Wednesday, 9 November 2016

Assignment of Part B Provider Transaction Access Numbers (PTANs) / Ordering/Certifying Suppliers – Background / CMS Final Rule 6010 / Processing Initial Form CMS-855O Submissions

 Assignment of Part B Provider Transaction Access Numbers (PTANs) 

The contractor shall only assign the minimum number of PTANs necessary to ensure that proper payments are made.  The contractor shall not assign additional PTAN(s) to a supplier merely because the individual or entity requests one - the only exception being for hospitals that request separate billing numbers for their hospital departments in section 2C of the Form CMS-855B.  However, a hospital requesting an additional PTAN must associate the new PTAN with a National Provider Identifier in section 4 of the Form CMS-855.

Internet-based PECOS Applications 

This section furnishes guidance to contractors on the proper handling and processing of Form CMS-855 applications submitted via the Internet (hereinafter referred to as "Internet-based PECOS" applications).

Unless otherwise stated:

• The instructions in this section 15.15 apply only to Internet-based PECOS applications.

• The instructions in sections 15.7 through of this chapter take precedence over those in this section 15.15.

A.  General Background Information 

The principal logging and tracking (L & T) statuses for PECOS Internet applications that are not in a final status are:

• Received;
• In Review;
• Returned for Corrections;
• Corrections Received;
• Review Complete; and
• Application in Process.

The submission of a PECOS Internet application will immediately place the L & T record into a “Received” status.

B.  Certification Statement

If the provider fails to submit a signed and dated certification statement to the contractor within 45 calendar days of the date on which it submitted its Internet-based PECOS application to the contractor, the contractor may – but is not required to - reject the application.  (For purposes of this policy, the certification statement must be received by the contractor’s provider enrollment unit by the 45 th

The 45-day rule applies to all CMS-855 PECOS Internet applications, regardless of the transaction involved.  For initial PECOS Internet applications (as the term “initial” is defined in section 15.6.1 of this chapter), it is only necessary that the dated signature of at least one of the provider’s authorized officials be on the certification statement that must be sent in by the 45 th  day; obtaining the signatures of the other authorized and delegated officials shall be done through the normal application development process.

For PECOS Internet changes of information (as the term “changes of information” is defined in section 15.6.2 of this chapter), if the certification statement is signed by an individual who is not on file with the contractor as being an authorized or delegated official of the provider, the contractor may accept the certification statement but shall develop for information on the person in question in accordance with sections 15.5.15 and 15.5.16 of this chapter.

If the provider submits: (1) an undated certification statement, or (2) a certification statement on which the Web Tracking ID does not match that in PECOS, the contractor shall treat it as a non-submission; while it is recommended that the contractor contact the provider to request a signed/correct certification statement, it is not required.  (This requirement applies to any Form CMS 855 transaction, including requests for additional/clarifying information.)  If the contractor elects to contact the provider to request a dated/valid certification statement, the contractor may give the provider an additional 15 days (or, for that matter, any additional time beyond the initial 45-day period) to submit the new certification statement.

In determining whether to accept an untimely certification statement, the contractor shall take into account factors such as: (1) the degree of the provider’s cooperation, (2) the time it took for the certification statement to be transferred from the contractor’s main mailroom to the provider enrollment department, and (3) the number of days by which the provider missed the 45-day deadline.

C.  Application Returns  

If the contractor can determine (without actively processing the application) that an application can be returned under section 15.8.1 of this chapter (e.g., was submitted more than 30 days prior to the effective date), the contractor shall return the application without waiting for the arrival of the certification statement.

D.  Switch to “In Review” Status  

After – and only after - it receives and accepts the provider’s certification statement, the contractor shall: (1) enter the date of signature into the “Certification Date” box in the L & T record, and (2) change the L & T status to “In Review.”

The contractor, in other words, shall not initiate any application verification activities prior to its receipt and acceptance of the certification statement and its completion of tasks (1) and (2) in the previous sentence.

After changing the L & T status to “In Review,” the contractor shall review the Application Data Report (ADR), and shall commence all applicable validation activities identified in this chapter.  (The ADR is only available for printing when the L & T record is in one of the following statuses: “In Review,” “Returned for Corrections,” or “Corrections Received.”)

E.  Transferral of Data into PECOS

Once the contractor ties the L & T record to the enrollment record, the contractor shall begin the process of transferring the data into PECOS by accepting or rejecting the various data elements. The contractor shall note that: (1) it cannot undo any transfer of information into PECOS, and (2) once the L & T is tied to the enrollment record, the application cannot be returned to the provider for corrections.  F.  Miscellaneous Instructions  NOTE: The contractor is advised of the following:

• Deletion of Erroneous Record - The contractor shall only delete an erroneously created L & T record by: (1) moving the L & T record to a status of “Rejected,” and (2) using an L & T status reason of “Deleted.”

• Gatekeeper/Enrollment Screens - The Gatekeeper and Enrollment screens are  only used in the case of Form CMS-855 initial enrollment PECOS Internet submissions.

• Post-Processing Recordkeeping - After processing a particular PECOS Internet transaction, the contractor shall maintain in the provider’s file: (1) a copy of the final version of the ADR, (2) all submitted certification statements and applicable supporting documents, and (3) documentation of all contacts with the provider (e.g., phone calls, e-mails) per section 15.7.3 of this chapter.

State Agencies - In situations described in this chapter in which the contractor is required to submit a copy of the provider’s paper Form CMS-855 to the state agency, the contractor shall send a copy of the ADR in lieu of the Form CMS-855 if the provider sent in its application via the Internet.

Ordering/Certifying Suppliers – Background 

A. Who Can Order/Certify

Generally, depending upon state law, the following physicians and non-physician practitioners are permitted to order or certify items or services for Medicare beneficiaries:

• Doctors of medicine or osteopathy
• Doctors of dental surgery or dental medicine
• Doctors of podiatry
• Doctors of optometry
• Physician assistants
• Certified clinical nurse specialists
• Nurse practitioners
• Clinical psychologists
• Certified nurse midwives
• Clinical social workers

Most physicians and non-physician practitioners enroll in Medicare so they can receive reimbursement for covered services to Medicare beneficiaries.  However, some physicians and non-physician practitioners who are not enrolled in Medicare via the Form CMS-855I may wish to order or certify items or services for Medicare beneficiaries.  These individuals can become eligible to do so by completing the Form CMS-855O via paper or the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) process.

NOTE:  It is important to observe that physicians and non-physician practitioners that complete the Form CMS-855O do not and will not send claims to a Medicare contractor for services they furnish. They are not afforded Medicare billing privileges for the purpose of submitting claims to Medicare directly for services that they furnish to beneficiaries.  Such persons may be:

• Employed by the Department of Veterans Affairs (DVA)
• Employed by the Public Health Service (PHS)
• Employed by the Department of Defense (DOD) Tricare
• Employed by the Indian Health Service (IHS) or a tribal organization .
• Employed by a federally qualified health center (FQHC), rural health clinic (RHC), or critical access hospital (CAH)
• Licensed residents and physicians in a fellowship (see subsection B) • Dentists, including oral surgeons • Pediatricians

B. CMS Final Rule 6010-F 

CMS-6010-F was published in the Federal Register on April 27, 2012.  It set forth and/or reiterated several policies including, but not limited to, the following:

1.  Residents (as defined in 42 CFR § 413.75 and which includes interns and fellows) who are enrolled in an accredited graduate medical education program in a state that licenses or otherwise enables such individual to practice or order these items or services may enroll in Medicare to order and certify.

2.  To order and certify for Medicare items and services, a provider or supplier must be enrolled in either PECOS or the Medicare contractor’s legacy system.

3.  The ordering/certifying provisions of the final rule only apply to items of durable medical equipment, prosthetics, orthotics and supplies, imaging and clinical laboratory services, and home health services.    An interim final rule – CMS-6010-IFC, which was published in the Federal Register on May 5, 2010 – used the terms “refer” and “referring,” rather than “certify” and “certifying.”  The April 27, 2012 final rule stated that the latter two terms should be used instead of “refer” and “referring.”

 Processing Initial Form CMS-855O Submissions 

The instructions in sections 15.7 through of this chapter take precedence over those in sections 15.16.2 and 15.16.3.  

A.  Receipt  

Upon receipt of an initial Form CMS-855O (or - for Internet-based Provider Enrollment, Chain and Ownership System (PECOS) submissions - a certification statement), the contractor shall create a logging & tracking (L & T) record.

NOTE:  The physician/non-physician practitioner need not submit a Form CMS-460, a Form CMS-588, or an application fee with his or her Form CMS-855O.  Section 15.8.1 of this chapter outlines the reasons for which the contractor may immediately return a Form CMS-855O.  If the contractor determines that one or more of these reasons applies, it may return the form in accordance with the instructions outlined in that section.

B.  Verification  

Unless stated otherwise in this chapter or in another CMS directive, the contractor shall verify all of the information on the Form CMS-855O.  This includes, but is not limited to:

• Verification of the individual’s name, date of birth, social security number, and National Provider Identifier (NPI).

• Verification that the individual meets the requirements for his/her supplier type. (The contractor reserves the right to request that the individual submit documentation verifying his or her professional licensure, credentials, or education.)

• Verification that the individual is of a supplier type that can legally order or certify.

• Reviewing the Medicare Exclusion Database (MED) and System for Award Management (SAM) to ensure that the individual is not excluded or debarred.

If, at any time during the verification process, the contractor needs additional or clarifying information from the physician/non-physician practitioner, it shall follow existing CMS instructions for obtaining said data (e.g., sending a developmental letter). The information must be furnished to the contractor within 30 calendar days of the contractor’s request.

C.  Disposition  

Upon completion of its review of the form, the contractor shall approve, deny, or reject it.  Grounds for denial are as follows:

• The supplier is not of a type that is eligible to use the Form CMS-855O.

• The supplier is not of a type that is eligible to order or certify items or services for Medicare beneficiaries.

• The supplier does not meet the licensure, certification or educational requirements for his or her supplier type.

• The supplier is excluded per the MED and/or debarred per the SAM.

If the contractor believes that another ground for denial exists for a particular submission, it should contact its CMS Provider Enrollment Business Function Lead for guidance.  The Form CMS-855O may be rejected if the supplier fails to furnish all required information on the form within 30 calendar days of the contractor’s request to do so.  (This includes situations in which information was submitted, but could not be verified.)  The basis for rejection shall be 42 CFR § 424.525(a).  

When denying or rejecting the Form CMS-855O submission, the contractor shall: (1) switch the PECOS record to a “denied” or “rejected” status (as applicable), and (2) send a letter to the supplier notifying him or her of the denial or rejection and the reason(s) for it.  The letter shall follow the formats outlined in sections 15.24.22 (rejections) and 15.24.23 (denials) of this chapter.  Denial letters shall be sent via certified mail.  Rejection letters shall be sent by mail or e-mail.  (NOTE: A denial triggers appeal rights.  A rejection does not.)

If the Form CMS-855O is approved, the contractor shall: (1) switch the PECOS record to an “approved” status, and (2) send a letter (via mail or e-mail) to the supplier notifying him or her of the approval.  The letter shall follow the format outlined in section 15.24.21 of this chapter.  E.  Miscellaneous

NOTE:  The contractor shall observe the following:
1.   The supplier shall be treated as a non-participating supplier (or “non-par”).
2.   If the supplier is employed by the DVA, the DOD, or the IHS, he or she – for purposes of the Form CMS-855O - need only be licensed or certified in one State.  Said State need not be the one in which the DVA or DOD office is located.
3.   Nothing in sections 15.16.2 through 15.16.4 affects any existing CMS instructions
regarding the processing of opt-out affidavits.
4.   Suppliers cannot submit an abbreviated version of the Form CMS-855I in lieu of the
Form CMS-855O.
5.   The effective date of enrollment shall be the date on which the contractor received
the paper form or Web-based certification statement in its mailroom.
6.   If the supplier’s Form CMS-855O has been approved and he or she later wants to  obtain Medicare billing privileges, he or she must voluntarily withdraw his or her Form CMS-855O enrollment prior to receiving Medicare billing privileges.  (The supplier, of course, must complete the Form CMS-855I in order to receive Medicare billing privileges.)

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