Document 6501975

Transcription

Document 6501975

DME Enrollment Issues & How to Avoid
Disenrollment
Moderated by Paul Kesselman DPM
Participants Karen Hurley, CMM, CPC, President of HPMSI Katherine Sharp, BA, President of Keystone Professional
Solutions
Sponsored by PICA
June 25, 2014
Disclaimer
The contents of this lecture and handouts are to serve as a
reference point for the provision of DME and its reimbursement and
are solely the opinion of Dr. Kesselman, Karen Hurley and Katherine
Sharp. These opinions are not necessarily endorsed or shared by PICA
or APMA.
One should check with your health care attorney and liability
carrier for further advice and with your patient’s insurance carrier for
coverage information. Products discussed and/or illustrated are provided as examples
and
not necessarily an endorsement of their use.
Dr. Kesselman is a board member of Visual Foot Care Technology
and consultant to EHR and DME Manufacturers.
Karen Hurley is President of HPMSI and Katherine Sharp is owner of
Keystone Professional Solutions. Both have extensive experience with
administrative issues concerning medical billing for podiatrists.
Any reproduction of this presentation in any format without their
express written permission is prohibited.
DME For Dummies
• 
ALJ
Administrative Law Judge
• 
COI
Certificate of Insurance
• 
DME MAC’s
• 
DOS
Date of Service • 
DWO
Detailed Written Order (Similar to Prescription)
• 
LCDs
Local Carrier Decision
• 
NPI
• 
NSC
National Supplier Clearinghouse
• 
OIG
Office of Inspector General
• 
O&P
Orthotics and Prosthetics
• 
OTS
Off the Shelf
• 
PDAC
Price Data Analysis Contractor
• 
POD
Proof of Delivery
• 
POE
Provider Outreach and Education
• 
PSC
Program Safeguard Contractor
• 
PTAN
Provider Transaction Number
• 
RAC
Recovery Audit Contractor
• 
SACU
Supplier Auditing Contractor Unit • 
TPA
Third Party Administrator
Durable Medicare Equipment Administrative Contractor
National Provider Identifier
Enrollment in Medicare
DMEPOS
National Supplier Clearinghouse Palmetto GBA, AG-495 P.O. Box 100142 Columbia, SC 29202-3142
IVR: (866) 238-9652 Claims paid by Jurisdiction of Patient’s Home
Address
*Also in Region C: Puerto Rico & The U.S. Virgin
Islands
JURISDICTION
INCLUDED STATES
DME MAC
A
Connecticut, Delaware, District of
Columbia,
Maine, Maryland,
Massachusetts, New Hampshire, New
Jersey, New York, Pennsylvania, Rhode
Island, and Vermont
National Heritage
Insurance
Company
B
Illinois, Indiana , Kentucky , Michigan,
Minnesota , Ohio , and Wisconsin
National Govt
Services (NGS)
C
Alabama, Arkansas, Colorado, Florida,
Georgia, Louisiana, Mississippi, New
Mexico, North Carolina, Oklahoma,
Puerto Rico, South Carolina, Tennessee,
Texas, U.S. Virgin Islands, Virginia, and
West Virginia
Cigna Gov’t Svcs
D
Alaska, American Samoa, Arizona, California,
Guam, Hawaii, Idaho, Iowa, Kansas, Missouri,
Montana, Nebraska, Nevada, North Dakota,
Northern Mariana Islands, Oregon, South
Dakota, Utah, Washington, and Wyoming
Noridian
Administrative
Services
DME MAC’s
•  DME MAC A: 866-419-9458
www.nhic.com/dmerc.html
•  DME MAC B: 877-299-7900 www.ngsmedicare.com
•  DME MAC C: 866-238-9650
www.cignagovernmentservices.com
•  DME MAC D: 877-320-0390
www.noridianmedicare.com/
dme
•  PDAC: 877-735-1326 Help Desk www.dmepdac.com
•  NSC: 803-754-3951
www.palmettogba.com/nsc
Don’t forget Your Non MCR Third Party Payers (TPP)!!
Requirements for DPMs to Enroll in DMEPOS
•  NPI Type I As Prescribing/Ordering/Referring
DPM
•  NPI Type II as the Billing Entity
•  Tax ID Number with IRS Documentation
•  $300K Liability Insurance (Not Your Malpractice)
•  Insurance Policy Must List NSC as Certificate
Holder
•  $542 Application and Processing Fee Per
Location
•  Copy of Your State License
•  Application May be Paper or Electronic
•  Completed Application
Application Process Is it That Complicated?
•  Solo vs Group Practice
•  Single Location vs. Multiple Office
Location
•  Corporation vs Solo Practioner
•  Par vs. Non Par
What is Required to Become
DMEPOS?
•  Enrollment Fee Is Mandatory for DMEPOS
•  CMS 855S “The Application”
•  CMS 588 (“EFT”)
•  CMS-460 (“Participation Agreement”)
DME Application Fee
For 2014 – the fee is $542.00
You must pay online
The automated receipt copy must go with your
application
Where Do I pay the Application Fee?
•  www.palmettogba/medicare
•  Click on NATIONAL SUPPLIER CLEARINGHOUSE
(on the left side menu)
•  Under SELF SERVICE TOOLS, click on “Medicare
Enrollment Fees”
•  You will be taken to the web page that appears
on the next slide
Medicare Payment Web Page Be certain to have your practice information handy – then click on ‘CONTINUE’
Complete this section, then click on ‘PAY NOW’ at the bottom of the screen
What happens next……
•  You will receive an email that shows the fee
has been paid (you may also be able to print
an instant receipt.)
•  A copy of this email must sent with the
application, along with the email(s) you
received enrolling for your Organization NPI.
The Dreaded Application
Paper or Electronic?
http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/
cms855s.pdf
IXW1WNT Of M.(ALfH AHO J.«JMAH SERVK£S
QNll ltS JOit MU)l(M( a MrotCAID SER\llGS
DMEPOS SUPPLIER STANDARDS FOR MEDICARE ENROLLMENT
•-•r.d swnm.lfY of the standards evefY
DMEPOS suppt1or mun meet ordor to obtain and
, . _ lhelr bdffng p!!,,.__ These stondords. ther enUrety. lnwdlng the >urtty bond pro"111on>. ""'llsttd •2 CFR
llolow ts an
Medlatt1
In
In
Jn
i 414.$7(0 and (d} and gn be found .at bnp•Uwww cms.goytMectt(arepnw!1uQfnmll!Q DMEJtoSSuppll«Sunctp
amftopOtPm
A >UPl>lier mU51 be In compll;ince "'1th all appllcable
"-al and Stai. llol>nswe and reQIJatory requiremems.
2. A SUPPiier mU51 provide complete ond am.nte
1n1omiauon on the OMEl'OS SUIJllller appkmon. An1
ct..._ to INs lnfonnJUon IDU5t be reponro to the
,.._,..Suppler~-
3
30doys..
AA.il>l*er .....,,..... an...cl>orllro-...i wflose
1'gnal\ft IS~ llgrl the -
appllc;>tlon for
l>ftnO """-•
5
6
A supplw -
Ill onion from ltS own """"1oiy or
conlrall """ tor the purthase ot 1tm1<
........, to Ill ordon.. A allJlll« GmOt c:onuoa wnh
atry tntlty lllot 11 NT<!llllJ U<Uled from the Medicare
_
..... ..., sui. he.Jltll c;are programs. or mt "-al
or noo-proaJrement prognms.
A supplier mU51- benelklart<!S lhot they may"""
or purcNM lnQl!IOflSlve or rouunely purchased durable
rntdlCal equipment, and of the JUc11ase opdOn for
capped rtnul oquJpment.
A suppl1« mun notify benefl<W1es of w.irr.mty
covtt .ago ~ honor ~11 wa~nties under app11able
Sut1 •~. and rtp.Jlr or replace free of charge Medkare
procurom..nt
COVQf'td rttnu that are u:ndGr warranty.
A syppl1tr must malnbln a physKaJ fadltty on an
;ppropnato Sitt and must maintain a v1s1ble S!gn
with POrtod hours of operation. The locatlon must be
accos11blo to tho publl< and staffed during posted hours
of bUSJnoss. ThQ l0<at1on must~ at least 200 square
fott ;nd cont111n spa<q for storing records.
8. A supplior must pormn CMS or Its agents to conduct
on.Sitt 1nspoct1ons t o ascertain the su,pplle(s compllance
with 1119so stand•rds.
9. A $UPP11tr must maintain a pr1mary business telephone
llntd un<SQf' the name of the business In a local directory
or a toll troe number av.ilable through directory
iHISUnct. Tht t•dwtve use of a beeper. answenng
machl..._ a_,ng ""111oe or ceU phone dunng posted
15. A suppller must acct11t rwturm of subsl.and¥d Oeu INn
fUI quallty for the p.wucuor n-i or unsurt.ablt lt«n>
lorthe-flCl>ry at thet111141 ft flmd and,_ ortold)IT°"'16. A~ mU51 dlldoM U - SUncbnll to Nell
bontf10M)' n IUPl*4S • n...
17 A~ dlllcloM M ' f - ""'ng _...,,,,.,.
flnanaal or corct011n- on the IUPPllor
18. ,.
not conwy or N"'9' • IUPl>lier
u . the~ moy _,..,or anothor
entity to use IU' ~·Dang,_
19.
comp1o1ra moluaon
- - I O - - l l C l . v y c- - W t to mos. sundaRls. A reccnl of 1MM cornplotnts mU51 b4
mairutr-.d •t the pllyllc.al faClllty
20. Complaint records mull lnduclt tho na1114. adclr•
o_
_must
""""""'must,.....•
no-.
ut.phone number
buslntU "°"""prohibited.
llS _ , lt«n> thll lr1Annte must also cowr proclJct
llOOllll)' and complettd - . - . . .
_on
11 A suppllet 11 prohl>lted ITOm <lrect 50ll<1tolloo m
-
btnt-._ Fu complete
this
42 cm§ 424.57(<)(1 l).
12. A SllPIJllW 11 , _ _ f o r -...Y of and ""'5l ln5Uua
on the use of Medlo>re COfm!d " - and
....,...n proof or dolM<J and beneftOarJ ln5UUCtlOn.
~
11
*
"""""*"""'--and
<--1
~of---..-~
to
of lUCll CC<UCt>.
I• A supplier mlSl mainbln and ropbce at no chorge or
r - COil clrectly or through • seNICe controa
"'111 another company. ¥'f M-..re-covered ttems n
has rO<lltd IO btnoll<lar11!5.
and
prococol
htollll l111Ur.,,.t claim numbtr
of the llenthciaty. a summaiy or the comploint. and at'!
acoons won to ,.,.,,._ n
21 A •uppli.r must agrM to furn11h CMS any lnformauon
required by thO Mtd1<ar• natut• and rtQul•tlOns.
22. A supplier must b4 accrodlttd by • CMS·•PProved
.a<<redruuon organ11at1c>n 1n ordor to r1et1vo and
retain a suppl1or b1ll1no numbor Tho Kcrodtiauon must
7.
10 A suppllO< mU51 haw comprMen!M! hablllty lns.Gnce
In the amount of at least SJoo.000 tlldt C<M'IS both
1119 IUIJl>ltr'S pla(e of bu!llll!SS and all customen ond
...,._of the suppilef. 11 the supplier maootacnns
..
23.
24.
25.
26.
27.
lnd1me tho Sl)OClflC prod ucu and sorv1co1 for wh~h tho
supphor K ac.crodltod In ordor for tho 1upphor to rocoivo
payment fO< thoso sptclflC products ond sorv1<os (Ol<COPt
for <~rta 1n txompt phorm1,out1uts),
A supplier must nouty th·Olr 1ccrod1t; t1on org11n1iauon
when a now OMEPOS locauon IS o~nod .
All supplier locouons, whothor ownod or sutxontractod.
must meot tht OMEl'OS qu•l~y standards and b4
,.P•rately accrod1tod 1n ordor to blll Mtd!Qro
A supplier must dKdoso upon onrollmont all products
•nd Stl'VICOS. Including tho llddlUon of now Product llnes
for whlCh they aro soollll'lg acatdlUUon
A supplier mU51 """'t tho suroty bond roquiremonu
Sfl«lfltd In 42 CFR § •2H7(d)
A suppllO< mU51 obuin oiwon ftom
-~
•stat..._
28. A supplier mU11 maintain onllr1ng and rtl«nng
doaJmtntauon . - t n t "'111 P<0"1SIOnl In
U CFR § U• 516(1)
29. A $U11C11W 11 proNbrttd fr°"' lllMlng • pracuc. IOCallon
---...pr--~
30. A~---tOthe~fora
of )I) ho<n per IJICOlll ~las
1n 1141Q> 01 01 the AcO. p11y11ea1 anc1
~""'-or OM£P05 .....,.wor\Jng
wnll CllSlOm made or111oOO and prOSllWUcl
What Are Supplier
Standards?
§  Standards of Business Conduct
§  30 Supplier Standards
§  Not All Apply to DPMs
Supplier Standards 1-5
1. A supplier must be in compliance with all applicable Federal and State
licensure and regulatory requirements and cannot contract with an
individual or entity to provide licensed services. 2. A supplier must provide complete and accurate information on the
DMEPOS supplier application. Any changes to this information must be
reported to the National Supplier Clearinghouse within 30 days. 3. An authorized individual (one whose signature is binding) must sign
the application for billing privileges. 4. A supplier must fill orders from its own inventory, or must contract
with other companies for the purchase of items necessary to fill the
order. A supplier may not contract with any entity that is currently
excluded from the Medicare program, any State health care programs, or
from any other Federal procurement or non-procurement programs. 5. A supplier must advise beneficiaries that they may rent or purchase
inexpensive or routinely purchased durable medical equipment, and of
the purchase option for capped rental equipment. Supplier Standards 6-10
6. A supplier must notify beneficiaries of warranty coverage and honor all
warranties under applicable State law, and repair or replace free of charge
Medicare covered items that are under warranty. 7. A supplier must maintain a physical facility on an appropriate site. This
standard requires that the location is accessible to the public and staffed during
posted hours of business. The location must be at least 200 square feet and
contain space for storing records. 8. A supplier must permit CMS, or its agents to conduct on-site inspections to
ascertain the supplier’s compliance with these standards. The supplier location
must be accessible to beneficiaries during reasonable business hours, and must
maintain a visible sign and posted hours of operation. 9. A supplier must maintain a primary business telephone listed under the name
of the business in a local directory or a toll free number available through
directory assistance. The exclusive use of a beeper, answering machine,
answering service or cell phone during posted business hours is prohibited. 10. A supplier must have comprehensive liability insurance in the amount of at
least $300,000 that covers both the supplier’s place of business and all customers
and employees of the supplier. If the supplier manufactures its own items, this
insurance must also cover product liability and completed operations. Supplier Standards 11-15
11. A supplier must agree not to initiate telephone contact with
beneficiaries, with a few exceptions allowed. This standard
prohibits suppliers from contacting a Medicare beneficiary based
on a physician’s oral order unless an exception applies. 12. A supplier is responsible for delivery and must instruct
beneficiaries on use of Medicare covered items, and maintain
proof of delivery. 13. A supplier must answer questions and respond to complaints
of beneficiaries, and maintain documentation of such contacts. 14. A supplier must maintain and replace at no charge or repair
directly, or through a service contract with another company,
Medicare-covered items it has rented to beneficiaries. 15. A supplier must accept returns of substandard (less than full
quality for the particular item) or unsuitable items (inappropriate
for the beneficiary at the time it was fitted and rented or sold)
from beneficiaries. Supplier Standards 16-20
16. A supplier must disclose these supplier standards to each beneficiary to whom it
supplies a Medicare-covered item. 17. A supplier must disclose to the government any person having ownership,
financial, or control interest in the supplier. 18. A supplier must not convey or reassign a supplier number; i.e., the supplier may
not sell or allow another entity to use its Medicare billing number. 19. A supplier must have a complaint resolution protocol established to address
beneficiary complaints that relate to these standards. A record of these complaints
must be maintained at the physical facility. 20. Complaint records must include: the name, address, telephone number and health
insurance claim number of the beneficiary, a summary of the complaint, and any
actions taken to resolve it. Supplier Standards 21-25
21.A supplier must agree to furnish CMS any information required
by the Medicare statute and implementing regulations. 22.All suppliers must be accredited by a CMS-approved
accreditation organization in order to receive and retain a supplier
billing number. The accreditation must indicate the specific
products and services, for which the supplier is accredited in order
for the supplier to receive payment of those specific products and
services (except for certain exempt pharmaceuticals).
Implementation Date - October 1, 2009 23. All suppliers must notify their accreditation organization when
a new DMEPOS location is opened. 24. All supplier locations, whether owned or subcontracted, must
meet the DMEPOS quality standards and be separately accredited
in order to bill Medicare. 25. All suppliers must disclose upon enrollment all products and
services, including the addition of new product lines for which
they are seeking accreditation. Supplier Standards 26-30
26. Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c).
Implementation date- May 4, 2009 27. A supplier must obtain oxygen from a state- licensed oxygen supplier. 28. A supplier must maintain ordering and referring documentation consistent with
provisions found in 42 C.F.R. 424.516(f). 29. DMEPOS suppliers are prohibited from sharing a practice location with certain
other Medicare providers and suppliers. 30. DMEPOS suppliers must remain open to the public for a minimum of 30 hours
per week with certain exceptions. WHO SHOULD COMPLETE AND SUBMIT THIS APPLICATIO N
Th• following types of Durable Me<fica l Equipment, Prosth•tics, Orthotlcs and SuppllM (DMEPOS) suppll•11
must complete this application to enroll in the Medicare program and receive a Medicare Billing number:
Ambulatory Surgical Center
~partment Store
Grocery Store
Home Health Agency
Hosp.taI
Indian Health Semce or
Tnt..I F.alrty
Intermediate Care
Nurs1n9 Faohty
Medial 5...,py Company
Nursing Facility (other)
Ocularist
Occupational Therapist
Optician
Orthotics Pe..o~I
Oxygen and/or Oxygen
Relate<! EquipMnt Supplier
Pedorthic Penonnel
Pharmacy
Ph)llkal Therapist
Phl!lic4 1, 111dud1110 ~ntlst
and Optometrist
Pronhotla Personnel
ProsthetJc/Orthotlc Personn•I
Rehab<htatlon Agency
Slulled Nuning f..:ll1ty
s~ t..borator)iModiono
Sports Medione
If Y'O'Jr DMEPOS supplier type is not listed. contact the Nauonal Supploor 0.AnnQhouso MedocMe AdmlflHtratl\le
Controctor (NS( MAO before you submit this application.
«•
Complete thos -location if you plan to bill or al<eady btll MedJG1re for DMEPOS and you
• Enrolino ., Medicar• for the first time as a DMEPOS suppl.or
Currontly enrolled 1n Medicare as a DMEPOS ~and need to report d>angoo to your rurrent bus.nos!,
(• o, you are adding, remoWlg, or <hanging existing Wlfu<matl«I under the ModUr• R1P1>ltor btllong
number). Changes must be reporte<f within 30 days of the change
Currontly •nroUed in Medicare as a DMEPOS suppt,.r and need to enroll a new builness lo<.uon """II th•
wmo t.. identification number already enrolled wrth th• NSC MAC.
• Currently •nrolled in Medicare as a DMEPOS supplier and need to enroll a now business loutlon using a
t .. ldont1fication numbe< not currently enrolle<f wrth the NSC MAC.
• Curre-ntly enrolJt'd in Medicare as a DMEPOS supplier and received notKe to re-validate your enrollment.
• React1vat1no your Medicare DMEPOS supplier billing number.
• Voluntarily t•rminating your Medicare DMEPOS supplier billing number
DMEPOS suppli•rs can apply for enro llment in the Medicare program or make a change In their •nrollmont
information using either:
• The Internet-based Provider Enrollment, Chain and Owne11h lp S)/ltem (PECOS), or
• The paper CM S-8555 enro llment application. Be sure you are using the n'ost current version.
For oddltlonal In formation rega rding the Med icare enrollment process, Including Internet-based PECOS and lo
get the current version o f the CM S-SSSS, go to htto:l/www.cms.goy/Med !c1reProyiderSupEnro ll.
BILLING NUMBER AND NATIONAL PROVIDER IDENTIFIER INFORMATIO N
The Medicare Identification Number, often referred to as a Medkare supplier number Of' Medicare billing
number is a generk term for any number other than th• National Provider ld•ntlfl•r (NPI) that Is used by a
DMEPOS suppll•r to bill the Medicare program.
The National Providor Identifier (NP!) is the standard unique hoalth ld•ntJfl•r for h•alth car• pr0Yide11 and
suppli•n and is assigned by the National Plan and Pro111der Enumeration Syst•m (NPPES). To become•
Medure DMEPOS supplier, you must obtain an NPI and f.....W. it on this •ppll<.otlon prior to •nrolling in
Medl<.ore or when submitting a change to your existing Mediaro 01'rollment information. Applying for th•
NPI b a process .._ate from Me<ficare enrollment. To obtain an NP!, you may apply onhn• at httm:/lnDOH,
ems. hhs goy For more information about HPI enurneranon. vtSJt www mn oovlN••Joo•IPmytdrntStand
NOTE: Tho l.ogal BJJIUl6S Name (lBN) and Tax Identification Number ffiNl that you fum!Sh In SoctJon 18 of
thts apploc.uon must be the same LBN and TIN you used to obtam Y<KK NPI. One• the intonn.uon 11 ontered
Into PE COS from thos application, Y'O"' LBN, TIN and NPI must match euctly on both the Medcar• PrCMdor
Enrollment Cha., and Ownership System and the Nanonal Plan and PrOYlder Enumorauon S)/ltom
INSTRUCTIONS FOR COMPUTING THIS APl'UCATION
Al W>formatl«I on thJS form is required with the excoptlon of those fields ,_ifk.ally marled• "opb«\al •
Any f~ marted as optional is not required to be completed n« doe 1t need to bo upd1ted or roported as a
"change of mforrnatl«I" as required in 42 CFR § 424516. Howewr, 1t 11 hiohly recommondod that If reported,
those fields be kepi up-to-date.
INSTRUCTIONS FOR COMPLETING THIS APPLICATIO N (Conrinued)
• Type or print all information so that it is legible . Do not use pendl. Blue Ink k proferred.
• When ~sary to report additional information, copy and compl•t• the apphuble section as nttded.
At~ all supportmg documentation.
Kttµ. \.UV)' ur JVUI \.Uffl..,lt"lt:t.I Mc-ilit.ott" t"l'Wul11ncul f>cK.k~ rui )'Vt.II VW11 ·~.•uuh.
TIPS TO AVOID DELAYS IN YOUR fNROll.MENT
Complete all required sections as shown in Section l ;
Complete Section 9 for all delegated and authorized offidak ,._.ed on Sections 14 •nd 15;
~at lust one ownet' and one managing employff for •ad> loabO<\
• Enter your NPI on the applicable sections;
• lndude the El«tronoc FWlds Transf..- (EFT) Agr-eemern (CMS-588), who<\ -lic;oble, wnh yout enrollment
~bOI\
~ tJmoly to deftlopment/infonnation requem;
and
Be ..,, the legal Busmess Name shown in Section 1B matche< the name on your wo clotuments
Addouonal tnfom..tJOn and reasons for processing delays can t... found at www Dt!mtnoqbt mrn(ng.
PROCESS FOR OBTAINING MEDICARE APPROVAL
The standard proass for beconung a Medicare DMEPOS wpplier k as follows;
I The supplier obtains the required National PrOOiider Identification Number (NPI), wrety bond and/or
.caedrt.ation PIUOR to completing and submitting this application to the NSC MAC.
2 The supplier completes and submits this enrollment application (CMS-8555) and •II supporting
documentatJon to the NSC MAC
3 The NSC MAC r..,,ews the application and conducts a site 11isit to verify compliance with the wpplier
standards found at 42 CFR § 424.57, 424.58, and 42 CFR § 424.S00-565.
4, After completing its review, the NSC MAC notifies the supplier in writing about Its enrollment dedJlon.
ADDITIONAL INFORMATION
The NSC MAC may r.,quest additional documentation t o support or validate Information reported on this
application. You are responsible for providing this documentation within 30 days of the r.,quest.
The lnform•tlon you provide on this form is protected under 5 U.S.C. Section 552(b)(4) and/or (b)(G),
respe<tlve ly. For more information, see the last page of this application to read the Prlvocy Act Statem•nt.
ACRONYMS COMMONLY USED IN THIS APPLICATION
CFR: Code of Federal Regulations
DME MAC: Durable Medical Equipment Medicare
Administrative Contractor
DMEPOS: Our•ble Medical Equipment, Prosthetics,
Orthotia and Supplies
EfT: Electronic Funds Transfer
IRS: Internal R...enue Sonnee
Liit ~gal Business Nome
U.C: limited l'6bollly (orporatton
NPI: National Provider ld•ntlfler
NPPES: National Plan and Provld<!r Enumeration
System
NSC MAC: National Suppher Oearinghouse Medicare
Admlnistrauve Contr.ctor
PECOS: PrOY1der Enrollment Chain and Ownenhop
System
SSN: Sodal Se<urity Number
TW: Tu ldentJfication Number
WHERE TO MAil YOUR APPLICATION
NotOONI Supplier a.,annghouse
Post OffQ Bo. 100142
Columbia. SC 29202-3142
Cuuomer Sonnee. I"66-233-9652
Wt'b bnp=l/www polmcttggba com/me
Overnight Mal&ng Addr<:H:
National Supplier Clearonghouw
Palmetto GBA • AG-495
BOO Spnngdale Dr1Ye. Bldg
Camden, SC 29020
Org. Type
II NPI Each
Location
Must Have
Separate
NPI
Multiple NPI’s
May Be Linked to
Same Tax ID # S ECTIO N
1: BAS IC
IN FORMATIO N (Continued)
C. REASON FOR SUBMlnlNG THIS APPLICATION
Check on<! box and complete the Sections as indicat ed.
0 You are a M W enrollee in Medk.are or are enrolling a new location with "
klentiflc.otJon number not previously enrolled with the NSC MAC.
0
t4K
You are adding a new business location using a tax identificalion number
currently enrolled with the NSC MAC.
Complete all R<tlon1
Complete R<tlons 1- 7. 9
''"' mMlllfl/1111 _ , _
only), 11 (optloNI). 12.
and either 1' or 15
D You are ..tdong • new buJiness location using a tax identification number
NOT currently enrollt!d with the NSC MAC.
Complete all R<tion1
0
Complete .a R<tions
You 11tt rucdvwng your ~Supplier 8iling lbnber
D You 11tt mralodallnil your Mt!dKare enrolment.
0
Complete • R<tions
Complete RCtions 1, 2A.
11 (optloMI). and
enher 1' 15
You are YO!unr.ily tenniMtirlg your M edO... ""'°"'1>enL
... '°·
EfftttJve .U~ of tetm1Nuon:
0 You Vt cNno•llG your Mediare enrollment infonnation othtl than your tax
idenllfiabon nurnbt!r.
°'
Go co Section 1D
Complete all Mdlons
D. WHAT INFORMATION IS CHANGING?
Chttk all that apply and complete the required sections.
Pl.EASE NOTE: When reporting ANY information, Sections 18, 7 and either 14 or 15 MUST always be
completod In addotlon to completing the information that is changlng within the required Section.
CHECK ALL THAT APPLY
REQUIRED SECTIONS
0 Current Buslntss Location Information
1, 2, 7, 11(op'liona l),12 (II oppllcoble), and
e ither 14 or 15
0 Suppl ler Type (submit licensure if applica ble)
0 Products and Services (submit accreditation if applicable)
1, 3, 7. 11 (o pt lonol). 12 (If a ppllcoble), and
either 14 or 15
D Accreditation Information
1, 3, 7, 11(optional), 12 (If oppllcnble), and
e ither 14 or 15
1. 4 a s applicable for the address that is being
changed. 7. 11 (optional). 12 (If appllc.oble),
and eit~ 14
15.
0 Address lnlormatlon
0 I099 Malling Addrt!SS
0 Correspondonce Mailing Addrt!SS
°'
D Rt!Yalodation Ma1hng Address
D Remitta~ Payment Mailing Address
0 Re<o<d St0<- Address
0 Cornpr...._ U..bilrty Insurance lnfonnation
1, 5, 7. 11 (optlonaO.12, and either 1• or 15
D Sur"'Y Bond lnfonN1-
1. 5, 7. 11 (optlonaD, 12. and either 1' Of 15
1. 7. 11 (~ 12. and eitht!r 1' Of 15
1. 7. 8 and/Of 9, ,, (...,.ion.I). 12 (if
-liable). ei!Mr ,. Of 15
1. 7. 10, 11 (optional). and either 1' Of 15
1. 7. 9. 11 (osrt;oNQ. 12. ,. on<! 15
0
Authon1ed Offioal
1. 7, 11 (optional). 12 (if appliaible). on<!
eitht!r 1' or 15 and the apphcable ttttlon or
sulMection that ii <hanQing.
Land Line
(Supplier Standard
#9 Physicians are not
exempt
Physicians are
exempt from
30 hour total
These are legal definitions
Where You
Dispense
Not the Patient
Legal Place of
Residence
SECTION 3: PRODUCTS/ ACCREDITATION INFORMATION
A. TYPE OF SUPPLIER
The •upplier must meet all Medicare requireme nts for the OMEPOS wpploer t~ che<ked Any spedalty
- n e l including. but not limited to. R"'J>iratory Therapiru and Orthot ics/Prosthetla personnel must ha..,
<urrent li«nsure as applicable to the supplier type c:hecl<ed as -II as for 111 l)foduru ind >enricH ched<ed m
Sections 3C and 30.
a-It Ill that ewly;
0 AmWatory SurlJ)Cal Center
0 Dei>«trnent St0tt
0 Gtocery StOR
0 Home He.ith AlptC'f
0
HosprtM
0 Nunmg Fk!lily (othe<l
0 Ocul¥lst
0 O=pauonll Thefapost
0 Opoo...
0 Onho<ics Personnel
0 lndl.,, ~Sevier 0< Tribal Facility
0 lntonnedwte
N..w.g Facility
0 Oll)'9m and/or Oll)'9m Related
0 Medo! Supply Company
0 Medo! Supply Company
*oth Orthooo ~
0 Pedonhlc ~I
c.e
0 Med!Cal Supply Canpany
with Pedorthic ~l
0 Med!Cal Supply Company
with Prosthetla Penonnel
0 MedlCll Supply Company
with Prosthetic and Orthotic Personnel
Cl Medkal Supply Company
with Registered Pharmacist
0 Medical Supply Company
with Respiratory Therapist
E~Suppl1tt
0 Phannacy
0 Phy>iQI The<opist
0 Phy.lclan
0 Phy.ldan/Oenust
0 Phy.ldan/Opt ometrlst
0 Prosthetics Per>Ollnel
0 Prosthetic and Orthotk Personnel
0 Rehabllotadon Agency
0 Skilled Nursing Facility
0 Sleep l.4bora tory/Medldne
0 Sports Medicine
0 Other_ _
B. ACCREDITATIO N INFORMATION
NOTE: If more than one a ccreditation needs to be re ported. copy and complete thl• 1ectlon for each.
Check one of the following and furnish any additional information as requested:
Cl The e nrolling supplier busine.. location in Section 2A is acaedlted.
D The enrolling supplier busine. location in Section 2A is exempt from accreditation requirements.
To determine if you qualify for exemption, go to hnps:/fwww Mlmcttooba mml NSC
C. NON·ACCREDITED PRODUCTS
a-It .U that -1Y. These p<oducts do not requiR acaedir:a. -
0 Epoeun
Ol~Drug>
0 lnf\.!llOll Orugs
0 Nebulae< Drugs
0 Or.t An1J<M1a< Drug>
0 Or.t Antmnl<tlC Drug> (Replaamem for Intravenous Antlemenc:sl
NOTt; 0 0..0. here if the supplier p<ovides one ot more of the products shown aboYe bu< don not tum.sh
M'f of the products and/a< services listed in Section 30. If ched<ed. slup SectJon 30 and tonll~ to
Section 4.
Supplier Standard 25
“ All suppliers must disclose upon
enrollment all products and services,
including the addition of new product
lines for which they are seeking
accreditation.”
Check off all which apply to
your practice
State Licensure
•  Requirements Vary from State to State
•  15 States Require Licenses for O&P
•  Scopes of Practice (SOP) for C. Peds, CPO, CO. •  Pa In Process and Causing Controversy
•  Other Professionals SOP DO NOT Limit DPMs
SOP
•  NSC Website Home Page “Licensure Database”
SECTION 4: IMPORTANT ADDRESS INFORMATION
A. 1099 MAILING ADDRESS
1. Organlutlonal Supplien (e.g. Corporations, Panner>hips. LlCs, Sub-Chapt er S)
If you are an organ1i.ational supplier, furnish the suppliers legal busineu Mme (as reponed to the IRS) and
TIN Furnish 1099 rNobng address mformation where indicated. A Cort'/ of the IRS form CP·57S or other
document issued by the IRS showing the TIN and LBN for this business MUST be •ubmnted
If you are ~ a change to your 1099 mailing addr- ct..d: the box below and furlldh the effectJ""
date
Cha.n ge
Effedlve Date (mmlddlyyyyJ: _ _ _ __ __ _ _ __
a
l•kl____
ll'riattu._.,_,._"'__,
11099 M:>iing -
SUU!
2. Sole PrOl)rletors
If you are a sole proprietor (the only owner of a business that is not Incorporated). lln your Social Security
Number ISSN) and the full legal name associated with your SSN as reponed to the IRS In the appropriate fields.
If you want your Medicare payments reponed under your Employer Identification Number (EIN) furnish It In
the appropriate space below. Furnish 1099 mailing address information where Indicated.
NOTE: Sole Proprietor.: If you fu rnish an EIN, payment will be made to your EIN. If you do not furnish an EIN.
payonent will be made to your SSN. You can not use both a n SSN and EIN. You can only use one number to bill
Medi care. If furnishing a n EIN, a copy of the IRS Form CP-575 or other document Issued by the IRS •howlng the
EIN and legal name for t his business MUST be submitted.
If you ore reponing a change to your 1099 mailing address, check the box below and furnl•h the effective
date.
D Change
Effective Date (mm/ddlyyyy): - - - -- - -- - - -
Sole PrOl)rletors: 1099 M.Hing Address
, .. l .... - - ...... ""' So<wl s.curity-
'°""'...., _ ......
l_
_
...,.. •• ""}
1 '(911 ~- r. Codt·•
CMWSU.frt))
IO
SECTION 4: IMPORTANT ADDRESS INFORMATION (Conrinued)
B. CORRESPO NDENCE MAILING ADDRESS
This Is the ~ross where correspondence will be sent to you by the NSC MAC and/or the DME MAC. OR
D Chedc here If you want all Correspondence mailed t o your Business location Address in Section 2A and
sic!!> this section
If you are reporting a cnange to yow Correspondence Mailing Ad.ress, check the box below and furnish the
effective date
Ette<tl~ Date (mmlddlyyyyl; _
_ _ _ _ _ __ __
--
. ......., _ _ ,,.o _ ,,,_,,,,_.,,,,_,
1ZIP~
••
C. REVALIDATIO N REQUEST PACKAGE MAIUNG ADDRESS
Thi> Is the address where the NSC MAC will send your enrollme nt revalidation request pack49e, OR
D
Ch~k here If your Revalidation Request Package should be mailed t o your Buslnou Location AcklrHs in
Section 2A and slclp this section, OR
Ch eck here ii your Revalidation Request Pa ck.age should be mailed to your Corrospondence Malling Address In
Section 48 and skip this section.
If you are reporting a change to your Revalidation Request Package Mailing Address, check the box below omd
fu rnish the e ffective date.
0
Chonge
Effective Date (mm lddlyyyy); - -- - - - -- - - -
An.tntton (optHNYI}
11
EHR – Where is
the Server?
Cloud
Based?
Supplier Standard 10
Do Not Lie,
Alter Facts or
Forget to Fill
This Out if It
Applies No
Matter How
Many Years
Have Passed
SECTION 8: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS)
Only report orgonizations in t his section. Individuals must be reported In ~ion 9. The supplier MUST hove
ot least ONE ow ner or controlling entity and ONE managing employee report<-<I In Section 8 and/or Section 9.
Complete th" section with information about all organiiatJOnS that have 5 percent or more (direct or 1ndorect)
ownership interest of, any partnership imerest ii\ and/or managing con11ol of, the suppher Identified in
Seaions 1Bl2A. as well as any information on final advene l~I actions that have been Imposed ag.>1nst that
org.>n~ation. fo< more information on *direct* and *indirett• ownen and eumples of organ1u1JOns ~
must be report<-<I on this section, go to: https;//www.ans,qoy!MsdiqrtPipyidcrSupEorol!. If there os more
than one org.>nizabon with ownership interest or managing <IOntrol, copy and complete this l«1JOn for e<Kh.
OWNERSHIP INTEREST (ORGANIZATIONS)
All org.>na.at>ons that ha... any of the following mun be "'POfted
5 Po<<ent or more direct or indirea ownership of the OM£POS IUllPiCf
• A partMnhlp im..-est in the DMEPOS supplier, regardless of the - n · pe<cen'- of ownenhop
• Man19ong control of the DMEPOS sullllliff
Owni~ong <><ganizati<lns are generally one of the fol9-inQ typH.
Corporoboru (l nclud1ng nor>?Ofit corporations)
Portnenh1ps end l.anited Partnerships (as indicated above)
IJmited Uob<hty Companies
Charitable end/or Religious Organizations
Govemmental and/or Tribal Organizations
MANAGING CONTROL (ORGANIZATIONS)
Any organization that exercises operational or managerial control over the OMEPOS supplier, or conducts
the day·to-day operations of the OMEPOS supplier, is a managing organlzotlon and must be reported. The
organization need not have an ownership interen in the OMEPOS supplier In order to qualify as a managing
organization. For example, it could be a ma nagement services organization under contract with the OMEPOS
supplier to furn ish management services for this business locatlon.
SPECIAL TYPES OF ORGANIZATIONS
Govemmental/Triba l Facilities:
If a ~eral, State, county, city o r othe r level of government, the Indian H•alth Servi«• (IHS), or an Indian
tribe will be legally and financially responsible for Medicare payments received (including any potontial
overpayments), the name of that government, the IHS or Indian tribe mun be roponed as an owner or
controlling entity. The DMEPOS supplier must submit a letter on the letterhead of the responsible government
-oency or 1t1bal organization that attests that the goyomment O< tnbol organization will be legally and
finonoolly ...._,..ble in the e""1lt that there is any outstanding debt owed to CMS. Thk letter must be Signed
by an appoint<-<I or elected official of the ~nt or tnbal organlutoon who hos the wthonty to leg.,lly
and finanooly bind the government 0< tribal organization to the laws, regulations, and program insttuctions
of Medocare. The appo1me<Veleaed official who signed the letter must be reported In Section 9
Indian He.Ith Service or Tribal Facilities:
Sc>eoAI rules concemng onswance and ticenses apply. Corna<t the NSC MAC concerntng these ruin.
Non-11-ofot. Owuitoble and Religious Organizatiom:
Many non-profit~ ace charitable or refogioos m tWD.lfe.
-ated end/or manaoed by
•Bo.rd of Trusttt< or other governing body. The actual name of the Board of Tru<1tt1 or other~ng
body must be reported in this section. While the organaatoon must be reported on
8. ondoVldual board
IMmben must be reported in Section 9. Ea<h non-ptofit orgaNUIJOft must submit • copy of the IRS Fonn
50 l(c)(l) _,fyfng Its ~ofit status..
and••
s.a-.
IS
(ORGANIZATIONS) (Continued)
A. ORGANIZATION IDENTIFICATION INFORMATION (OWNERSHIP ANO/OR MANAGING CONTROL)
D Check here If Uus ~ is not applicable for the supplier ~ In Seaiom 18/2A. •nd skip to Se<\Jon 9.
If you •r• <hanging information about a currently reponed owning or m.11nag1n9 OtQOnlZatoon or ..sd1M11 or
romoving an owning or managing organization, check the applicable bo., fumlih the effecttvt dote. •nd
complete the _
_..te fields in this section.
D
a..,.
D Add
D Remove
l.,.. ____
Effedive Datt (mmlddlyyyyt _ _
I Complete .a ict~ng .,fonnation
t o l h obelow.
_S-_
._,._,........_,,,_
-- ·---.....
---l!Sw~-~·.--1
Nl'l ( < f -
2. What Is the abov• organization's ownenliip interest in th• supplier reported In Section IB/2A7
0 S~ or Greater Oirectllndirect Owner
0 Partner
D Govemment/Trlbol Owner
3. What Is the effective date the above organization acquired and/or ended the above ownership Interest ?
D Acquired
Effective Date (mmlddlyyyy): - - - -- - - Effectiv• Date (mmlddlyyyy): - - - -- - - - 4. Wha t Is the above organization's managing control of the supplier reported In Section IB/2A? (Chec:k all
that apply)
D Managing Organization 0 Board of Trustees 0 Governing Body O Controlling Entity (Gov't/Tribe)
0 Ended
5. What Is the effective date the above organization acquired and/or ended the above managing control?
D Acqulrfll
Effective Date (mmlddlyyyy): - - -- - - - 0 Ended
Effective Date (mmlddlyyyy): - - -- - - - - B. FINAL ADVERSE LEGAL ACTION HISTORY
Complete thos section for each organization reported in Se<tion BA..
If you •re reporting a new final adverse legal a ction, check the bo• below and furnish effectlvt dot•.
Effmjye Date (mmlddlyyyy): _ _ _ __ _ _ __
D Now
I H.. tho organiubon m Section 8A above, t.W>der any anent°' former ,..,,,. or buslneu icknuty, .,_ Md
• final adve<w le1jal listed in Section 1 of this application 1 - . I 1911nst it1
D YES-ContJnue Bdow D NO-Skip to Section 9
2. If YES, report tach ftnal adw<se legal action, when it ocrurred, tho Ftdttlll 0< State agency or the court/
..wnoncstratrY< bocly thot imposed the action, and the resoMion, if .,.y
Attach • copy of the relevant final adve<se legal action documents.
ANAL ADVERSE LEGAL ACTION
DATE
TAJCEN BY
RESOUITIOH
..
(INDIVIDUALS)
Only repon lndivid"8ls in this oection. Organiunions must be reported In Se<tlon 8. The supplier MUST have
•t le•st ONE owner or controlling entity and ONE managing employu reported In Section 8 •nd/or Section 9.
NOTE: An lndMd"81 owne< may also be the managing employee to satlsfy this requiremenL
C:O-lete th• section wrth information about all individuals that have S percent or more (direct or ind"'KI)
ownership interest of, any partnership interest ir\ and/or managing control of, the supplJer ldenbfled 1n
Section> 18/2A. .. _u .. any infonnation on final~ legal actions that h4ve been imposed ag•ir'I"- that
lnc!Mdu.l For more .,formation oo "direct" and "indirect" owntt> and~ of 1r>d1Yiduols that must be
reported 1n this fieCtJOf\ go to: https;//www~/MedicattProyidnSypEDfPI If there is more than one
ondoVKlu.I with ownenhip interest or managing cootrol. copy and complete thll sectoon for eadl
The following tndmcll..lo must be reponed in Section 9A:
All pertOnS wf>o h4ve a 5 pe<emt or greater ownenhip (direct or indirect) tnterest tn the DMEPOS s;uppli«r
• All offlctn. dlrtticn ..ld board membe<s if the DMEPOS supplier Is • <OfPO'lllOn (whether for-profit or
non-profrt)
• All maNOtnQ employtts of the OMEPOS supplier
• All onc!Mduals with a partnenhip interest. regardless of the - r s · ~ttntllge of ownership, and
All ~~•ted ar>d authonzed offi<ials reponed in Sections 14 ar>d IS
£.umple: A supplier rs 100 ~ent owned by Company C. whkh it>elf Is 100 percent owned by lndoVKlu.1
D Assume that Company C is reported in Section 8 as an owner of the supplier Assume further that
lndtVldual D... an indirect owner of the supplier, is reported in Stttion 9A 1. Based on this eumple, the
suppler would chedt the ·s Percent or Greater Direct/Indirect Owner" bo• in Stttlon 9A2.
NOTE: All partners W1th1n a partnership must be reported in this appltcatton. This 1pplle• to both 'GeMral"
and ·umlted" partner"1ips. For instance, if a limited partnership has several limited partners and each
of them only has a I percent interest in the DMEPOS 5'lpplier. each limited partner must be reportod In
thl• application, ovon though each owns less than 5 percent. The S percent threshold primarily 1pplle1 to
corporations and other organizations that are not partnerships.
For purposes of this application, the terms "officer,• "director,· and "managing employee" oro doflned
os follows:
The term 'Offi<er' is defi ned as any per.;on whose position is listed as being lhot of an offlcor In the
OMEPOS supplier's "artkles of incorporation" or "corporate bylaw,_• OR anyone who Is appointed by the
board of directors a• an officer in accordance with the DMEPOS supplier's corporate bylaws.
The term 'Director• is defined as a member of t he DMEPOS 1upplier's 'board of directors.• It does not
necessarily lndude a person who may have the word "Director· In his/her job title (e.g • Depertmental
Director. Director of Operations).
~term ' M1neginv Employee• means a general manager, buslnfiS manager, admlnl<trat0<, director,
or other Individual who exercises operational or managerial control o-. or who directly or indirealy
conducu lhe d<oy-to-day operations of the DMEPOS supplier. either under cootrlCt or through'°"'" other
1rr1nge~t. whether or not the individual is a W-2 ernplo)'l'e of the DMEPOS supplier
NOTE: If• 90vemmental or tribal organization will be legally and finanoally r.._,..ble for Medt<Me
paymenu rett1ved (per the lllStrUCbons foe GovemmentaVTribal Organoutoons 1n Section 81. the supplier,.
only required lO report the appomtedlelected official wf>o ligned the requwed letter l~lly and fononoally
btnd.ng the ~rnment/Tnbal Organization and its managing employee• In Se<toon 9 Ownen. partners,
offictrs, and directors do not need to be reported
"
(INDIVIDUALS) (Continued)
A. INDIVIDUAL IDENTIFlCATION INFORMATION (OWNERSHIP A N D/OR MANAGING CONTIIOU
If you need to re-1, mO<t th.n on• individual. copy and complete this ~ for uch.
If you •re cn•ngong lnformatlon about a currently reponed individual owner « man6Qff « ..idlng or
rMIC>Ving .n jnd1111c1.,.1 owner or manager. <heck the applicable bol(, fumhh the effea."" dote, •nd c:omplete
the
te 1..1c1s "' th.. Stttion.
0 Chenge
0 Add
0 Remove EH~ Date (mmlddlyyyyt: _ _ _ _ __
•ppr-..
_
Tlr. St.lol D.ot<.
LastNamo
-....s._ _ _
_,,_,,_
Nl'l lif-
2 'l'lhat Is the abo... lndmcluars trtle1 _ _ _ _ _ _ _ _ __ _
l \Nhat Is the abo... lndmd.,.rs ownership interest in the supplier r._,.ed in Sect'°" 1812A7
0 S~ or GrHter D1re<1Jlndtre<t Owner
0 Partner
4 What Is the efftctl"" date th• abov• individual acquired and/or •nded the above ownership lnt•rest?
Effective Date (mmlddlyyyy): - - - - - -- - - - Effective Date (mmlddlyyyyj: - - - - - -- - - - -
Acquired
0 End•d
S What Is the above Individual's managing contro l of the supplier reported In Section 1Bl2A7 (Check all that
apply).
DOffkor
D Director
D Contracted Managing Employee
Cl W·2 Managing Employee
D Appointed/Elected Official
6. What Is the effective date the above ind ividual acquired and/or ended the above managing control7
Effective Date (mmlddlyyyy): - - - - - -- - - - Acquired
0 Ended
Effective Date (mmlddlyyyy): - - - - - -- - - - -
7. ls the above lndlvldual also a Delegated Official or Auth orized Official reponed In Se<tlons 14 or 157
D Delegated Offlclal
Cl Authorized Official
D Neither
B. FlNAL ADVERSE l£GAL ACTION HISTORY
Complete thlS sectlon for the indMduaJ reported in Section 9A above.
If you .,. reporting • new final ac1ve..,., legal aaion, cne-clt the box below and fumlsh efftctlve dote
Effe<11ve O.te (mmlddlyyyy}: _ _ _ _ _ _ _ __ _
0 New
Hes the ind.Yldu.I reported 1n Section 9A. under any anent or fonner name or busoness entity. ever heel •
flNI adYme ltgal aruon lrsted 11 S«tion 7 of this application imposed agalnst h11Mltrl
0 YES-<ontinue Below
0 NO-Sit.IP to Section 10
r._,. e.cn
fin.I ..iv...,., le90I action. when it occurred, the Fedttal « Sme llQ<n<)I or the C»AJnl
edmtMll•Uvt body that imposed the action, and the resolution, if any.
Att..Kll • copy of the relew•nt fina.1..tve<se legal action doa.ments.
2 If Yft.
FINAL AOV£RS( LEGAL ACTlON
DATE
TAKEN BY
AISOltmON
ti
Delegate
This
Failure to
provide
any of the
require
document
s will
result in a
delay or
denial of
applicatio
n
SECTION 13: PENALTIE S FOR FALSIFYING INFORMATION ON THI S APPLICATION
This section explains the penalties for deliberately furnishing false information In this application to gain or
maintain enrollment fn the Mcditare program.
1. 18 U.S.C. § 100 1 authorlzos aiminal penalties aga inst an individual who, in any manor within the
Jurisdiction of any department or agency of the United States. knowingly and w1ilfully falsifle' conct1l1
or covers up by 1ny trick. sdleme or device a material fact, or makes any false, flctitlou\ or fraudulent
n.>temenu or representatio,... or makes any false writing or document knowing the same 10 contain 1ny
f1lse, fictitious or fraudu1"1lt ltatement or entry. Individual offenders are subject to fines of up t o S250,000
ind impritonment for up to five years.. Offenders that a re organizatJons are subjea 10 fines of up to
SS00,000 (18 US .C. § 3571). Semon 3571(d) also authorizes fines of up to~ the g<ou Ill"' ~rlwd by
the offender rf it ,. greater than the amount specifically authorized by the sentendng statute
2 Section 11288(.X 1) of the Soaal Security Act authorizes aiminal penalties against any 1nd1\lldual who,
·iu.ow.ng1y and wiUfuly, • makes or causes to be made any false statement or representation o l 1 moterl1I
l11ct ., any Apploatoon for•"'! benefit 0< payment under a Federal heahh <Me prognwn The offender i>
subject to fines of up to S2S,OOO and/0< imprisonment for up to five ~ars..
3 The CMI Folse O.ms Act, 31 US.C. § 3729, impo5escivil riability, in PM\ on any person who.
1) """"'1ngly present\ or aouses to be presented, to an officer or any ~ of the United States
Gowmment 1 false or IT.udulent claim for payment or approval;
bl kno""ngly make\ - . . or aouses to be made or used. a fals<o record 0< SUteiMM 10 get 1 f.ise or
fr .udu~nt claim paid 0< ._.<Med by the Go""'1VllEflt; or
<) conspres to defr.ud the Gow~t by getting a false or fraudulent dalm allowed or paid
The Act imposes a ckr1I penalty of SS,000 to S 10,000 per violation, plus dvtt omes the amount of damage>
sustained by the ~t
4 Section 1128A(aX 1) of the Social Secunty Act impcnes civil liability, on pan. on any person (1ndud1ng on
org1niutlon, agency or other entity) that knowingly presents or causes to be present ed 10 an officer,
employee, Of' agent of the Unrted States. or of any department or agency thereof, or of any St6te
agency... a daim ...that the Secretary determines is for a medical or other item or ~M~ that the
person knowt or should know:
a) was not provided as claimed; and/or
b) the claim Is false or fraudu lent.
This provision authorizes a civil monetary penalty of up to S10,000 for each Item or service, on assessment
o f up to three times the 1?1mount claimed, and exclusio n from participation in the MedlCllr e program and
Sta te health care programs.
5. 18 U.S.C. 1035 authorizes criminal pena lties aga inst individuals in any matter Involving a health care
bene fit program who kno wingly and willfully falsifies, conceals o r covers up by any trick, schem e, or dovlce
a materlal feet; or makes any materially fa lse, fictitious, or fraud ulent statemen·ts or representat lon1,
o r make-s or uses any materially false fictitious, or fra u dulent statement or entry, In connection with
the delivery of or payment for health care benefits, items or services. The Individual shall be lln"d or
Imprisoned up to S years or both.
6. 18 U.S C. 1347 authorizes aiminal penalties against individuals who knowing and willfully execute, or
1nempt, to executive a sdleme or artifice to delTaud any health care ben.,flt program, or 10 obtoll\ by
mHns ol f1lse or ITaudulent pretenses, representations, 0< prom~1, a ny of the money or property owned
by or under the control of any, health care benefit program in conntttlon with the dehv~ of 0< paymerit
for he1lth are benefiU. items,. or semces. Individuals shall be fined or imprisoned up t o 10 ~•rs or both.
II the VIOl1llon resulu on senous bodily injury, an individual wiR be fined 0< Imprisoned up to 20 ~·,... 0<
both 11 the vlol1toon results m dealt\ the individual shaU be fined or imprllOned for any term of ye41rs or
for hit, or both
7 The gowmment IM)'....,rt common law claims such as •common law fraud.· •money paid by rnlStlkt."
and "unjust ., o ldln ~ 1t.•
Rerntd1es include - t O < Y ..1d punitive damage,,. restitution, and recovery of t he amount of the
UnfUSI profrt.
II
SECTION 14: ASSIGNMENT OF DELEGATED OFFICIAL(S) (Optional)
A DELEGATED OfflCIAl means an individual who is delegated the authority to rtl>Oft changM and updatM to
tht oupploer's el\l'ollment record by an authorized official. The delegated official must be an lndtvldual with
"ownenhlp or convol inttrtst in" (as that term is defined in ~aion I 124(a)(3) of tht Soci•I ~wr1ty Act) or
be • W-2 man•glng emplo~e of the supptie.-. An independent contractor Is not considered employed by the
supplle< and therefore cannot be a delegat ed official.
O.leg1ted offlc:.Mlls m•y not delegate their a uthority to any other indMdual Only an authonzed officMll may
deleg.te the ..,thonty to make changes and/or updates to the <upplitr's Mediate e<Vollmtnt .,formatlon
Even when deleg.ted officak - reported in this a pplication, the authonttd offlOll "''"""the authonty to
cNtlges and/CK updates.
mae
You •rt not rt<IU•ed to have a delegated official However. if no delegated offtOal is nsogntd, the authonttd
offlcul(s) ""'' be the only penon(s) who can make changes and/or updatM to the enrollment 1nformat>on
The "llf"'tl#e of a delegated offici.11 shal have the same foroe and efft<t as that of an authonzed offooal,
and shall leg.ly and finanoaly bmd the ~ier to the laws, "'9Ulauons. and progrMn lnstru<t--.s of the
Medtart program. By hd or her signature, a delegated official certifies !hat he or sl>t has read the ~...
f0< hlsofytng lnformauon 1n s..ctJon 13 and the Catification Statement in~- ISA and agrees to adhere
to an of the stated requnrnenu. The delegated official also ce<ttfies !hat heliht rnttts the deflflit.,., of
• delegated off>e,.L When malong changes and/or updates to the suppll<f's e<Volimtnt inlormat>on, the
dele~ted off>eill ctrtrf>es lhat the infonnation provided is true, CO<rt<t and complete
The "gnatwe of an -'-<ted official in Section 14 constitutes a legal delegauon of autho<lty to 111
dele~ted off>e1al(s) asstgned in Section 14. If you are delegating mott than two indnliduals, COl>Y and
complete tlus section for eadl addrtional delegated individual
NOTE: A delegated official who is being re.-noved does not have to •ign or date this appllcotJon
ASSIGNMENT O F DELEGATED OFFICIAL
All Del09attd Officials must be reported in Section 9 of this application.
If you art adding or removing a delegated official, check the applicoble box and furnish the e ffective date.
1" Del09ated Offld al's Name and Signature
0 Add 0 Remove Effective Date (mm/ddlyyyy): - - - -- - - - - - Undor ponalty o f 1>4rjury, I, tho undersignod, certify that I have read and undorstand tho C..rtlflcatlon Statomonl In
Soctlon 1SA end a ccopt tho rolo of Dologatod Official.
Otltt•ttd Oflk'ltl Finl Nam• {PnntJ
MiddJe Initial
Last Name (PrlnO
Jf .Sr.., MD,ttc
o.l991tff Otfldll ~n1tutt {F11Tf. MHJdle. List N~ Jr.. Sr.,. M.D.. ete..}
E-<nail - ( d _,iQbHJ
2"' 0ele9ated Off'tcial's N&me ond Signature
0 Add 0 Rt..-e ~Dale (mmlddlyyyyj: _ _ _ __ _ _ __
Undot l*\lhy of pequry, l llM w d@sigiK!d. cel1ify that I haw rHd ond understand lht Ctrtlftutlon SIA-
t In
Section t SA ond _ . llM roi. of l>@logoU!d Official
22
SECTION 1S: AUTHORIZED OFFICIAL CERTIFICATION STATEMENT AND SIGNATURE
An AUTHORIZED OFFICIAL means an appointed officia l (for example, chief executive officer, chief financial
officer, general partner. chairman of the board, or 5~ or greater direct owner) to whom the organlut lon
has gronted the legal authorrty to enroll it in the Medic.are program, t o make changes or updat.. to the
organ1utlon's enrollment Information in the Medicare program, and to commn the organization t o fully
oblde by the st1tutts, regulattans, and program instructions of the Medicare program.
By his/her signature, an authorized official b!llds the supplier to an of the ttqulrements listed In the
Ceruficltlon Stotement Ind adcnowtedges that the supplier may be denied Mtty to or have rts bllllno
priY1leges revoked from the Medicare program if any requirements""' not met. All 5'gnlltures must be
orlgln1I ind ., bM rnk. Faxed, photooopied, or sta.mped signatures Wtft not be accepted
By SIQNng this 1pplie1toon, an iMlthonzed official agrees to immediately notify the NSC MAC rf .ny
.,formo,_., tn this
"not 1rue. correct. or complete. In additkMi, an authorized offrct1l by hW
her 51gn1tun, IO'ttS to notify the NSC MAC of any fut1.n changes to the informo,_., cont1rned on this
opplraUon •fttt the ~ "e.rvolled in Medicare, within 30 days of the efferove dote of the ~
ApplaUons Aibmrtted for onru.i enrollment must be signed by an Authoriud <>trio.I or they Wll be rei«ted
Ind returned unprocessed.
~ cenrf!ution below rndudes addrtJonal requi.ements that the .._iier mun meet Ind m.1nt1., t o blll
the Medt<Me pr09t1m Reid thew requuements ca<efully. By signing, you are anesuno to ha"'no reld the
reqwrements Ind underslandll'IQ 1hem.
-Ila-.
Your "ONJl\lre ~ stipulates U..t you agree to adhe<e to al of the requirements lrsted below and
..:ltnowl_. thlt you may be denied entry mto or have yocw bilfing P<Mleoes revolced from t he Medrcare
prog:r•m 1f any requi~m~ts Me not mfi.
A. CERTIFICATION STATEMENT
You MUST SIGN AND DATE Section 158 of this certification statement to become enrolled In the Medi<ore
program. In doing so. you are attt:stmg to meeting and maintaining the M•di<ar• requirements st1tf:d below
Under penalty of perjury, l the undersi11ned, certify to the following:
1. I have read the contenu of this application. and the information contained herein is true. COf'rect and
complete. If I become aware that any information in this application is not true, correct, or complete, I
•or.. t o notify the NSC MAC of this fact immediately.
2. I agree to no tify the NSC MAC of any current or future changes to the Information contained In this
application In a ccordance with the t imeframes established in 42 CFR § 424.57, I understand tha t any change
In the business s tructure o f this supplier may require the submission of a new appllcatlon.
3. I have read and understand the Penalties for Falsifying Information, as printed In this application. I
understand that eny deliberate omission. misrepresentation. or falsification of any Information contained
In this application or contain~ in a ny communication supptying information to Medicare, or any deliberate
alteration of any text on this application form, may be punished by criminal, clvrl, or administrative
penalties Including. but not limited to, the denial or revocation of Medicare Identification numberb),
1nc:Uor tM lmposttion of fin~ dvil damages, and/or imprisonment..
4. I agree to •bide by the Social St:Writy Act and a ll applicable Medicare la ws, regulauons end program
Instructions that opply to th" supplier. The Medicare laws, regulations, and progrom lnstl'Uctlons
ire •••tlable through thf: MedKare contractor. I understand that payment of a claim by Medi<are"
condttioned upon the da1m and the underlying transaction complying with such I"""- regul1t rons, Ind
prog11m rnstNctt<>m (rndudrno, but not !united to, the Federal anti-lodcbadt Stltute M>d the Stork 1-).
ind on the "'1>Pi1er's cornplt1n« with all applicable conditions of participation •n Medure
5 Nenher tlvs supplier, nor any fr.,, percent°' greater owner,
officer. dirf:ctor. manogono ernploytt,
d.._ted of~ or IUthonz~ official thereof is currently sanctioned, ..._nded, deborred, or excluded
by Mf:dicwe or M'IY St1te Health C..,,, Program (e'}.. Medicaid program), or any other Fedtr1I pr09f.,,,, or
is otherwise prol\fblted from supplying services to Medicare or other Ff:deral ~m beMf10111es.
(; I IQltt U..t M'IY el<dlJn9 or fut11e """'J>ayment made to the~ by the Mtdoa<e pr09t1m ""'Y bf:
recouped by MedlCl<e through the wrthholding of fuwre paymems.
7. I Wlil not knowlngly present or~ to be !l'esented a false 0< fraudu~nt datm for p,tyment by MedocMe,
ind w~I not Aibmrt dawns Wllh deliberate ignorance or rectJess disttgard of their truth or lllS<ty
8 I IUthorue 1ny n1t1onal ao:r~rtJng body whose standards are remgnae<I by the SecretMy os meetJno the
MedtU<e program paruop,ttJon ttQUWf:lllelts, to release to any authorized
em~•. or
•oent of Medoclre • ClOPY of my most rf:Cent accreditation surwy, together with any .,form.trc.. rol•ted to
the surwy !hat Medare may rejUire (including corrective action plans).
-r.
,_....,.,.tiw,
n
SECTION 15: AUTHORIZED OFFICIAL CERTIFICATION STATEMENT AND SIGNATURE
(Conrlnued)
8. AUTHORIZED OFFICIAL SIGNATURE(S)
All Authorized Officials must be reported in Section 9 of this application.
If you ue .dd1ng or removing an Authorized Official, check the applicable box and furnish the effective date
1• Authorized Offkllll
I have re.cl the content• of this applic.ation and the certificanon statement in~ 1SA of th.. applk41tion
My llgn<lture reo.i1y and finanoally bonds this supplie r to the laws, regulatJOm, and pr-am 1nstructk>nl of
w
!Md.are program. By my ggnan.e, I unify that the information contalntd ~e1n Is true, <MK!.. and
complete, M>d I aut'-'ze the NSC MAC to Vl?"rify this infonnation.
1• Authorued Offklllr• lnformwon and ~
D Add
0 Rernow
Effe<tMe Date (mmldd/yyyyj';
-·All •IQNWre mun bo origin.JI ~ signed in blue ink. Applbtiom wi1h sign.>tW9• not OflglNI
or not d.ltad wfl not bo pn>c...ad. Sumped. faxed or copied lignotum will not bo xcapWd.
2"" Authorized Official
I have read the contents of thi• application and the certification statement In Section 15A of thl• appllutlon
My llgnature legally and frnancially binds this supplie r to the laws, regulations, and program Instruction• of
the Medicare prOQram By my signature. I certify t hat the informat ion contained herein Is true, corrttt, ind
comp le to, and I authorize the NSC MAC t o ve rify this information.
2"" Authorized Official's Information and Signature
D Add
D Remove
Effective Date (mmlddlyyyy):
Finl N1m11 (Pt nt>
1.ttphont Numbfi
Middle Initial
l ast Name (Prin t)
E-m.ad Address (;f applic.able)
II ,. 51 , M .O, t lC.
TitlelPowllon
All slgnotum must bo orlgl~I •nd sigRQCI in blue ink. Applicatiom with •lg~tures dMmad not orlgtnol
or not d.ltad wil not bo pn>c...ad. Sumped. faxed a< copied slg~tures will not bo actaplod.
l"' Authorittd OffKial
I haYe re.cl the contents of ttus application and the certification statement in Section 15A of thi• appbation
My MQnatlKt ieo.11y and finanoally bonds this supplier to the laws, regulatiom, and pr-am lmtrU<tlOnl of
the MedKMt
By my signatU<e, I certify that the information contained herein a tru•, CMKI.. and
complete, and I aut'-'ze the NSC MAC to verify this infonnation.
-•m.
r
Authorued Official'• Information ....i Signature
D Add
D Remoft
Effe<tMe Date (mmld<fl1yyyt;
-·-
-- Lost--
All sl;NtUm mun bo origin.JI ~ signed In blue int. Applicatlom wi1h lignoturH not orlQlr>ol
or not d.llad wl1 not bo proceswd. Sumped. faxod or copied lignotum will not bo auapt..i.
CMS.m\11 covn>
DCPAAl~lNr or Jl[ALfU AHO MUMAN U
aNr~"!S
IMCH
ro" Mla.cN!l I MfOtCAID UINl(tS
MEDICARE SUPPLIER ENROLLMENT APPLICATION PRIVACY ACT STATEMENT
lht Autho<lty for malnttrnin<t of tho systom is given under provisions o f sectlons 1102(0) mtlt 42 U S.C 1302(1)),
1128 (42 U.S.C 13200-7), 1814(1)) (42 U.S.C. 139Sf(a)(1), 181S(al (42 U.S.C. 139'5g(a)), 1833(t) (42 U S.C 13951(3)),
1871 (42 U S.C. 1395hhl, end 1886(d)(S}(f), (42 U.S.C. B9Sww(d)(SXFl of tho SOcial S4KU<lty Act, 1842(t) (42 U.S C.
139Su(r)), 1«1Jon 1124(4)(1) (42 U S.C. 132Ga-l(a)(1), and 1124A (42 U.S.C. 132Ga-3o), s.<tion 431), 1s arTMndld, of
tho 88A of 1997, and section 31001ro 01 u.s.c. nol) of the OCIA <Pub. L 104-134), es am.ndld
TIM 1nfonn1uon coli.cted hart will be onn>rod into the Provider Enrollment. Chain Ind Own..-shlp Systtm !PECOSI
P{COS will collect lnfOf'INuon P<ovldod ~an apptocarn rolated to identity, qual.ticatJOn$, pr..,_ loatoom,
-.h•p, bdhng 11JOOCf lnfonnatlon. roaWgnrnEm of 00..fits. electronic funds VM>Sfer, tho NPI ond rolotld
"'°'ntllll
Of91NZ•tlOnS P{COS w•ll 1lso
infonnation on business owners. <Nin homo officM ond provldo<ldll•n
OllOdlbonS, ma~ dnctlno .....,,ee~ panners, authori2ed and dek!gatod offlOlls. .._,.._ phyMclins
of tho iupp1..,, ombuloru voNd<o infonnatlon. andlor intgpromg physidilns Ind ~ tochNoons lhn synom
of roa>rds .,.;a conU111 tho norM$o social SO<Urity runbers (SSH), date of binh (008), ond omj)loy« ldenbflat>on
numbon ([IN) and NPl's lo< tad\ dlsdmlng entity, owners with S percent or 11IOA ~ 0< Cl0'1trol 1nter0<t, es
well es ~dlrecmg employ-. M>~ecting snpiayees include _ . . . manoger, bU1lnt1& odnwvruot~ dlroa~ Ind ...i- lndMduals who ae-cise opera-..1 or......_,., O>ntrOI ...., tho provldo<I
suppt..,. Tho sys1Mn w I 1lso COflUJtl Mediate kkmilicatico numbon 0.o. CCII, PTAH 1nd tho NPO, domo!lr6PllK
dai., pn>fosMOnll dai.. post end presom history as well as inlcnnation regording ...., ..tverM legol 1<11ons
11
txdullons. soncuons, Ind felonious l»havlor.
wen
Tho Pnvocy Act permits CMS to difdose Information wfthout an individuats c - if the lnfOf'INuon ll to be uwd
lo.- 1 purpolO !hit Is <>0mPltlblt wi1h me purposoW for which the information wos a>l14<11d ,.,.., such dhdosuro
of doi. ls known 11 1 •rouono USt • Th& CMS wiU only release PECOS information that <An be 11sodltod With
1n lndlvlduol as provided f0< undor Section DI "Proposed Routine Use O!Sdow:res of Dato In tho Systtm • 8oth
ldenttf11bl• and non-ldontlfi.blo date may bE disclosed under a routine use. CMS will only colltct tht mlnjmum
pononol dot• nocosllf)' to ad>ltvo tho purpose of PECOS. Below is an abbrevi<ltod wmmary of tht six routine
uMH To vlow the routine u5'n In tha1r entirety go t o: http://www.cms.oov/RequJ1ttonandGytdonc1tGutd1nct{
PdyocyA<1Svs1tm0f8tcords!c!ow nloads/OS32.pdf_
1 To supPO<t CMS contractors, consultants, or grantees, who have been ongagod by CMS to assist In tht
performance of 1 service related to this collection and who need to have accoll to tht rocords In ordor to
perform tho actlVlty.
To llHln anothor Federal or state agency. agency of a state government or tts fi s<bl agent to:
ft . Contribute to tho accuracy of CMS's p roper payment of Medicare benefits,
b. Enablo such agency to administer a federal health benefits program thot lmplomtnts e hoelth btnoflu
program fundod In wholo or In part w ith fodoral funds, and/or
c. Evaluato and monitor tho quality of homo health care and contributo to tho atcuracy o f hoolth lnsuron<o
operations.
3 To onlst on Individual or organization for research, evaluation or epidomiologlcol projtcU rolatod to tho
pr1venllon of dlsuw or dlsabllrty, or the restoration or maintenance of health. and for paymient related
projtcU
4 To support tht O.partmtnt of Junko (OOJ), court or adjudkatory body when;
o Tht agency or any component thoreof, or
b Any omployet of tht agency In ht. or her official capacity,
cc Any omployet of tht agoncy In ht. or her individual capacity where tho OOJ ha• egrHd to roprtsont tho
employee,°'
d Tho United States Gow<rvntnt. Is a pany to litigation and that the use of sudl rtcorch ~ tlM 001, coun or
odjudocatory body i. cz>me>a1lble with the purpose for which CMS coll@ctod tho rtcorch
S lo llSlst 1 CMS contra<tor that a<Slsu In the administration of a CMS admonm..-od hoolth benofrts PfOQf.,,,, 0<
to combat ft1ud, w..i., or 1busa In !UCh program.
6 To onodlo< ~I agency to lnwstigate potential fraud. waste. or •buse in. 1 Mlhh benof1u prOQrlm
lundod 1n whole or In Pon by kd«al funds.
°'
Tho 1ppljunt lhould be aware that tho Comput0< Matching and Privacy ProtiKtJOn Act of 1988 Cl' L 100.SOJ)
lmended tho PrMKy Aa, 5 U.S.C. § SS2o. to permit the government to vonly lnformat>on d v o u g h -
matctw.Q
Acmrd1'910 tN ,.,~ ~ N.f. of 199§..., perm ilre requinod co respood to.~ of~ . . ..,.,._"......,., •
....... ()Ml COl'lt'OI
The
Ola mnuol ~for di& intormallCm ~. 09.Jl..1'1S6.. n. """" ,......... &o a:wnpllil• . .
""~ IDOilenlOn a~ lO
houri p« teipClftSi!. inckdiog the UM SO~~ Mll"d\ _,.,,,,., ~ ~
V-'* f t d#\.1 Medlll llftd COlftSlill't• #Id rwww !M tnfonnation c~ If rou haw ""F~ ~ 1N .crut"M'f tN
"""*"'
...w
be:'
°'
.
ro:CMS. ~So<unl7-.-d.""" _._,.Cit•-*~.... _.. ~111Mlfi0
DO NOT MAil APNCATIOHS TO 1MS ADDIESS. M.;i;.g your appioation to this-.,..,... MgNI,._,, _ , _ _ oro<--0
._ _t<>I • - ... _ " " ' -p1.... -
C heat Sheet on Completing the
C~fS-855$
h at UllpOl'Wll 10 ttad lbt uutrucnous that art included wilh eacl:a Sttrion throupout !he appbe1t10D form If you WI 10 comp~tt lbt
appb<1nao proptrly. pro<e$$U>! llJDe will lib lybt delayed silre ,.,. will thon .....i to de\'elop !he appbunoD \1& phont and or wnttt11
\"ahcUbOD. dtpolldmg oa l\'hat DO<di to bt eoJI4>ltted. Do not""' p..cil OD rhr OIS.S5$S (011n .~ppl1nnont rhr
fit/I'll o•r m
pninl ••II 01 "I"'' •trh • rwbbn- """'P• copf or ilf pma1 ,.-ii/ pro.,pdJ' br ' """""' •• •01,,.ormobl•" Tbt CMS-USS form" a
~gal clocumtal md mmt b. l>Nted .. such. Read mh section arefu!Jy
thoroqghly Tbm art 1...,.,rt1n1di«iboxes111
tacli ote:llOD tha! maybttasalymwecl Below you will fiDdsome rips ID bolpmg)'Oll to oompk'lt lbt CMS-USS l!)'OU ha\'e uy
qllf<IXml. ~ call tbt toll fltt jl,)C c - . Senice Ce=< .. 1-866-23&.96.H F..t fr«< to ollo
~ cht ::O."SC """ Utt
b uWmiwioa (,.,.,.. ~O(b&.c:om ~ chck"" ~Other PartDBS ac l'm\*n ~ wl«t ::.'ano.W ~ ~)
••t
ml..,.,...,.
"'°"""
°""'"
Tbt CMS-IUS fona 1110 bt med for eun>llmem of•
D)JE?()S "'PPM ll!!!rber. "'~DI. rtae11\"ll>Oll. mroU..... of a ...,...,._for a cmncdy ~ Sllppba:. chmg< ofin!mmrion. am~ 1mllllOOD of a bilWla aumbtr Pltaw mad die <btd:
beat ~ tbt ......., 6't wllach f""""' filling oat !be fmm i!l ..men I "" po~ S
XOTF: A"'°"'h tM &SSS 111dia1:.1> dlGl o "'1'¢cr Im 90 <h}-. "' ullll a ""J" r""'zo cf~- dw: I ~ s-.lorC ..U
i'ttwc c.,.,p/prolt s-a-11'1 b) sntt!mz c1-p
"idibt JO"->• ofdw <'-:•
<(,,.,,,_r-
fl'W-'-• "'., tM ~fora
FOR AU. E:'"ROLUJL\l'S. R.E-DlWl.U.II:XTS, A..\"D RE-.\ClffATIO'.'\S:
U~o• art~:
Complere sttcions:
L 2. 3. 4. 5A, 6. 8- 13. 15. 16, 17 - md 1t<t10D I~ carttlally
BUUD<UIPtol!wooo11.amil<d wbwry
Co 11100
Otnttal Por11ltt OR JOUll V...iun
L 2. 3. 4. 5B-5C, 6. 8, 13, 15, 16, 17 - "'ad stc:llCO
I~
Cattlldly
L 2. 3, 4, 5A OR 5B-5C (•Hpp~). 6, a, 13, I~. 16, 17 - .....
...,-lt<ll--OD-14_c_art_full_lly_ _,
Plu,. nott 1b>1 sumy bonds an 001 rrqu.irnL S.ction 11 "S11ttry Bond IofornurioD" 11uy b• ltfl blouk on all appllurio.,.
FOR ALL CHANCES TO YOUR SUPPLIER ffiI:
Stltcl ''Chang• oflnformation• in oection 1.AJ , mark the sections (boxes 1 - 16) 1lu1 you ore cb.~ngmg, and wnl• your suppbtr nuwb<r
an die blonl: opoce besadt O>t change option. Then in the section(s) where changts art bting mAM, mark the "Chang• .. cbtck oox al lh<
lop or toch stcliou and complel• the section. The appropriate authorized or d.legat<d offiml mu:tr sign Jtcllon IS (Ce11>6carion
Siot•nitlll) Send the compltled sections and any applicable attachments 10 rhe NSC at 1he oddr"s an 1he fron1 of the opplic111on form.
FOR \ 'OLl'NTARY T£R:\11J\ATION OF DMEPOS BILLING NID!BER:
Stltcl ''Vol11D1arr Termuution" in ...:hon LA.1. and \\Tite your supplier nnmbtr in~ blank space btsidt "Change of btformauon·· ngbt
above tht \'Oluntalj' tenmnario.Dch«k box. Enter tht date of tennination. Fill out stc:non l .A and 4 A fo11dt1111f1c1nou of suppbtr &Dd
loc1bon Only the aulhonzl.d (Dot dtl•g1ted) official can s.ign section 15 (Cerofiunon Suntm<Dl) of a Voluntll)' Ttrmuiabon foam.
DO NOT iatlud• •h• follo1'ia.g: Cfh• xsc dots DOI do uything mrh rlili p•p••.,...rk aad h It DOI rtqoirtd.)
Fot m HCF."-5SS mtttionrd undu sntion 4.C.
Tbt [DI toa1racr tlaac is Dtt.Adontd in stttio.n 9. Pltast do nor ('ODl'ltl yoar DllERC 10 adt for dtl.s paptrn'Ork.
f11al Cbu14iu
Im-. )'OU co..p...d rbr oppn>pD1Z S«llaDS?
.u llfllltOPIW• an:ochmeJm? (C'becl; secllOJl 17)
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ID • - lllllloon:itd ol5aal 11 ..,, locabGD speafic.)
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Proofof emp!o~m may be requutd This ofrit.w -Y abo be an
indi\iduaJ \\ilo holds S"o or mort dmct OWlltnlup Ullt rtsl ID lbt COmpoDy
These indi\'iduili will bt hsttd ID lt<llOD 6
M•u:a~ Employot {gtttral mmagu.
Where Can I Obtain an Application?
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OC:PAR:TMCNt oi: MWtM ANO MUMA.N SERVICES
GHTER.S FOR MEDICARE & MEDICAJD SERVICES
r«mApptcwtd
OMB No. 0933-0626
PART IV: CONTACT PERSO N
Contact Penon"s Name
Contact Penon's Title
Contact Penon's litlephone Nurnt»r
Cont.act P.rson's E-mail Address
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT
PART I: REASON FOR SU BMISSION
Reason for Submission:
0 New EFT Enrollment
0 Check here if EFT payment is being made to
the Home Office of Chain
0 Change to Current EFT Enro llment
(Attach letter Authorizing EFT payment to
(e.g. ac:count or bank changes)
Chain
Homo Offko)
0 Cancel EFT Enrollment
Since your last EFT authorization agreelll'lent submission, have you had a:
0
Change o f Ownership, and/or
D Change o f Practice location?
If you checked elthM a change of ownerslnlp or change of practka locatlon above. you must submit a change of
information (using the! Medicare f:!nrollme>nt applk ation) to the Medicare contractor t hat services your geographical area(s)
prior to or accompanying this EFT authori:z_ation agreement submission.
PART II: ACCOUNT HOLDER INFORMATION
ProvidtrlSuppUtrllndirtct P1ymen1 Procedure (IPP; Biller ltgi l Busin•u Ntmt
Chi in Orgiilniu tion Nime Of Home Offic;e Ltgiill BWneou Nilffle (if d ifferent from Chi in Org i niziilt ion Ni me)
Account Holder's Practice Loc.alion Street Address
Acc;ount Holder's Practice Loc.alion City
I
A.ccount Holder's Practice Locat ion State
I
Account Hokle-r's Practice Location Zip Code
ooocaooo'oooooo"N
I lod
oo'o'oooo'oo DD
PART V: AUTHORIZATION
I hereby authorize the Centers for Medicare & Medicaid Se rvices (CMS) to initiate credit entries, and in accordance
with 31 CFR part 210.6(1) initlat• adjust,,,.nts for any dupliC.!Jte ot erronoous ont ries made In errot to the account
indicated above. I hereby authorize the financial institution/bank named above to credit and.tor debit the same to
such account. CMS may assign its rights and obligations u nder this agreement to CMS' designated fee-for-service
contractor. CMS may change its designated contractor at CMS' d iscre tion.
If payment is being made to an account controlled by a Chain Home Office. t he Provider of Services hereby
acknowledges tha t payment to the Olain Office under these circumstances is still considered payment to the
Provider, and the Provldor authorizes t h• forwarding of MediC.!Jro paym•nts to t ho Chain Home Office.
If the account is drawn in t he Physician's or Individual Practrtione r's Name, o r the legal Busin~ Name o f the
Provider/Supplior ot IPP •ntity, th• said Providor/Supplier ot IPP entity cortifi•s that ho/she has sole control of
the account referenced above, and certifios that all arrangemonts between the Financial Institution and t ho said
Provid er/Supplier or IPP entity are in accordance with all applicable Med icare regulations and instructions.
This authorization agreement is effective as of the signature daite below and is to remain in full force and
effec.1 until CMS has received writte n notification from m e o f its termination in such time a nd such manner as
to afford CMS and the Financial Institution a reasonable opportun ity to ac.1 on it. CMS w ill continue to send the
d irect depo<it to the Financial Institution indiC.!Jted above until notified by me that I w ish to change th• Financial
Institution receiving the direct deposit. If my Financial Institution information change~ I agree to submit to CMS
an updated EFT Authorization Agreeme nt.
SIGNATURE LINE
AuthoriledlOelegated Offic:ia l Name (Print)
AuthoritedlOelegated Officia l Telephone Number
AuthonzedlDelegated Officia l title
AuthonzedlDelegated Officia l E-majl Address
Health Plan Identifier (HPIO) or Other Entity Identifier (OEID) (IPP Entities Only)
DODD DD DD DD
0'0'0°"0'000000 lo'o'ffD'oo'2iooo lo'o'ffD'oooooo
PART Ill: FINANCIAL INSTITUTION INFORMATION
AuthorizedlD.&.gatad Offic:Lat Signaturw (Nor.: Must IN °"9i"MI sign1iu,. in bl•d: or blu. Ink..)
I°...
Fln1nc11l IMtltuti0n's Nam•
PRIVACY ACT ADVISORY STATEMENT
Fln1nc11l lniUt u Uon'1 StrHt Addrt'n
Sections 1842, 1862(b) and 1874 of t itle XVIII of t he Social Security Act authorize t he collection of t his
information. TM purpose of collecting this information is to authorize e:l~ctronl c funds transfe:rs~
<Em
Fin1nci1l ln1tit ution's City/Town
fin1n<ii l Institution'• StitelProvince
Financial lrn:t it ution's Telephone Number
Financial Institution's Contact Penon
Financial Inst it ution Routing Number
DDDDDDDDD
Per 42 CFR 424.Sl ()(e)(l), providers and suppliers are requirod to receiv• electronic funds transfer
at the time
of enrollment. revalidation, change of MediC.!Jre contractors ot submission o f an enrollment chang• request; and
(2) submit the CMS-588 form to receive Medicare payment via e lectronic funds transfer.
The information collected will be e ntered into system No. 09-70-0501, titled ·carrier MediC.!Jre Claims Recotds, •
and No. 09-70-0S03, titled 'Intermediary Medic<>re Cla ims Recotds' publishod in the Federal Register Privacy Act
Issua nces. 1991 Comp. Vol. 1, pages 4 19 and 424, or as updat ed and republished. Disclosures of information from
this system can be found In this notice.
You should be awa re that P_L. 100-503, the Computer Matching and Pnvacy Protection Act of 1988, permits the
governm•nt. undor certain circumstances, to verify tho infotmatlon you provide by way of computer matches.
Please include a confirmation o f account information on bank letterhead or a voided check. When submitting
the dorum!ntatlon, It should contain t he na ~ on the account, electronic rout ing transit number, account
number and type. If submitting bank letterhead, t he bank officer's name and signature is also required. This
information will be used to verify your account number.
PLEASE NOTE: In accordan ce w it h section 1104 of t he Affordable Care Act, enrollment o f electronic fu nd t ransfer
(EFD is for electronic fund transfer authorization only. EFT enro llment does not constitute enrollment as a
provider o r supplier in t he Medicare program.
According to the ~pwwort hduction Act of 19K, no S*JOfS ar• r-.qui r~ to rnpond to 1 c;oltection of inform1tion unku it dispt.ys
a valid OMB control number. The valid OMB control number for thK infonnation collection is 0938-0626. The time r@qUiR"d to comple-te
this information colec.tJOn 6 estimatlld to aver-age &0 m inutes per re~. including t he time to rev.tw mstrutbOns,, searc;h Hirt.Ing d at.J
rnource:1, gath9t" the data nNd•d. ind oomplH• and r....WW tM inform•tion c;ohction. tt you~ any conwnt:nu «MKflning tM KC:UrKY
of Che time estimate(s) o r suggestions for improving th& fOITT\ please write to: CMS, Attn: PRA Reports Clea~aa Officer, 7~ Securrt)'
8ouJevard. 8alllm0ft, Marytand 21244-1850.
DO NOT MAil THIS FOAM TO THIS ADDRESS.
MAILING YOUR APIUCATION TO THIS ADDRESS Wl..l SIGNl=KANTLY DELAY PROCBSlNG.
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/
INSTRUCTIONS FOR COMPLETING THE EFT AUTHORIZATION AGREEMENT
Al EFT roquom...., subject to• 15-day pre<enifiation l*1od Ill wt>leh all xcounu >re Wfifl9d by the Qual'1y1>9 f!Noo.I
~nsbM:iOn bvfore ""I Medic.are direct deposits MR ma~.
PART ~ REASON FOR SUBMISSION
lndb,. your re.non for~ this form by <hecklng the
bolt How EFT -ollmonl. ~to your EFT
>«OUnt ilfonr.ation, CK G>nCl'llatlon of your [fl-~ II roo> >r• outhanl1>9 [fl to lhe home
omto of• m.il org>niz;;ltion of which roo>...., •member, roo>"'""' •tudl • -mng the con11Xtor to moke
~due the prov;dor of senice to the XCOUlll moinulnod by U. Offtte Of the clWn ~Tho must
be iigrlOd by .,, .MhorizRd official of the prowidr!r of and an OU111o1'1?9d offlcl>I of the clWn ,,.,,... offic».
_e>prb,.
-ts
PART I: ACCOUNT HOlDER INFORMATION
Ur-. I Ent« the pnMdor'WJppla's.'indDa payment pr0<Gn (11'1') bolet's lf!µI ,,.,,,. Ot the,,.,,,. of the
~CK indMdual practitiomr, as repotmd lO the lntefNl-.... s.mc. (lltS) Tho XU>l.Wlt to which
EFT
mado must eJOilsiwly be>r the.....,. Of the~ Ot _ . . , PDCU-. Ot the~ t>usirlosl
....... of the po<son CK mtity--wfth Mediate
NOTI; ~billets !Ill& n>pon the '"9aJ bc.lslNs ....no proom.d on thelAS CP·57S 1onn.
Ur-. 2: £mRr the <Nin O<g.1ni2ation's name"' the...,,,,. otflce 1t9>1- n.>me if ct.lleront from the d\M1 ~tion
name.
NOTI; ~ers/IPP billen must repon the ~I t>UllMS,,,..,,,. "'°"-on the IRS CP-S7S lonn.
Lino .i: Entor the occount holder's pnaice loatlon strHt >ddross
l.lno • Entor the occount hold«'s practice loc•tion city, sui., and zip code
1.1no S· Entor the tax ldentifiation number as rej)Orted to th<! IRS If tho busirM>U Is• CotpOt.tlOO, prov~ the Fodor'1I
employer identiootion number, otllerwlse prollide your SOCl•I Security Number If luutd, ontor the Medkllro
ldQntification number as.signed by a Medicare feo-for.servlc:t contractor
tt you ara not tnrollQd In MO<lkart. leavt! this
fteld bl•nk.
Lint 6: IPP billers. enter tile HPID or OEID •ssigned by CMS.
LIM 7: Entor th• 10 digit NPI number(s). Too NPI Is required to process this form.
NOTE; Institutional providers enter only ONE: NPI.
PART Ill: FINANCIAL INSTITUTION INFORMATION
Lino 8: Entor your Financial Institution's nam• (tllls Is the n•mo of tho b•nk or qu•lllylng doposltory th•t wlll rocolve the
funds). Noto: Th• account name to which £FT paymonu will bo p•ld 11 to tho nomo submitted on P•rt II of tllis form.
line t: Enter the financial institution's street addre-ss.
Lint 10: Enter the financial institution's city or town. state or province. and zl:plposul code.
line 11: EntQr the bank or financial institutional telephone number and cornxt ponon's name
l.lno t2· Enter tile banlt or financial institutional nin&-dlgit routlng number, lndudlng oppl\Qblo loodlng zoros.
l.lno U . Entor the provider'slsuppti«'sllPP ontity's occount number with the flnancl>l lnstltutlofl, lneludong ~· looding
Z«os. Selli!Ct the .XCount type.
II you do -
submit this inlonn• tion. your EFT authorilltion - n t wtll bo ..wmec1 wttl1out IUrtlw prom.Ing.
PART IV: CONTACT PERSON
l.lno 1• Em.. the n;imo Mid tide of •
oontact pmon who an -
quosuons >bout the lnformatlon llUb<nrtUcl on this
~588form.
l.lno IS Enw lhe contoct penon's telophone . . - rm. the <Onuct - · · - · PART V: AUTIIOlllZATIOH
U.. 1' By your signoture on this form - ore c«tifYing NI the actol#n ts dDwn in the Of the PllrMCion « . , _
~.CK the~ Business Name of !he penon CK ..,till' Tho penon « onoty hos sole control Of the occount to
which EFT dellosits are mado in acconl.1nc@with ;at opplbblt l'OglUbOnS ond lnltN<tJOr4. Al .. , • .,.. ......
the FlllOlldal Institution and the gjd penon CK lnl>ty.,. In xconlaKe wltl1 •I~~
rogulotJom .oo instructions with the effoctiw ma of the EFT >uthollutlon You must notJ1y CMS ~ ""
clla>gl!S in the ocrount in sufficient lime to the
the fin.ln<lol lnsbtuUon to oct on the dla>ges.
Tho EFT ...UOOOZ.tion form must be signed and d.1md by the...,. AIMO<Uod lto!l<Ment>tM
O.~ OfTid.. owmoc1
on the ~5 Medbre _ , applic.nion- the contr.ICtof Ila on ftlo Include•~ number wher•
the Alnlloriled Reprosoncnive CK Dolegoted OffidaJ an be conuao<I
~ tins form Wltl1 the original signature in bl.a CK lob! onlt (no faalmolo llgn.>tw• an be xmpted) to the MtdlQro
contrxtor tllat senricos your googr.iplliGll ....... Aro £FT >utllCKIUt.IOn form mun bo submitted f« ~ ModiUn Q)fltrxtof to
wllOm you submit claims foe MediG>re paymonL To loc•te the mailing >ddrou f0< roo>r r...f « - • conttoct«. go to:
COtl1nCUlr....,
WWW can,goyfMedbreProvH»rSupEnroll.
°' •
N atio nal S upplier C l earin gho u se
MEDI CARE DivIEP OS S UPP LIER PARTICIPATION AGREEMENT - CMS 460
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To s i gn a part.icipat:io n ag r eement is to agree to accept assi gnment for a ll cover ed serv ices that you
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A
A supplier"s participation status i s referri ng to whether they wi sh to ..accept .ass ig nment: on claims or not.
Although there at'e some items on whi ch assignm ent is mandatory regardless of the suppl i er's
participation status. It i s not _,. in an y w a y_,. r eferrin g t o whether the suppl i er .,.,.ish e s to parti ci pate in the
Medicare program. Y ou may still bill Medicare if- yo u d o not choose to sign a participation agreeme nt.
New s up p li ers_,. who h a v e n ot: p r e viou s ly submitted a parti cipati on agr eement_,. h a v e up t o 90 days after
the date its num ber i s assi gned to choose t o participate. If .a suppl ie r does noth ing .. it w ill be li s t ed as
non-participating. If the suppl ier wishes to become a participat ing s u pplier, t he n it i s im portant: to
comp lete the particip a tjng agreement form ( CMS 460 ( P D F _,. 217 KB)) and send it to t he NSC wit h in the
a l lotte d 90 days.
& E ducatio n
t:
f
pati ents .
Change of Information Guide
Related Sites
$C)
A new s up p li er w ho in itial ly subm itted a n
participating wit h in the first 90 days. The
l etter during the ope n e nrollment period.
become nonparticip a ting on Ja n ua ry 1 of
app li catio n to be com e partici pating ca nnot cha ng e t o nonsupplier has t ·o wait unt il the e nd of t h e year and subm it a
T his l etter must be r eceived before December 31 i n o r der to
n e xt y ear.
N ote: It i s impo rtant t o note participatio n status i s asso ci ated wit h ..an e ntity (tax ID number) and not
a lo cation . A b u siness e ntity with multipl e locations und er t h e same ta x ID numbe r cannot c hoos e to
have different participation statu ses for ea ch l ocati on. All location s wil l a u tomatical ly be assig n ed the
s a me status ( participatin g or non-participatin g) dep endin g what the e n t it y h as chos en .
Cj)UNKEOTN
Prior to the open e nrollme n t period_,. which i s u sua lly be·tween mid-NoYember and t h e en d of
D ece mb er ~ the N SC w ill send a letter a nd a pa rticipating ..agreemen t to each acti ._.e s upp li er on file . One
l etter and ag r eement will be sent per ta x ID number to the mailing add ress on the s u pplier file.
Below i s addition af inf o r mati on about participatin g and wh at s up p li ers n eed to d o if c h angin g the ir
s tatu s during open e nrollme n t .
Why Pa.-t:icipa'be
Regardl e ss of the M edicare Part B servi ces for wh ich you ..are billing .. participants h aYe 'one stop' billin g
for beneflci ari es who h ave no n-emp loyment-re lated M edigap co...,e r age and who ass ig n b oth thei r
Medicare and Med igap payments to participants. After we h ave made payment.- we automatically sen d
the cl a im on to the rY1ediga p insurer for payment of- a ll coinsura n ce and ded u ctibl e am ounts due unde r
the Cv1edigap policy . Th e (v1edi ga p in surer mu st pay the participa n t d irectly.
Wha-t:to Do
I f you choose t o be a participa nt::
If you aYe not cu rrently a participating Medi ca r e Durabl e Med ical Equipme n t _,. Prosthetics_,. Orthotics_,.
Su ppl ies (DMEPOS) supp li er.- complete the b lank agreemen t a n d mail it w ith a n origina l s ig n ature
o f an authori zed official to t h e National Suppli e r C l ea rin ghou se. On the form.- sho w the n ame(s)
and id entifica ti on num be r( s ) und e r w h ich you b il l. T hi s agreement must be submitted on ly durin g
the ope n enrol lm ent p e riod. This open enro llm ent pe riod is between mi d-Nov embe r and the end
o f Dece r-n be r.
If you w is h to chang e to non-participatin g .. you mu st submit a lett.e r- sig ned by the a u t h orized
official to t h e NSC du rin g the o pen e n roll m ent pe r iod. Th e cha n ge will be effectj v e Janu a ry 1 of
the follow ing year.
I f you dec ide not: to participate:
Do not hing if you do not have a participatin g agr eement in effect at a ny lo cation
I f you wi sh to cha ng e to no n -partici patin g .. you mu st submit a lett.et' sig ned by the a u t h orized
official to the NS C du ring t h e o pen e n rollment pe riod . The c h a n ge will b e effecti v e Janu ary 1 of
the fo llow ing year.
W e hop e yo u will decide to be a M ed i ca r e participant.
Please call 866-238-9652 if you ha!.J'e an y question s or ne ed further information o n DMEPOS
participation.
A
+
DEPARTMENT OF HEALTH AND HUMAN SEltVICES
CENTERS FOR MEDtCA.RE & M:EDtCAID SERVICES
FORM APPROVED
OMB NO. 0938-0373
MEDI CARE PARTI CIPATING PHYSICIAN OR SUPPLIER AGREEMENT
Name(s} and Address of Part:icipan-t•
National Provider Identifier (N.PO•
•un all names and the NPI under which the partic.ipant files daims wi'th 'the Medicare Admlnistra'tive: Contractor (MAC)lcarrier
with whom this ag,.eeme.nt. is being filed_
The above named person or organization,, called "·the participant_"~ hereby enters into an agr.e ement '\.vi th the Medicare
program to accept assigmnent of the Medic.are Part B payment for all services for which the panicipant is eligible to
accept assignxnent under the Medicare law and reguJations and which are furnished v.rhile this agreement is in effect..
1. !\leaning o f Assignment: For purposes of this agreement, accepting ass ignment of the Medicare Part B
payment means requesting direct Pan B paymenl from the Medicare program. Under an assignn1ent ~ the
approved charge. detennlned by tbe MAC/carrier. shaU be che fuU charge for tbe service cmtered under Part B.
The participant shall nor collect from the beneficiary or other person or organization for covered services more
than the applk'1hle deductible and coinsurance.
2.
E ffective Date: If the participant files the "eoreement with auy MAC/carrier during tbe enrollment period. the
agreement becomes effective - - - - - - - - - - - -
3.
Term and Termination oC Agreement This agre>e,ment shall continue in effect through December 3 I following
lhe date the agreement becomes effective aud shall be renewed automatically for each 12-month period January
l through December 31 thereafter unless one of the following occurs:
a.
During the enrollment period prov ided near the end of auy calendar year. the participant notifies
ia v.rriting every _MAC/carrier with '\vhom the participant has filed the agreeme:rn or a c.opy of the
agreement that the participant wishes to terminate the agreement at the end of the current tenn. In the
event such notification is mailed or delivered during the enrollment period provided near the end of
any calendar year. the agreement shall end on December 31 of that year.
b.
The Centers for ~Iedicare & Medicaid Services may find. after notice to and opportunity for a bearing
for the participanL tbat the participant has substantially f"J.iled to comply with lhe 3:,<>reemeoL In the
event such a finding is made. the Centers for ~edic.are & Medicaid Services will notify the panicipant
in writing that the agreement "vill be tenninated at a time designated in tbe notice. Civil and criminal
penalties may also be imposed for violation of the agreement.
Signature of participant: (or authorized r-epresental:ive of participating o.rganizalion)
OaU!
Tide {if signer- is a\l'thorized represeo"tative of organization)
Office Phone Number (indudl~ area code)
Received by (name o-f canie<)
I
tn;tials of Carrie< Officia I
Effective
Da~e
According -i-o t:he P'aperworlt Reduction Act of 1995. no persons are required to resporxf to a collection of information unless it displays a
valid OMB control number-. The valid OMB control num.bef- for this information collection is 0938-0373_ The tim.e requited to complete dii:s
information collection is estima't.ed to average 1 S minutes per response, inctuding the time -.:o review- i:nstn.J:Ctions. search existing da'ta resources,,
gather t:h.e dat.a needed and com.pfete and review ttle information collection. If you ha"Ye any comments concerning the accuracy of the
time est.ilnal:.e(s) or suggestions fot improving t:his form. please write to: CMS~ 7500 Seo.Jetty Boulevard.. Attn:: PRA Reports Oearance_Offk.e r.
Battimcwe~ Ma:rytand 21244-1850.
Form CMS-460 (Cl4f10)
Pa l m etto GB A Med icare
Pa lme tto GSA Hom e I National Sup plier Clearinghou se I Sup p lier Enro llmen t I Standa rds 8c C o mpliance
I Ad ditio nal Inform atio n I Orthotics & Prosthetics. ..
NATIONAL SUPPLIBR
CL£ARINGHOUSE
•
ORTHOTICS & PROSTHETICS SUPPLIERS
TOP LINKS
Contact I nformation
~
Stand ard s & Compliance
Appe a ls Process
Chan ge o f I nform atio n Gu ide
L
Re lated Sites
National Su pplier Clea ringho use Home
All s upp lie rs are re quired to b e in com pliance with the Medicare DMEPO S s u pplier stan d ards . As a
supplier of O rthotics and/or P rosthe tics (O&P}, k eep the f o llowing in m ind a s you ope rate '/OUr
bu siness.
Suppfiet"' Stand.ant # 1 st ate s a sup p lier 'o per ates its b usiness and fu mis hes Medicare-covered it e ms in
com plian ce with all app licable Fed era l a nd State lice nsure and re gulatory requirements.' If y our stat e
require s a n O&P license o r certification fo r these types of s pecialties a n d p r oducts/services> t hen a
cop y o f t his licen se m u st be inclu ded with th e CMS 8 SSS app lication fo rm.
Article s
Leam ing 8c Ed ucatio n
R eso urce s
S upp lier Enrollm ent
Suppfiet"' Stand.ant # 4 st ate s a sup p lier 'fills o rders, fa bric.ates > o r fi ts ite ms from its o wn inventory, o r
by contracting with other co m pan ies fo r th e purchase o f items n e cessa ry t o fi ll t he o rder. I f it does .. it
m ust p ro vide, upon req u est... cop ies of contracts or o ther docume ntation s h owing co mpliance with t h is
sta n dard. ' The C enters fo r Medicare a nd Me d icaid Services (CMS) interprets 1 834 (j) ( 1 ) of t he S o cial
Serurit'I Act t o m ean the supplier m ust be t he o ne f urnis h ing the s ervices/it e ms, a n d m ust b e the one
billin g fo r t h e s ervices/item s . Specifically> a supplier m ay n ot contract with o ther comp anie s f o r
service s .
St ay Co nnec ted
Keep u p with the latest inform ation
a b out Palm etto GBA b y taking
a d vantag e of th e Internet 's
conn e ctivity.
_..E-MAlLUPOATES .._,CON'TACTUS
( jFACEBOOK
1VllTTER
mJ MOBIU ,,,PS
{5 '1'0~8E
CTJUN!Ca>IN
Supplier Standard # 12 states a s u pplie r 'is respons ible for delive ry a n d must in struct b en eficiaries o n
use of Med ic.are co vere d item s and m aintain p roof of d e livery.'
Pursuant t o Title 4 2 of the Code o f Feder al Reg u lations, S ecs. 405. 8 74 a nd 4 24.57, your CMS S SSS
app lication fo rm will b e d enied if yo u are n ot in com p liance with these standa rds a s a sup p lier of O&P.
These d enials h ave t he concurren ce o f CMS.
If you h ave any q u estions, y o u m ay call the HSC t oll free at 866-238 -9652.
A
A
+
How Do The Supplier Standards Effect
My Daily Operations?
•  Operating As a Store
•  Inspection by CMS •  Signage Listing Hours Of Operations
•  Have Landline Phone •  Provide Written Instructions •  Provide Warranty Materials
•  Vendor Contracts for Supplies
Facility Inspections 8.” A supplier must permit CMS, or its agents to conduct on-site inspections to
ascertain the supplier’s compliance with these standards. The supplier location
must be accessible to beneficiaries during reasonable business hours, and must
maintain a visible sign and posted hours of operation.” •  Usually Brief & Conducted SACU
•  Looking for Physical Presence
•  Allowed During Hours of Operation Listed On
855S
•  Some Inventory
•  Signage & Supplier Standards
•  If Asked You Must Be Able to Prove Compliance
with Supplier Standards
Rules on Signage
•  At First Entrance to Office
•  “Permanent” Can’t Be Simple or Easily Removed •  Signage Access By Owner or Employee Only
•  Cannot Be “By Appointment Only”
Warranty
Supplier Standard # 6: “A supplier must notify beneficiaries of warranty
coverage and honor all warranties under applicable State law, and repair or
replace free of charge Medicare covered items that are under warranty”. •  Each Product Requires a Warranty
•  No Mandatory Warranty Period
•  Range from None to Lifetime
•  Provide Written Warranty Statement to Patients
Patient Instructions and Delivery Supplier Standard #12
“A supplier is responsible for delivery and must instruct
beneficiaries on use of Medicare covered items, and
maintain proof of delivery”. Patient Instructions
•  Product Specific •  Easy Vocabulary
•  Illustrations •  Be specific About Problem Notification
•  Instructions May Be Provided to You By Mfg
•  Instructions May Be Written By You or Office Staff
Therapeutic Shoe/Insert
Instructions
•  “Wear Your Shoes Only One Hour More Each Day
for the First Two Weeks, Preferably Inside Your
Home
•  Any redness or signs of irritation necessitate
stopping use of the shoes and inserts.
•  Report this to the doctor’s office immediately”
Instructions- Your Records
The patient signed a receipt of delivery and was
given a copy. The patient also received written
warrantee and usage information. The patient was
specifically instructed on how to apply (“Don”)
and remove the device. They were told the device
must be inspected daily prior to its application
and then upon its removal in order to evaluate for
any defects. The patient understands if they have
any questions concerning the integrity and safety
of the device they are to refrain from usage until I
have inspected the device.
Complaint Log and
Resolution
19. A supplier must have a complaint resolution protocol
established to address beneficiary complaints that relate to
these standards. A record of these complaints must be
maintained at the physical facility. 20. Complaint records must include: the name, address,
telephone number and health insurance claim number of
the beneficiary, a summary of the complaint, and any
actions taken to resolve it. Protocol for Resolving Complaints from Medicare Beneficiaries
• 
The patient has the right to freely voice grievances and recommend changes in
care or services without fear or reprisal or unreasonable interruption of services.
Services, equipment and billing complaints will be communicated to the office
manager and/or Doctor _______. These complaints will be documented in the
Medicare Beneficiaries Complaint log, and the completed forms will include the
patients name, address, telephone number, and health insurance claim number, a
summary of their complaint, the date it was received, the name of the person
receiving the complaint, and a summary of actions taken to resolve the complaint. • 
All complaints will be handled courteously and professionally. All logged
complaints will be investigated, acted upon, and responded to in writing or by
telephone, by the office billing manager within a reasonable time after the receipt
of the complaint. If there is no satisfactory resolution of the complaint, the doctor
will be notified. The patient is to be notified of this protocol at the time services are
first initiated.
Your Letter Head
Medicare Beneficiary Complaint Log
Date of receipt of Complaint: ________________________________________
Patients Name: __________________________________________________
Patients Address: ___________________State__________ Zip Code________
Patients Telephone Number: ________________________________________
Patients Medicare or Health Insurance Number: _________________________
Description of Complaint: __________________________________________
______________________________________________________________
_______________________________________________________________
Action taken to resolve the complaint: _________________________________
_______________________________________________________________
_______________________________________________________________
_________________________________
Signature of employee taking complaint
_______
Date
_______________________________
Patients Name
_______
Date
For Medical-Legal Purposes
•  “Prior to the patient leaving the office the device
was inspected and is in good working order free
of any visible defects.”
•  “Use of this CAM Walker in any manner other
than previously discussed with Dr. Smith or his
staff and/or included in the above instructions
will void the warranty and may result in severe
injury.”
Follow Up DME Related Visit
•  The patient’s custom fabricated AFO was examined. The device
appears to fit well and is free of any visible defects.
•  The patient’s custom AFO was examined and a screw on the medial
ankle hinge was noted to be loose. The hole in the AFO shell was
noted to be sufficient and there was no defect in the shell. The screw
and nut were replaced and tightened appropriately with “locktite”
applied to the bolt. The patient was advised that if there is any
shifting of the bolt or apparent loosening to discontinue the use of
the device and have a family member bring the device to the office.
•  The patient’s AFO was examined and a large hole was present in the
shell of the AFO where the rivet should go through the Lateral
Malleolar portion of the hinge. This will need repair by the
manufacturer and the device was removed from the patient’s service.
He was provided with a pre-fabricated device to use for the time
being and was advised to severely curtail his ADL’s…….. Patient will
be notified when repairs are completed.
Follow Up DME Related Visits
•  The Compression stockings (or diabetic socks)
have numerous tears and runs. These devices
should be removed from service.
•  The therapeutic shoes & inserts are worn and
irreparably damaged and require replacement &
should be removed from service.
•  The shoes have significant varus wear pattern
on the heels causing the patient to be in severe
genu varum and unstable. •  The patient was informed to either get rid of the
shoes or have them repaired prior to wearing
them again.
Compliance Methods
•  Prepare Proper Paperwork (NSC Guidelines)
•  Obtain a Thorough Patient History •  Order From Well Known High Quality
Manufacturers
•  Dispense Legible Written Instructions
•  Speak With The Referring Doctor
•  Maintain Copies of Prescriptions
•  Inspect Devices Regularly
•  Adhere to Manufacturers Guidelines
•  Receive & Log Proper Training of all Staff
•  Be Modest and Be Realistic With Expectations
•  Remove Damaged Products & Log Your Repairs
•  Use Your Digital Camera DMEPOS Quality Standards October 2008
•  Review the beneficiary’s record as appropriate and incorporate any
pertinent information, related to the beneficiary’s condition(s) which
affect the provision of the DMEPOS
•  Instructions: Clear written or Photos
•  Beneficiary and/or Caregiver Training
•  Model & Serial Numbers of Non Custom DME
•  Investigate Any Adverse Effects •  Ensure DME Can Be Used Safely
DMEPOS Quality Standards
•  Provision of custom fabricated or custom fitted
devices (i.e., other than off-the-shelf items)
requires access to a facility with the equipment
necessary to fulfill the supplier’s responsibility
to provide follow-up treatment, including
modification, adjustment, maintenance and
repair of the item(s). •  Individuals supplying the item(s) set out in this
appendix must possess specialized education,
training, and experience in fitting, and
certification and/or licensing. DMEPOS Quality Standards October 2008
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
12. Therapeutic Shoes and Inserts: Includes depth or custom-molded shoes along with inserts for
individuals with diabetes (Refer to Section 140 of Chapter 15 of the Medicare Benefit Policy Manual) a. Custom-Molded Shoes: Are constructed over a positive model of the patient’s foot; Are made from leather or other suitable material of equal quality; Have removable inserts that can be altered or replaced as the patient’s condition warrants; and Have some form of shoe closure. b. Depth Shoes: Have a full length, heel-to-toe filler that, when removed, provides a minimum of 3/16 inch of
additional depth used to accommodate custom-molded or customized inserts; Are made from leather or other suitable material of equal quality; Have some form of shoe closure; and Are available in full and half sizes with a minimum of three widths so that the sole is graded to the
size and width of the upper portions of the shoes according to the American standard last sizing
schedule or its equivalent. (The American standard last sizing schedule is the numerical shoe sizing
system used for shoes sold in the United States.) c. Inserts: Are total contact, multiple density, removable inlays that are directly molded to the patient’s foot or a
model of the patient’s foot and that are made of a suitable material with regard to the patient’s
condition. DMEPOS Quality Standards October 2008
A. Intake & Assessment
Supplier Product-Specific Service Requirements, the supplier shall:
• Assess the beneficiary’s need for and use of the orthoses/prostheses (e.g., comprehensive
history, pertinent medical history (including allergies to materials), skin condition, diagnosis,
previous use of an orthoses/prostheses, results of diagnostic evaluations, beneficiary
expectations, pre-treatment photographic documentation (when appropriate);
• Determine the appropriate orthoses/prostheses and specifications based on beneficiary need
for use of the orthoses/prostheses to ensure optimum therapeutic benefits and appropriate
strength, durability, and function as required for the beneficiary;
• Formulate a treatment plan that is consistent with the prescribing physician’s dispensing order
and/or the written plan of care, in accordance with Medicare rules, and consult the physician
when appropriate;
• Perform an in person diagnosis-specific functional clinical examination as related to the
beneficiary’s use and need of the orthoses/prostheses (e.g., sensory function, range of motion,
joint stability, skin condition (integrity, color, and temperature), presence of edema and/or
wounds, vascularity, pain, manual muscle testing, compliance, cognitive ability and medical
history);
• Establish goals and expected outcomes of the beneficiary’s use of the orthoses/prostheses (e.g.,
reduce pain, increase comfort, enhance function and independence, provide joint stability,
prevent deformity, increase range of motion, address cosmetic issues and/or promote healing)
with feedback from the beneficiary and/or prescribing physician as necessary to determine the
appropriateness of the orthoses/prostheses;
• Communicate to the beneficiary and/or caregiver(s), and prescribing physician the
recommended treatment plan, including disclosure of potential risk, benefits, precautions, the
procedures for repairing, replacing, and/or adjusting the device or item(s), and the estimated
time involved in the process;
• Assess the orthoses/prostheses for structural safety and ensure that manufacturer guidelines
are followed prior to face-to-face fitting/delivery (e.g., beneficiary weight limits, ensuring that
closures work properly and do not demonstrate defects); and
• Ensure the treatment plan is consistent with the prescribing physician’s dispensing order.
DMEPOS Quality Standards October 2008
C. Training/Instruction to Beneficiary and/or Caregiver(s) The supplier shall:
• Provide instructions to the beneficiary and/or caregiver(s) for the specific orthoses, prostheses, or therapeutic
shoe/inserts as follows:
• How to use, maintain, and clean the orthoses/prostheses (e.g., wearing schedules, therapy, residual limb
hygiene, other pertinent instructions);
• How to don and doff the orthoses/prostheses, including how to adjust closures for proper fit;
• How to inspect the skin for pressure areas, redness, irritation, skin breakdown, pain, or edema;
•  How to utilize an appropriate interface (e.g., stockinettes, socks, gloves, shoes) to accommodate the orthoses/
prostheses where appropriate;
•  How to report any problems related to the orthoses/prostheses to the supplier or the prescribing physician if
changes are noted (e.g., changes in skin condition, heightened pain, increase in edema, wound concerns, changes
in general health, height, weight, or intolerance to wearing the orthoses/prostheses as applicable); • How to schedule follow-up appointments as necessary; and schedule for tolerance of the orthoses/prosthesis;
• Establish an appropriate “wear schedule”
• Provide necessary supplies (e.g., adhesives, solvents, lubricants) to attach, maintain, and clean the items, as
applicable, and information about how to subsequently obtain necessary supplies; and
•  Refer the beneficiary back to the prescribing physician as necessary for intervention beyond the supplier’s
scope of practice
DMEPOS Quality Standards October 2008
The supplier shall:
•  Have access to a facility with the equipment necessary to provide
follow-up treatment and fabrication/modification of the specific O&P
Product • Review recommended maintenance with the beneficiary and/or
caregiver(s);
• Solicit feedback from the beneficiary and/or caregiver and prescribing
physician prn. to determine the effectiveness of the orthoses/prostheses
(e.g., wear)
• Review and make changes to the treatment plan based on the
beneficiary’s current medical condition; • Continue to assist the beneficiary until the O&P Product reaches the
optimal level
• Provide appropriate follow up treatment consistent with what has been
dispensed and the specific care rendered;
• Make appropriate recommendations
FAQ
Doctor (Supplier) Required to be Onsite During Inspection?
Supplier Standard #8:
“The supplier location must be accessible to beneficiaries
during reasonable business hours, and must maintain a
visible sign and posted hours of operation.”
Supplier Standard #13
“ A supplier must answer questions and respond to
complaints of beneficiaries, and maintain documentation of
such contacts.”
A trusted employee should always be in the office who has the
knowledge required to pass the inspection
What Should Be Easily
Accessible for Inspection?
•  Signage
•  Supplier Standards
•  Inventory
•  Delivery, Complaint Resolution & Warranty
Forms
•  Complaint Log Book
•  Insurance Certificate
•  Vendor Contract
Can I Make an Appointment
for an Inspection?
•  No Appointments
•  Randomly Made By SACU
•  Accessibility During Hours Listed on 855S
•  2 Missed Inspections = Revocation of DMEPOS for 2 Years
What’s a Vendor Contract? A vendor contract is as simple as a credit application with a
vendor. It stipulates your credit amount/month and the
average time it will take to fill an order.
Why Do I Need Vendor
Contracts?
Supplier Standard 4
“A supplier must fill orders from its own inventory, or
must contract with other companies for the purchase of
items necessary to fill the order. A supplier may not
contract with any entity that is currently excluded from the
Medicare program, any State health care programs, or
from any other Federal procurement or non-procurement
programs.” WHAT IS CONSIDERED PERMANENT VISIBLE SIGNAGE IN REGARD TO
SUPPLIER STANDARD 7?
A. The supplier should maintain a permanent visible sign(s) in plain
view and should post hours of operation. The sign must be visible to
the public and posted outside of the facility. If the supplier's place of
business is located within a building complex, the sign(s) must be
visible at the main entrance and/or lobby area of the building and
show the exact location of the supplier within the building. However
the hours can be posted at the entrance of the supplier with a
separate sign. Permanent Signage including the hours of operation
should not be easily removed or detached by weather or a person
who does not have a business need to remove it. Taped paper signs
are not acceptable. Beneficiaries should be able to locate the
supplier and their hours of operation through the use of these
permanent signs without help from the supplier or other parties
DO I HAVE TO SUBMIT AN AUTHORIZATION AGREEMENT
FOR ELECTRONIC FUNDS TRANSFER (CMS 588) TO THE
NSC?
Answer:
DMEPOS suppliers are required to submit the EFT
agreement with the application form when initially
enrolling or submitting an application for a new location.
When completing the form, suppliers should ensure the
form has the original signature of the authorized or
delegated official. Further, suppliers must include with
each form submitted a voided check, preprinted deposit
slip or confirmation of account information on bank
letterhead for verification of the account number.
The NSC will then send the agreement to the appropriate
DME MAC for processing.
The CMS 588 (PDF, 112 KB) form may be downloaded
from the CMS website.
Do I Need to File an Application for
Each Office Location?
Supplier Standard #24
All supplier locations, whether owned or subcontracted, must meet the DMEPOS
quality standards and be separately accredited in order to bill Medicare
• 
You Must Have a Provider Transaction Number (PTAN) from
Each Physical Location from Which You Regularly Transact
Business
•  Failure to Do So Can Result in Revocation or Suspension of
Your DMEPOS Privileges for One Year Can I Participate in One
Office and Not Another?
Only if the Tax ID Numbers are Different
Do All Thirty Supplier
Standards Apply to Me?
•  Only Those Which Apply to Those Products and Type of
Supplier Apply
•  Example: Those Which Apply Only to Oxygen Suppliers Do
Not Apply to You
•  Exemptions: Requirements for Facility Accreditation, Surety
Bonding,30 Hour of Operation
What Do I Do About
Vacations, Holidays?
Post Signage of Expected Date Of Closure and Return
Try and Have Office Always Staffed During Revalidation Period

Document 6501975

Transcription

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