read the Privacy Act Statement carefully
 Information will be entered into and
maintained on PECOS
 Permits CMS to disclose information to
support contractors, consultants, Federal/
State agencies and the Department of
Justice (DOJ) as it relates to the Medicare
program and its protection
• Do not include this sheet when
submitting your completed application
58
Submitting 855-R Application
• Retain a copy of the completed
application and any submitted
documentation for your records
• If submitting your application
for a Part B provider on or after
July 1, 2015 be sure to verify
mailing address due to possible
Jurisdiction J changes
59
Electronic Funds Transfer
• EFT allows Medicare to send payments directly to a provider’s
financial institution through electronic transmission
– All new Medicare providers are required to receive payment
electronically through EFT
– Exist provider are required to begin EFT when submitting changes to
their existing enrollment or have received a Revalidation request
Medicare Claims Processing Manual
100-04, Chapter 24, Section 40.7
http://www.cms.gov/Regulations-and-G
uidance/Guidance/Manuals/Downloads/
clm104c24.pdf
60
588 - Instructions
Instructions for Completing the Application:
• Line by Line Instructions for completing the
CMS-588 form
• National Provider Identifier (NPI) must be
obtained prior to applying to be a Medicare
Supplier
• Know where to mail your completed
paper application
• Sign/Date application using blue or black ink
• Do not include this sheet when submitting
your completed application
61
588 – Part I
• Indicate application
submission reason
Select one option:
 New EFT enrollment
 Change to current EFT
 Cancel EFT enrollment
 EFT payment to Home Office
of Chain
• Indicate if you have
experienced a change in
ownership or practice location,
if you have you must update
your 855 application also
62
588 – Part II
•
Enter the Bank/Financial
Institution account holders
information
Include:
 Legal Business Name or
Physician/Individual
Practitioner
 Enter the practice location
address
 Tax ID or Social Security
Number
 PTAN
 NPI
63
588 – Part II Developments
•
•
•
•
•
The legal business name should
reflect the name of the business in
which you file your taxes under –
not the DBA name
If you list a Group NPI, list the
corresponding Group PTAN
Sole Owner/Proprietors should list
Individual NPI and corresponding
PTAN
Only the Individual provider
receiving EFT fund may be listed on
the account – no joint account i.e.
spouse
Check for transposed numbers
Review all to avoid developmental
delays
64
588 – Part III
•
Enter the Financial
Institution information
Include:
 Financial Institution Name
 Financial Institution
physical address
 Financial Institution phone
number
 Contact person name at
Financial Institution
 Routing Number
 Account Number
65
588 – Part III Documents
•
An account confirmation
document must be included
with the 588 application
submission:
 Voided Check
Or
 Bank Letterhead
Include:
• Name on Account
• Routing Number
• Account Number
• Type of Account
• Bank Official’s name and
signature is required on
letter
66
588 – Part III Developments
Enter the actual physical
address of the Financial
Institution – no P.O. Boxes
• Include a name at the
Financial Institution that
may be contacted for
account verification purposes
• Check to ensure you have
entered the routing number
and the account number in the
designated blocks
• Indicate the type of account
• Include the voided check or an
account letter from the
Financial Institution
Review all to avoid developmental
delays
67
•
588 - IV
• Complete the contact
person information –
gives authorization to
discuss issues concerning
the 588 application
68
588 – V
• Read the Authorization notice
 Permission to deposit funds
 Permission to initiate adjustments for
duplicate or erroneous entries
Renea Cloud
• Authorized/Delegated Official Signature
and date required
• Authorization is effective as of the
signature date
• Read the Privacy Act Advisory Statement
69
588 – V Developments
Renea Cloud
• Include a signature date
to avoid developmental
delays
70
Submitting 855-R Application
• Retain a copy of the completed
application and any submitted
documentation for your records
• If submitting your application
for a Part B provider on or after
July 1, 2015 be sure to verify
mailing address due to possible
Jurisdiction J changes
71
Announcements
•
•
•
•
•
Jurisdiction J Transition
MSI Satisfaction Indicator
2015 Cahaba Medicare Expo
ICD-10
ForeSee Survey
http://www.cahabagba.com/
72
Resources
Cahaba GBA
www.cahabagba.com
Centers for Medicare and Medicaid Services
http://www.cms.gov/
Medicare Provider-Supplier Enrollment
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Medi
careProviderSupEnroll/index.html
Medicare Learning Network
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network
-MLN/MLNProducts/index.html
73
Question & Answer
For claim specific questions, please call:
Provider Contact Center 1-877-567-7271
74
Thank You
• Thank You for Your Participation Today!
• The evaluation for today’s presentation will launch immediately
upon conclusion
75