Non-Certified Suppliers and Individual Practitioners
(This section does not apply to ambulatory surgical centers, portable x-ray suppliers, or providers and suppliers that complete the Form CMS-855A.) If the contractor approves a supplier’s enrollment, it shall notify the applicant via letter of the approval.
The letter shall:
• Follow the content and format of the model letter in section 15.24.7 of this chapter;
• Include the National Provider Identifier (NPI) with which the supplier will bill Medicare and the Provider Transaction Access Number (PTAN) that has been assigned to the supplier as an identifier for inquiries.
• Provide instructions on how suppliers should use the assigned PTAN when they use the contractor interactive voice response (IVR) system for inquiries concerning claims status, beneficiary eligibility, check status or other supplier-related IVR transactions.
• Include language reminding suppliers to update their NPPES record whenever their information changes. Absent a CMS instruction or directive to the contrary, the contractor shall send the approval letter within 5 business days of approving the enrollment application in PECOS. For all applications other than the Form CMS-855S, the letter shall be sent to the supplier’s contact person if one is listed; otherwise, the contractor may send the letter to the supplier at the supplier’s correspondence address or special payment address.
For claims submitted by physicians and non-physicians prior to the date of enrollment, the contractor shall follow the instructions in Pub. 100-04, chapter 1, section 70, with respect to the claim filing limit. Payments cannot be made for services furnished prior to the date the applicant is appropriately licensed.
Certified Providers and Certified Suppliers
(This section only applies to: (1) initial Form CMS-855A applications or change of ownership (CHOW), acquisition/merger, or consolidation applications submitted by the new owner; and (2) initial ambulatory surgical center and portable x-ray supplier applications.) If the contractor decides to recommend approval of the provider or supplier’s application, the contractor shall send a recommendation letter to the applicable State agency, with a copy to the Regional Office’s (RO) survey and certification unit.
(For those provider/supplier types that do not require a State survey, such as federally qualified health centers, the letter can be sent directly to the RO.) The recommendation letter shall, at a minimum, contain the following information:
• Supplier/Provider NPI Number
• CMS Certification Number (if available)
• Type of enrollment transaction (CHOW, initial enrollment, branch addition, etc.)
• Contractor number
• Contractor contact name
• Contractor contact phone number
• Date application recommended for approval (and, for FQHCs, the date that the package is complete)
• An explanation of any special circumstances, findings, or other information that either the State or the RO should know about.
• Any other information that, under this chapter 15, must be included in the recommendation letter.
The letter can be sent to the State/RO via mail, fax, or e-mail.
The contractor shall also:
• Send either a photocopy (not the original), faxed version, or e-mail version of the final completed Form CMS-855 to the State agency or RO (as applicable), along with all updated Form CMS-855 pages, explanatory data, documentation, correspondence, final sales agreements, etc. (which can also be sent via mail, fax, or email).
If the CMS-855, associated documentation, and recommendation letter are mailed, they should be included in the same package. The contractor shall not send a copy of the Form CMS-855 to the RO unless the latter specifically requests it or if the transaction in question is one for which State involvement is unnecessary.
• Notify the applicant that the contractor has completed its initial review of the application. The notification can be furnished via e-mail, or via the letter identified in section 15.24.6 of this chapter (which may be sent to the applicant’s contact person), and shall advise the applicant of the next steps in the enrollment process (e.g., site visit, survey). The contractor may, but is not required to, send a copy of its recommendation letter to the provider as a means of satisfying this requirement. However, the contractor should not send a copy to the provider if the recommendation letter contains sensitive information.
• Inform initial applicants (including new owners that have rejected assignment of the provider’s or supplier’s provider agreement) that Medicare billing privileges will not begin before the date the survey and certification process has been completed and all Federal requirements have been met.
• Notify the applicant of the phone numbers and e-mail addresses of the applicable State agency and RO that will be handling the survey and certification process; the applicant shall also be instructed that all questions related to this process shall be directed to the State agency and/or RO.
Approval of Suppliers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
As stated in 42 CFR §424.57(b), a DMEPOS supplier must, among other things, meet the following conditions to be eligible to receive payment for a Medicare-covered item:
• The supplier has submitted a complete Form CMS-855S, including all supporting documentation, to the National Supplier Clearinghouse (NSC); and
• The item was furnished on or after the date the NSC issued to the supplier a DMEPOS supplier number conveying Medicare billing privileges. The date identified in the previous bullet represents the “date of approval.”
Changes of Information - General Procedures
Unless otherwise specified in this chapter or another CMS directive, if an enrolled provider is adding, deleting, or changing information under its existing tax identification number, it must report the change using the applicable Form CMS-855.
Letterhead is not permitted. The provider shall (1) furnish the changed data in the applicable section(s) of the form, and (2) sign and date the certification statement. In accordance with 42 CFR §424.516(d) and (e), the timeframes for providers to report changes to their Form CMS855 information are as follows:
A. Physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse-midwives; clinical social workers; clinical psychologists; registered dietitians or nutrition professionals; and organizations (e.g., group practices) consisting of any of the categories of individuals identified in this paragraph.): The following changes must be reported within 30 days:
• A change of ownership
• A final adverse action
• A change in practice location
All other informational changes involving the providers listed in this section 15.10.1(A) must be reported within 90 days.
B. All providers and suppliers other than (1) those listed in section 15.10.1(A); (2) suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS); and (3) independent diagnostic testing facilities (IDTFs):
Any change of ownership, including a change in an authorized or delegated official, must be reported within 30 days. All other informational changes involving the providers listed in this section 15.10.1(B) must be reported within 90 days.
The reporting requirements for IDTFs can be found in 42 CFR §410.33(g)(2) and in section 15.5.19.1(A)(2) of this chapter. Reporting requirements for DMEPOS suppliers can be found in 42 CFR §424.57(c)(2)). In addition:
• Unsolicited Additional Information - Any new or changed information that a provider submits prior to the date the contractor finishes processing a previously submitted change request is no longer considered to be an update to that change request. Rather, it is considered to be and shall be processed as a separate change request. The contractor may process both changes simultaneously, but the change that was submitted first shall be processed to completion prior to the second one being processed to completion.
• Unavoidable Phone Number or Address Changes – Unless CMS specifies otherwise, any change in the provider’s phone number or address that the provider did not cause (i.e., area code change, municipality renames the provider’s street) must still be updated via the Form CMS-855.
• Application Signatures - If the signer has never been reported in section 6 of the Form CMS-855, section 6 must be completed in full with information about the individual. (This policy applies regardless of whether the provider already has a Form CMS-855 on file.) The contractor shall ensure that all validation required to be performed with respect to the individual is conducted.
• Notifications – For changes of information that do not require Regional Office approval (e.g., Form CMS-855I changes; Form CMS-855B changes not involving ambulatory surgical centers or portable x-ray suppliers; minor Form CMS-855A changes), the contractor shall (1) furnish written, e-mail, or telephonic confirmation to the provider that the change has been made, and (2) document (per section 15.7.3 of this chapter) in the file the date and time the confirmation was made. If, however, the transaction only involves an area code/ZIP Code change, it is not necessary to send confirmation to the provider that the change has been processed.
(This section does not apply to ambulatory surgical centers, portable x-ray suppliers, or providers and suppliers that complete the Form CMS-855A.) If the contractor approves a supplier’s enrollment, it shall notify the applicant via letter of the approval.
The letter shall:
• Follow the content and format of the model letter in section 15.24.7 of this chapter;
• Include the National Provider Identifier (NPI) with which the supplier will bill Medicare and the Provider Transaction Access Number (PTAN) that has been assigned to the supplier as an identifier for inquiries.
• Provide instructions on how suppliers should use the assigned PTAN when they use the contractor interactive voice response (IVR) system for inquiries concerning claims status, beneficiary eligibility, check status or other supplier-related IVR transactions.
• Include language reminding suppliers to update their NPPES record whenever their information changes. Absent a CMS instruction or directive to the contrary, the contractor shall send the approval letter within 5 business days of approving the enrollment application in PECOS. For all applications other than the Form CMS-855S, the letter shall be sent to the supplier’s contact person if one is listed; otherwise, the contractor may send the letter to the supplier at the supplier’s correspondence address or special payment address.
For claims submitted by physicians and non-physicians prior to the date of enrollment, the contractor shall follow the instructions in Pub. 100-04, chapter 1, section 70, with respect to the claim filing limit. Payments cannot be made for services furnished prior to the date the applicant is appropriately licensed.
Certified Providers and Certified Suppliers
(This section only applies to: (1) initial Form CMS-855A applications or change of ownership (CHOW), acquisition/merger, or consolidation applications submitted by the new owner; and (2) initial ambulatory surgical center and portable x-ray supplier applications.) If the contractor decides to recommend approval of the provider or supplier’s application, the contractor shall send a recommendation letter to the applicable State agency, with a copy to the Regional Office’s (RO) survey and certification unit.
(For those provider/supplier types that do not require a State survey, such as federally qualified health centers, the letter can be sent directly to the RO.) The recommendation letter shall, at a minimum, contain the following information:
• Supplier/Provider NPI Number
• CMS Certification Number (if available)
• Type of enrollment transaction (CHOW, initial enrollment, branch addition, etc.)
• Contractor number
• Contractor contact name
• Contractor contact phone number
• Date application recommended for approval (and, for FQHCs, the date that the package is complete)
• An explanation of any special circumstances, findings, or other information that either the State or the RO should know about.
• Any other information that, under this chapter 15, must be included in the recommendation letter.
The letter can be sent to the State/RO via mail, fax, or e-mail.
The contractor shall also:
• Send either a photocopy (not the original), faxed version, or e-mail version of the final completed Form CMS-855 to the State agency or RO (as applicable), along with all updated Form CMS-855 pages, explanatory data, documentation, correspondence, final sales agreements, etc. (which can also be sent via mail, fax, or email).
If the CMS-855, associated documentation, and recommendation letter are mailed, they should be included in the same package. The contractor shall not send a copy of the Form CMS-855 to the RO unless the latter specifically requests it or if the transaction in question is one for which State involvement is unnecessary.
• Notify the applicant that the contractor has completed its initial review of the application. The notification can be furnished via e-mail, or via the letter identified in section 15.24.6 of this chapter (which may be sent to the applicant’s contact person), and shall advise the applicant of the next steps in the enrollment process (e.g., site visit, survey). The contractor may, but is not required to, send a copy of its recommendation letter to the provider as a means of satisfying this requirement. However, the contractor should not send a copy to the provider if the recommendation letter contains sensitive information.
• Inform initial applicants (including new owners that have rejected assignment of the provider’s or supplier’s provider agreement) that Medicare billing privileges will not begin before the date the survey and certification process has been completed and all Federal requirements have been met.
• Notify the applicant of the phone numbers and e-mail addresses of the applicable State agency and RO that will be handling the survey and certification process; the applicant shall also be instructed that all questions related to this process shall be directed to the State agency and/or RO.
Approval of Suppliers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
As stated in 42 CFR §424.57(b), a DMEPOS supplier must, among other things, meet the following conditions to be eligible to receive payment for a Medicare-covered item:
• The supplier has submitted a complete Form CMS-855S, including all supporting documentation, to the National Supplier Clearinghouse (NSC); and
• The item was furnished on or after the date the NSC issued to the supplier a DMEPOS supplier number conveying Medicare billing privileges. The date identified in the previous bullet represents the “date of approval.”
Changes of Information - General Procedures
Unless otherwise specified in this chapter or another CMS directive, if an enrolled provider is adding, deleting, or changing information under its existing tax identification number, it must report the change using the applicable Form CMS-855.
Letterhead is not permitted. The provider shall (1) furnish the changed data in the applicable section(s) of the form, and (2) sign and date the certification statement. In accordance with 42 CFR §424.516(d) and (e), the timeframes for providers to report changes to their Form CMS855 information are as follows:
A. Physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse-midwives; clinical social workers; clinical psychologists; registered dietitians or nutrition professionals; and organizations (e.g., group practices) consisting of any of the categories of individuals identified in this paragraph.): The following changes must be reported within 30 days:
• A change of ownership
• A final adverse action
• A change in practice location
All other informational changes involving the providers listed in this section 15.10.1(A) must be reported within 90 days.
B. All providers and suppliers other than (1) those listed in section 15.10.1(A); (2) suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS); and (3) independent diagnostic testing facilities (IDTFs):
Any change of ownership, including a change in an authorized or delegated official, must be reported within 30 days. All other informational changes involving the providers listed in this section 15.10.1(B) must be reported within 90 days.
The reporting requirements for IDTFs can be found in 42 CFR §410.33(g)(2) and in section 15.5.19.1(A)(2) of this chapter. Reporting requirements for DMEPOS suppliers can be found in 42 CFR §424.57(c)(2)). In addition:
• Unsolicited Additional Information - Any new or changed information that a provider submits prior to the date the contractor finishes processing a previously submitted change request is no longer considered to be an update to that change request. Rather, it is considered to be and shall be processed as a separate change request. The contractor may process both changes simultaneously, but the change that was submitted first shall be processed to completion prior to the second one being processed to completion.
• Unavoidable Phone Number or Address Changes – Unless CMS specifies otherwise, any change in the provider’s phone number or address that the provider did not cause (i.e., area code change, municipality renames the provider’s street) must still be updated via the Form CMS-855.
• Application Signatures - If the signer has never been reported in section 6 of the Form CMS-855, section 6 must be completed in full with information about the individual. (This policy applies regardless of whether the provider already has a Form CMS-855 on file.) The contractor shall ensure that all validation required to be performed with respect to the individual is conducted.
• Notifications – For changes of information that do not require Regional Office approval (e.g., Form CMS-855I changes; Form CMS-855B changes not involving ambulatory surgical centers or portable x-ray suppliers; minor Form CMS-855A changes), the contractor shall (1) furnish written, e-mail, or telephonic confirmation to the provider that the change has been made, and (2) document (per section 15.7.3 of this chapter) in the file the date and time the confirmation was made. If, however, the transaction only involves an area code/ZIP Code change, it is not necessary to send confirmation to the provider that the change has been processed.
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