Wednesday, 19 October 2016

Processing Alternatives – Form CMS-855O / Processing Alternatives – Form CMS-855R / Paper Applications / Internet-Based PECOS Applications

A. General Processing Alternatives 

The following general alternatives are applicable to all sections of the Form CMS- 855O, unless otherwise specified:

1. Information Disclosed Elsewhere - 
If a data element on the supplier’s Form CMS- 855O application is missing but the information is disclosed (1) elsewhere on the application or (2) in the supporting documentation submitted with the application, the contractor need not obtain the missing data via an updated Form CMS-855O page and a newly-signed certification statement; no further development – not even by telephone – is required. The following information, however, must be furnished in the appropriate section(s) of the Form CMS-855O, even if the data is identified elsewhere on the form or in the supporting documentation:

a. Any final adverse action data requested in section 3
b. Legal names
c. Tax identification number (TIN)
d. NPI-legacy number combinations in section 2 (if applicable)
e. Data in section 1B

Data available on a previously submitted Form CMS-855 enrollment application, or information currently in PECOS, does not qualify as a processing alternative. In addition, per section 15.7.3 of this chapter, the contractor shall document in the provider file that the missing information was found elsewhere in the enrollment package.

2. Licenses 
In situations where the supplier is required to submit a copy of a particular professional or business license, certification, registration, or degree but fails to do so, the contractor need not obtain such documentation from the provider if the contractor can verify the information independently. This may be done by: (1) reviewing and printing confirming pages from the applicable state, professional, or school web site, (2) requesting and receiving from the appropriate state, professional, or educational body written confirmation of the supplier’s status therewith, or (3) utilizing another thirdparty verification source. Likewise, if the provider submits a copy of the applicable license, certification, registration or degree but fails to complete the applicable section of the form, the section need not be completed if the data in question can be verified on the license/certification itself or via any of the three mechanisms above.

• The above-referenced written confirmation of the supplier’s status can be in the form of a letter, fax, or e-mail, but it must be in writing. Documentation of a verbal conversation between the contractor and the body in question does not qualify as appropriate confirmation.

• This exception only applies to those documents that traditionally fall within the category of licenses, registrations, certifications, or degrees such as adverse action documentation. Furthermore, the exception is moot in cases where a particular license/certification is not required by the state.

3. City, State, and ZIP Code - If a particular address lacks a city or state, the contractor can verify the missing data in any manner it chooses. In addition, the contractor can obtain the zip + four from either the U.S. Postal Service or Finalist in PECOS.

4. Drug Enforcement Agency (DEA) - DEA certificates need not be submitted if the applicable DEA information was furnished on the CMS-855. Similarly, if the aforementioned certificates are furnished but the applicable CMS-855 sections are blank, no further development is needed.

B. Sectional Processing Alternatives 

The processing alternatives in this subsection B are in addition to, and not in lieu of, those in subsection A.

1. Section 1 

With the exception of the voluntary termination checkbox, any blank data/checkboxes in section 1 can be verified through any means chosen by the contractor (e.g., e-mail, telephone, fax).

2. Section 2 

• If blank, “Type of Other Name” and “Gender” can be captured orally.

• If the contractor is aware that a particular state does not require licensure/certification and the “Not Applicable” boxes are not checked in section 2C, no further development is needed.

• When processing a non-physician practitioner’s (NPP) application, the contractor need not automatically request a copy of the NPP’s degree or diploma (if it is not submitted) if his or her education can be verified through other authorized means; requesting a copy of the degree or diploma should only be done if educational information cannot otherwise be verified.

3. Section 4 

If the supplier uses a checkmark, an “X,” or other symbol to identify his/her primary and secondary specialties (as opposed to a “P” or “S”), no additional development is needed.

4. Section 6

If this section is completely blank, the contractor need not develop for this information and can simply contact the physician or practitioner.

Processing Alternatives – Form CMS-855R

 All data elements in sections 1, 2, 3, and 4 must be completed via the CMS-855R. Regarding section 5:

• If this section is completely blank, the contractor need not develop for this information and can simply contact the party that submitted the form (e.g., the enrolling physician).

• If a contact person is listed, any other missing data (e.g., address, e-mail) can be captured via telephone.

Paper Applications

If (1) the provider submits an application with at least one missing required data element, (2) the provider fails to submit at least one required document, (3) submits an invalid certification statement, or (4) the contractor determines that clarification is needed regarding certain information (e.g., particular data cannot be verified or there are data inconsistencies), the contractor shall send a development letter to the provider – preferably via e-mail or fax - that contains, at a minimum, the applicable elements in

(a) through (f) below. (See section 15.24 et seq. for model letters.) (a) A list of all of the missing required data/documentation, an explanation of the certification statement’s deficiencies, and/or the issues/information to be clarified.

(b) A request that the provider submits the missing data/documentation, clarification, and/or revised certification statement within 30 calendar days.

(c) Unless the only data that is missing is documentation, a request that the provider submit an appropriately signed and dated certification statement, which will cover both the submission of any missing data as well as any deficiencies associated with the original certification statement.
(A new certification statement is not required if the only missing material is documentation or if the clarification to be provided does not require any changes to the provider’s Form-855 application.)

(d) If missing data is involved, the CMS Web site at which the CMS-855 forms can be found. The contractor shall instruct the provider to (1) print out the page(s) containing the missing data; (2) enter the data on the blank page; (3) sign and date a new, blank certification statement; and (4) send it to the contractor. (As an alternative, the contractor can fax the blank page(s) and certification statement to the provider.) The provider need not furnish its initials next to the data element(s) in question.

(Step (d) is not needed if the only missing material is documentation.)

(e) An e-mail address, fax number, and mailing address to which the missing/clarifying data/documentation/correct certification statement can be sent to the contractor.

(f) The name, phone number, and e-mail address of a contact person at the contractor site.

Internet-Based PECOS Applications

If the contractor determines that (1) required data/documentation are missing, (2) clarification is needed (e.g., certain data cannot be verified), and/or (3) the certification statement is invalid, the contractor shall – after switching the L & T status to “Returned for Corrections” - send an e-mail (via PECOS Internet) to the provider containing:

(a) A list of all missing data/documentation, information to be clarified, and/or certification statement issues;

(b) A request that the provider submit the data/materials in question within 30 calendar days; and

(c) The name, phone number, and e-mail address of a contact person at the contractor site.

The contractor shall not attempt to contact the provider for the missing/clarified information and/or valid certification statement prior to sending the e-mail referenced above, though the contractor is free to make a follow-up contact with the provider after sending the e-mail.

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