Processing Tie-In Notices/Approval Letters
With respect to Form CMS-855A transactions for which a post-tie-in notice/approval letter site visit is not required (e.g., providers in the “limited” risk category), the contractor shall complete its processing of said notice/letter within 21 calendar days after its receipt of the tie-in/approval notice. For purposes of this requirement, the term “processing” includes all steps taken by the contractor’s enrollment and non-enrollment units (e.g. financial area, reimbursement area) to establish the provider’s ability to bill Medicare such as, but not limited to:
1. Entering all relevant data into the Provider Enrollment, Chain and Ownership System (PECOS).
2. Changing the provider’s PECOS record to the appropriate status (e.g., “approved”).
3. Facilitating the provider’s electronic funds transfer and electronic data interchange arrangements.
4. Notifying the provider (via any mechanism the contractor chooses) that it may begin billing.
The 21-day period begins on the day that the contractor receives the tie-in notice and ends on the day that the contractor notifies the provider that it can commence billing.
Regarding Form CMS-855A transactions that require a post-tie-in notice/approval letter site visit, the contractor shall process the tie-in notice/letter within 45 calendar days of its receipt of the notice/letter. This is to account for the additional time needed for the site visit to be performed.
State Surveys and the Form CMS-855A
• The contractor becomes aware of such a delay;
• The delay is the fault of the provider; and
• At least 6 months have passed since the contractor sent its recommendation for approval to the State.
If these criteria are met, the contractor shall send a letter to the provider requesting an updated Form CMS-855A. The application must contain, at a minimum, any information that is new or has changed since the recommendation for approval was made, as well as a newly-signed certification statement. If no information has changed, the provider may instead submit: (1) a letter on its business letterhead stating as such, and (2) a newly-signed Form CMS-855A certification statement.
NOTE: If the applicant is a home health agency (HHA), it must resubmit capitalization data per section 12 of the Form CMS-855A regardless of whether any of the provider’s other Form CMS-855A information has changed. To illustrate, if no Form CMS-855A data has changed, the HHA must submit the letter, capitalization data and the signed certification statement.
If the provider fails to furnish the requested information within 60 days of the contractor’s request, the contractor shall submit a revised letter to the State that recommends denial of the provider’s application.
Sole Proprietorships
If the provider indicates in section 2B1 of the Form CMS-855A that he/she is a sole proprietor, the contractor shall note the following:
• The LBN in section 2B1 should list the person’s (the sole proprietor’s) legal name.
• The TIN in section 2B1 should list the person’s social security number.
• Section 3 of the Form CMS-855A must be completed with information about the individual’s final adverse action history.
• Section 5 of the Form CMS-855A will not apply unless the person has hired an entity to exercise managerial control over the business (i.e., no owners will be listed in section 5, as the sole owner has already reported his/her personal information in sections 2 and 3).
• No owners, partners, or directors/officers need to be reported in section 6. However, all managing employees (whether W-2 or not) must be listed.
• The sole proprietor may list multiple authorized or delegated officials in sections 15 and 16. Since most sole proprietorships that complete the Form CMS-855A will also have an employer identification number (EIN), the contractor shall request from the provider a copy of its CP-575, any federal tax department tickets, or any other preprinted information from the IRS containing the provider’s EIN
Additional Form CMS-855A Processing Instructions
In some instances, the contractor cannot forward an application to the State until it performs certain non-enrollment functions pertaining to the application (e.g., the reimbursement unit needs to examine patient listing data). The contractor may flip the provider’s status in the Provider Enrollment, Chain and Ownership System (PECOS) to “approval recommended” prior to the conclusion of the non-enrollment activity if: (1) all required enrollment actions have been completed, and (2) the non-enrollment action is the only remaining activity to be performed.
B. Multiple Providers under a Single Tax Identification Number (TIN)
Multiple providers may have the same TIN. However, each provider must submit a separate Form CMS-855A application and the contractor must create a separate enrollment record for each.
C. Future Effective Dates
If the contractor cannot enter an effective date into PECOS because the provider, practice location, etc., is not yet established, the contractor may use the authorized official’s date of signature as the temporary effective date. Once the actual effective date is established (e.g., the tie-in notice is received), the contractor shall change the effective date in PECOS.
Contractor Jurisdictional Issues
A. Audit and Claims Contractors
1. Background
For purposes of enrollment via the Form CMS-855A, there are generally two categories of contractors: audit contractors and claims contractors. The audit contractor enrolls the provider, conducts audits, etc. The claims contractor pays the provider’s claims. In most cases, the provider’s audit contractor and claims contractor will be the same. On occasion, though, they will differ. This can happen, for instance, with provider-based entities, whereby the parent provider’s contractor (audit contractor) will process the provider’s enrollment application and a different contractor will pay the provider’s claims (claims contractor).
Should the audit and claims contractors differ, the audit contractor shall process all changes of information, including all Form CMS-588 changes. The audit contractor shall notify the applicant during the initial enrollment process that all future changes of information must be sent to the audit contractor, not the claims contractor. If the provider inadvertently sends a change request to the claims contractor, the latter shall return the application per section 15.8.1 of this chapter.
2. Process
If the audit contractor approves the Form CMS-855A transaction in question (e.g., initial enrollment), it shall:
(a) Send an e-mail to the claims contractor identifying the specific Form CMS- 855A transaction involved and confirming that the information has been updated in the Provider Enrollment, Chain and Ownership System (PECOS). Pertinent identifying information, such as the provider name, CMS Certification Number and National Provider Identifier, shall be included in the e-mail notification. Any supporting documentation that contains personal health information or personally identifiable information may still be faxed to the claims contractor.
(b) As applicable, fax or mail a copy of the submitted Form CMS-588 to the appropriate claims contractor.
Upon receipt of the e-mail notification, the claims contractor shall access PECOS, review the enrollment record, and, as needed, update its records accordingly.
The audit contractor shall keep all original copies of Form CMS-855A paperwork and supporting documentation, including all Form CMS-588s.
3. Tie-In/Tie-Out Notices and Approval Notices
If the provider’s audit contractor and claims contractor are different, the audit contractor shall e-mail or fax a copy of all tie-in/tie-out notices and approval letters it receives to the claims contractor. This is to ensure that the claims contractor is fully aware of the RO’s action, as some ROs may only send copies of tie-in/tie-out notices and approval letters to the audit contractor. If the audit contractor chooses, it can simply contact the claims contractor by phone or e-mail and ask if the latter received the tie-in notice.
Again, it is imperative that audit and claims contractors effectively communicate and coordinate with each other in all payment-related and program integrity matters involving the provider.
B. Provider Nomination
With respect to provider nomination and changes of contractors, the contractor shall follow the instructions in Pub. 100-04, chapter 1, sections 20 through 20.5.1.
If the contractor receives a request from a provider to change its existing contractor, it shall refer the provider to the RO contact person responsible for contractor assignments.
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