General Principles – Paper and Internet-Based PECOS
Applications
A. Only One Request Needed – This the only request the contractor must make. The contractor should, of course, respond to any of the provider’s telephone calls, e-mails, etc., resulting from the request. Yet the contractor need not – on its own volition – make an additional request unless the contractor uncovers missing data (or data that must be clarified) that it failed to detect prior to sending the original development letter.
To the extent possible, the contractor should avoid contacting the provider for missing/clarifying data/documentation until it has attempted to validate all of the data on the application. This will obviate the need to contact the provider each time the contractor discovers an issue.
B. Commencement of Timeframe – The 30-day clock referred to above commences when the contractor, as applicable: (1) mails, faxes, or e-mails the letter/request, or (2) sends the aforementioned Internet-based PECOS e-mail.
C. Telephonic Requests
Unless otherwise stated in this chapter or in another CMS directive, telephonic requests for missing/clarifying data/documentation are generally not permitted for paper or Internet-based PECOS applications; it is important that requests for information or clarification be formalized in writing. However, in cases where CMS permits telephonic requests for such data, the contractor shall adhere to the following:
• A telephonic request is made when the contractor: (1) speaks with an appropriate provider official, or (2) leaves a message either with an appropriate official’s staff (e.g., his/her executive assistant) or with an appropriate official’s voice mail service. In situation (2), the contractor shall leave the name, telephone number, and e-mail address of an appropriate individual at the contractor site who the official can contact; otherwise, the contact does not qualify as a legitimate request for clarification.
• When leaving a message, the contractor shall also state that the requested data/clarification must be furnished within 30 days.
• Telephone requests shall be made on weekdays between 9 am and 5 pm of the provider’s time zone.
• The 30-day clock begins on the date (1) of the telephone conversation with the appropriate official, or (2) the message is left.
D. Inability to Contact Provider - If the contractor cannot, for the reasons listed below, communicate with the provider to request information/documentation, it shall attempt one alternative means of communication:
• The mailed letter is returned because the provider is not at that address
• The contractor cannot e-mail the letter to the provider because of issues with the recipient’s e-mail system.
• The provider’s fax number is repeatedly busy
If an alternative communication also cannot be completed for one of the above reasons, the contractor need not make another attempt to obtain the data and may reject the application once the applicable 30-day period expires. However, it is strongly advised that the contractor make a third attempt to contact the provider prior to taking this step, especially if it appears that the provider is otherwise acting in good faith. (The contractor shall document each attempt to contact the provider.)
(With respect to e-mail, an alternative communication includes sending an e-mail to another listed contact person, delegated official, or authorized official.)
Receiving Missing/Clarifying Data/Documentation
The procedures in this section 15.7.1.5 are subject to the processing alternatives identified in sections 15.7.1.3.1 through 15.7.1.3.4 of this chapter. A. Requirement to Furnish All Missing/Clarifying Material The provider must furnish all missing/clarifying data/documentation requested by the contractor within the 30-day timeframe. Whether the provider furnished all the information is a decision resting solely with the contractor. Should the provider furnish some (but not all) of the requested data/clarification within the specified time period, the contractor need not contact the provider again to request the remaining information. For instance, suppose the contractor requested missing data in sections 3, 4, and 5 of the Form CMS-855A. The provider only furnished the section 3 data. The contractor may reject the application without attempting another contact.
For Internet-based PECOS applications, the provider may mail its paper certification statement and its documentation separately. They need not be sent in the same package.
B. Format of Furnishing Missing Data
1. Paper Applications
Unless stated otherwise in this chapter or in another CMS directive, the provider shall: (1) provide the missing/clarification information (excluding documentation) on the applicable Form CMS-855 page(s) and (2) submit the missing material via mail, fax, or scanned e-mail. A newly signed and dated certification statement must accompany the Form CMS-855 page(s) containing the missing data – unless the only missing information is supporting documentation, in which case no new certification statement is needed.
2. Internet-Based PECOS
Applications Unless stated otherwise in this chapter or in another CMS directive, the provider may (1) submit the missing information by entering it into PECOS, (2) submit the missing documentation via fax, e-mail, mail, or the Digital Data Repository (DDR), and/or (3) submit the certification statement via paper or e-signature. (The provider may submit the missing data via the applicable paper Form CMS-855 pages if it submitted its application via Internet-based PECOS.)
C. Format of Clarifying Data
In cases where clarifying (as opposed to missing) information is requested, the contractor may accept the clarification by e-mail, fax, or letter. If the provider furnishes the clarification via telephone, the contractor shall – unless another CMS directive states otherwise - request that the provider furnish said clarification in writing (preferably via e-mail).
If the provided clarification ultimately requires the provider to change or alter data that must be reported on the paper or Web Form CMS-855, the contractor shall instruct the provider via a follow-up e-mail or fax to submit the revised data on the applicable Form CMS-855 page or via Internet-based PECOS and to furnish a new certification statement. The provider must submit the revised data and new certification statement within 30 days of the original request for clarification (rather than 30 days from the date of the follow-up request to provide the data via the Form CMS-855).
Consider the following illustrations:
EXAMPLE 1: The contractor notifies the provider via an e-mailed letter on March 1 of a discrepancy regarding its ownership information on the Form CMS-855A. The provider e-mails the contractor on March 3 and explains the discrepancy. Based on this e-mail, the contractor determines that the provider must correct its ownership data in section 5 of its Form CMS-855A. The contractor sends a follow-up e-mail to the provider on March 7 instructing the provider to do so. The provider must submit the revised data on the Form CMS-855 (with a new certification statement) by March 31 (not April 6, or 30 days from the date of the follow-up e-mail).
EXAMPLE 2: The contractor notifies the provider via e-mailed letter on March 1 of a discrepancy regarding its ownership information on the Form CMS-855A. The provider telephones the contractor on March 6 and explains the discrepancy to the contractor’s satisfaction. Although the discrepancy does not require the provider to make any revisions to its Form CMS-855A, the contractor shall request that the provider furnish its explanation in writing no later than 30 days from its March 1 e-mail (or March 31), not 30 days from the date of its March 6 request for the written explanation.
EXAMPLE 3: The contractor notifies the provider via e-mailed letter on March 1 of a discrepancy regarding its ownership information on its paper Form CMS-855A. Determining (based on the contractor’s e-mail) that the ownership information it provided was incorrect, it submits a revised section 5 of its Form CMS-855A to the contractor with a new certification statement but without any accompanying explanation of the change (e.g., no accompanying letter or e-mail). The contractor receives the revised section 5 on March 12. If the contractor determines that the discrepancy has been resolved via the revised submission, it is not required to contact the provider for an accompanying written explanation. (This is because the clarification was furnished in writing via the CMS-855 itself.) If, however, the contractor would like a written explanation or otherwise needs clarification about the submission, it may request that a written explanation be submitted no later than March 31.
D. Maintenance of Received Material
The contractor shall maintain all missing/clarifying information or documentation received (including new certification statements) in the provider file. Storage can be electronic or via hard copy, but it must be in an otherwise easily accessible format.
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