Processing Form CMS-855O Change of Information Requests
A. Receipt
Upon receipt of a Form CMS-855O change of information request (or - for Internetbased Provider Enrollment, Chain and Ownership System (PECOS) change requests - a certification statement), the contractor shall create a logging and tracking (L & T) record. 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 change request via the instructions outlined in that section. Suppliers who are enrolled in Medicare via the Form CMS-855I may not report changes to their enrollment information via the Form CMS-855O. They must use the Form CMS-855I. Similarly, suppliers whose Form CMS-855O submissions have been approved must use the Form CMS-855O to report information changes; they cannot use the Form CMS-855I for this purpose.
B. Verification
Unless stated otherwise in this chapter or in another CMS directive, the contractor shall verify the new information that the supplier furnished on the Form CMS-855O. (This includes checking the supplier against the Medicare Exclusion Database and the System for Award Management (SAM).)
If, at any time during the verification process, the contractor needs additional or clarifying information, 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 change request, the contractor shall approve, deny, or reject the submission. The principal ground for denial will be that the new information was furnished, but could not be verified. If the contractor believes that another ground for denial exists with respect to a particular submission, it should contact its CMS Provider Enrollment Business Function Lead (PEBFL) for guidance.
The change request may be rejected if the supplier failed to furnish all required information on the form within 30 calendar days of the contractor’s request to do so. The basis for rejection shall be 42 CFR § 424.525(a). When denying or rejecting the change request, the contractor shall: (1) switch the PECOS record to a “denied” or “rejected” status (as applicable), and (2) send a letter (via mail or e-mail) to the supplier notifying him or her of the denial or rejection and the reason(s) for it. If the change request 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.
Form CMS-855O Revocations
If the contractor determines that grounds exist for revoking the supplier’s Form CMS855O enrollment, it shall:
• Switch the supplier’s Provider Enrollment, Chain and Ownership System (PECOS) record to a “ revoked” status,
• End-date the PECOS record, and
• Send a letter via certified mail to the supplier stating that his or her Form CMS855O enrollment has been revoked. The letter shall follow the format outlined in section 15.24.24 of this chapter. Grounds for revoking the supplier’s Form CMS-855O enrollment are as follows:
• The supplier is no longer of a type that is eligible to order or certify.
• The supplier no longer meets the licensure, certification or educational requirements for his or her supplier type.
• The supplier is excluded per the Medicare Exclusion Database (MED) and/or debarred per the System for Award Management (SAM).
For purposes of the Form CMS-855O only, the term “revocation” effectively means that:
• The supplier may no longer order or certify Medicare services based on his or her having completed the Form CMS-855O process.
• If the supplier wishes to submit another Form CMS-855O, he or she must do so as an initial applicant.
There are appeal rights associated with the revocation of a supplier’s Form CMS-855O enrollment.
Conversion from Form CMS-855O to Form CMS-855I – PECOS Requirements
Internet-based PECOS permits an individual provider to convert his or her current Form CMS-855O application to a Form CMS-855I enrollment and vice versa. Such providers shall follow the current process for creating a new application. When PECOS detects existing approved enrollments, the provider will be prompted to select from a list of those enrollments that will be used to pre-populate the information for the new application.
The provider must confirm that he or she wants to withdraw the existing enrollments before the new application may be submitted. The enrollments to be withdrawn are displayed in a new section of the ADR in PECOS Administrative Interface (AI). The contractor shall review this information and take the appropriate action to voluntarily withdraw the enrollments listed.
The contractor shall begin working the Form CMS-855I enrollment but leave it in “In Review” status while withdrawing the other enrollments. A logging and tracking (L&T) submittal reason of Voluntary Termination shall be used to withdraw the Form CMS-855O enrollment. The effective date of the withdrawn enrollments shall be one day prior to the effective date of the Form CMS-855I enrollment.
If it is determined that the Form CMS-855O enrollment requiring withdrawal is outside of the contractor’s jurisdiction, the contractor shall notify the other contractor via email using the “Associate Profile Contact List,” stating that the enrollment needs to be voluntary withdrawn. The second contractor shall take action based on the email and include the email in its files as documentation. If the provider submits a paper Form CMS-855I application and it is determined that a current Form CMS-855O enrollment exists within the contractor jurisdiction, the contractor shall voluntarily withdraw the Form CMS-855O enrollment.
If it is determined that the current Form CMS-855O enrollment is outside of the contractor’s jurisdiction, the contractor shall notify the other contractor via email using the “Associate Profile Contact List” that the enrollment needs to be voluntary withdrawn. The second contractor shall take action based on the email and include the email in its files as documentation.
If the provider submits a paper Form CMS-855O to voluntarily withdraw his or her enrollment as well as a paper Form CMS-855I to begin billing Medicare, the contractor shall not contact the provider to confirm the submissions unless the contractor has reason to believe that what was submitted was not the provider’s intention.
If it is determined that the provider submitted applications to convert his or her existing Form CMS-855O enrollment into a Form CMS-855I enrollment in error (either via paper or Internet-based PECOS), the contractor shall reject the application, thus returning the enrollment record back to its previous state.
Establishing an Effective Date of Medicare Billing Privileges
(This section only applies to the following individuals and organizations: physicians; physician assistants; nurse practitioners; clinical nurse specialists; certified registered nurse anesthetists; anesthesiology assistants; certified nurse-midwives; clinical social workers; clinical psychologists; registered dietitians or nutrition professionals; physician and non-physician practitioner organizations (e.g., group practices) consisting of any of the categories of individuals identified above; or ambulance suppliers.
A. Background
In accordance with 42 CFR §424.520(d), the effective date for the individuals and organizations identified above is the later of:
• The date the supplier filed an enrollment application that was subsequently approved, or
• The date the supplier first began furnishing services at a new practice location.
NOTE: The date of filing for Internet-based Provider Enrollment, Chain and Ownership System (PECOS) applications is the date that the contractor received an electronic version of the enrollment application and a signed certification statement submitted via paper or electronically.
B. Retrospective Billing
Consistent with 42 CFR §424.521(a), the individuals and organizations identified above may retrospectively bill for services when:
• The supplier has met all program requirements, including state licensure requirements, and
• The services were provided at the enrolled practice location for up to —
1. 30 days prior to their effective date if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries, or
2. 90 days prior to their effective date if a Presidentially-declared disaster under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. §§5121-5206 (Stafford Act) precluded enrollment in advance of providing services to Medicare beneficiaries.
The contractor shall interpret the phase “circumstances precluded enrollment” to mean that the supplier meets all program requirements (including state licensure) during the 30-day period before an application was submitted and no final adverse action, as identified in §424.502,precluded enrollment.
If a final adverse action precluded enrollment during this 30-day period, the contractor shall only establish an effective billing date the day after the date that the final adverse action was resolved, as long as it is not more than 30 days prior to the date on which the application was submitted. If the contractor believes that the aforementioned Presidentially-declared disaster exception may apply in a particular case, it shall contact its CMS Provider Enrollment Business Function Lead for a determination on this issue.
C. Legal Distinction between Effective Date of Enrollment and retrospective Billing Date
The effective date of enrollment is “the later of the date of filing or the date (the supplier) first began furnishing services at a new practice location.” The retrospective billing date, however, is “up to…30 days prior to (the supplier’s) effective date (of enrollment).” To illustrate, suppose that a non-Medicare enrolled physician begins furnishing services at an office on March 1. She submits a Form CMS-855I initial enrollment application on May 1.
The application is approved on June 1. The physician’s effective date of enrollment is May 1, which is the later of: (1) the date of filing, and (2) the date she began furnishing services. The retrospective billing date is April 1 (or 30 days prior to the effective date of enrollment), assuming that the requirements of 42 CFR §424.521(a) are met. NOTE: However, that the effective date entered into the Provider Enrollment, Chain and Ownership System (PECOS) and the Multi-Carrier System will be April 1 and that claims submitted for services provided before April 1 will not be paid.
Effective Date for Certified Providers and Certified Suppliers
The final Fiscal Year (FY) 2011 Hospital Inpatient Prospective Payment System (IPPS) final rule was published on August 16, 2010 (75 FR 50042) and became effective October 1, 2010. Several provisions in the rule directly affect areas of survey and certification responsibility. Section 489.13 governs the determination of the effective date of a Medicare provider agreement or supplier approval for health care facilities that are subject to survey and certification. Section 489.13 was revised to clarify that the date of a Medicare provider agreement or supplier approval may not be earlier than the latest date on which all applicable federal requirements have been met.
Such requirements include the Medicare contractor’s review and verification of the provider/supplier’s Form CMS855 application. These clarifications were necessary because of a September 28, 2009 decision of the Appellate Division of the Department Appeals Board (DAB). The DAB’s interpretation of §489.13 was that it did not include enrollment application processing as among the Federal requirements that must be met. In that case, a State Agency (SA) had conducted a survey of an applicant on July 6, 2007, prior to receiving the November 21, 2007 notice from the Medicare contractor that was recommending approval of the applicant’s enrollment application.
The CMS Regional Office (RO) issued a provider approval effective November 21, 2007, consistent with our traditional interpretation of §489.13. The DAB, however, ruled that the effective date must be July 6, 2007. The DAB agreed with the applicant that the requirement for the Medicare contractor to verify and determine whether an application should be approved is not a requirement for the provider to meet [under §489.13], but rather a requirement for Medicare contractor action (DAB Decision No. 2271, page 5).
Although SAs and accreditation organizations (AOs) are aware that - in accordance with Section 2003B of the State Operations Manual (SOM) - they should not perform a survey of a new facility until the Medicare contractor has made a recommendation for approval, circumstances do occur where the sequence is reversed. AOs, in particular, often find it challenging to confirm whether the Medicare contractor has made its recommendation.
This is because AOs are dependent upon the applicant providing copies of the pertinent notices. When the survey occurs prior to the enrollment verification activities, we believe it is essential that the provider agreement or supplier approval date be based on the later date, i.e., the date on which the contractor determined that the enrollment application verification. Accordingly, §489.13(b) now states that: “Federal requirements include, but are not limited to –
(1) Enrollment requirements established in part 424, Subpart P, of this chapter. CMS determines, based upon its review and verification of the prospective provider’s or supplier’s enrollment application, the date on which enrollment requirements have been met;
(2) The requirements identified in §§489.10 and 489.12; and
(3) The applicable Medicare health and safety standards, such as the applicable conditions of participation, the requirements for participation, the conditions for coverage, or the conditions for certification.”
Ordering and Certifying Documentation - Maintenance Requirements
A. Background
Under 42 CFR §424.516(f)(1), a provider or supplier that furnishes covered ordered items of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), clinical laboratory, imaging services, or covered ordered/certified home health services is required to:
• Maintain documentation (see next paragraph) for 7 years from the date of service, and
• Upon the request of CMS or a Medicare contractor, provide access to that documentation.
The documentation to be maintained includes written and electronic documents (including the National Provider Identifier (NPI) of the physician who ordered/certified the home health services and the NPI of the physician - or, when permitted, other eligible professional - who ordered items of DMEPOS or clinical laboratory or imaging services) relating to written orders and certifications and requests for payments for items of DMEPOS and clinical laboratory, imaging, and home health services.
In addition, under §424.516(f)(2), a physician who orders/certifies home health services and the physician - or, when permitted, other eligible professional - who orders items of DMEPOS or clinical laboratory or imaging services is required to maintain the documentation described in the previous paragraph for 7 years from the date of service and to provide access to that documentation pursuant to a CMS or Medicare contractor request. If the provider, supplier, physician or eligible professional (as applicable) fails to maintain this documentation or to furnish this documentation upon request, the contractor may revoke enrollment under §424.535(a)(10).
B. Justification for Request for Documentation
Absent a CMS directive to the contrary, the contractor shall request the documentation described in subsection (A) if it has reason to believe that the provider, supplier, physician or eligible professional (hereinafter collectively referred to as “provider”) is not maintaining the documentation in accordance with §424.516(f)(1) or (2). Examples of when a request might be appropriate include, but are not limited to:
• The contractor has detected an unusually high number of denied claims involving the provider, or the Fraud Prevention System has generated an alert with respect to the provider.
• The provider has been the subject of a recent Zone Program Integrity Contractor referral.
• The provider maintains an elevated surety bond amount. These are, of course, only examples of when a request could perhaps be warranted. Ultimately, the contractor would have to consider the surrounding circumstances of each case, including those involving situations not addressed in the aforementioned examples. The contractor may always contact its CMS Provider Enrollment Business Function Lead (PEBFL) if it is uncertain as to whether a particular documentation request should be made.
NOTE: Documentation cannot be requested for written orders and certifications dated prior to July 6, 2010. C. Maintaining and Providing Access to Documentation Under §424.516(f), CMS or a Medicare contractor may request access to documentation described in §424.516(f). The term “access to documentation” means that the documentation is actually provided or made available in the manner requested by CMS or a Medicare contractor.
All providers and suppliers who either furnish, order, or certify the items described in section A above are subject to this requirement and are individually responsible for maintaining these records and providing them upon request. For example, if a Medicare contractor requests copies of all orders for wheelchairs from an ordering physician for all beneficiaries with dates of service from November 1, 2014 through November 10, 2014, the ordering physician must provide the copies, in full, according to the specific request.
If copies cannot be provided because the physician or eligible professional did not personally maintain the records or can only be partially provided, then the requirement to maintain this documentation and provide access to it will not have been met and the provider, supplier, physician, or eligible professional may be subject to the revocation basis set forth in §424.535(a)(10).
D. Process
If the contractor believes that a request for documentation is warranted, it shall prepare and send a request letter to the provider via mail. If the provider:
• Fails to respond within 30 calendar days of the contractor’s request (i.e., a complete non-response), the contractor shall revoke enrollment using §424.535(a)(10) as the basis. Prior approval from the contractor’s PEOG BFL is not necessary. A 1-year re-enrollment bar shall be imposed.
• Timely furnishes documentation that the contractor nevertheless deems inadequate, the contractor shall send a developmental letter via mail, e-mail or fax to the provider that requests more sufficient documentation. If the provider fails to submit such documentation (either via a complete non-response or by submitting additional inadequate documentation), the contractor shall refer the matter (including the documentation submitted to date) to its CMS PEBFL. CMS will determine whether a revocation is warranted and will notify the contractor via e-mail of its decision.
• Furnishes documentation that the contractor deems adequate, the contractor
need not take further action other than to place the documentation and the documentation request letter(s) in the provider file.
E. Additional Guidance
The contractor shall also abide by the following:
1. When preparing the letter referred to in (C)(1) above, the contractor shall use the appropriate model language in (E) or (F) below. Note, however, that while the letters request copies of orders, the contractor has the discretion to ask for different or additional documentation (e.g., documentation that supports the legitimacy of a particular service or the payment of a particular claim). Copies of orders need not be requested in every situation. As alluded to in (B) above, the contractor would have to examine the facts of each case in determining the type(s) of documentation to be requested.
2. There may be situations in which CMS directs the contractor to request documentation in a particular case. The contractor shall follow the instructions in this section 15.18 with respect to doing so.
3. The contractor shall contact its CMS PEBFL if it has questions as to whether particular submitted documentation is adequate or legitimate – specifically, whether it falls within the category of documentation described in section (A) above.
F. Model Language for § 424.516(f)(1) Situations
The contractor shall use the model language below if it is requesting documentation from a provider or supplier furnishing the items or services addressed in §424.516(f)(1). “Dear Provider/Supplier: Under 42 CFR §424.516(f)(1), a provider or supplier that furnishes covered ordered items of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), clinical laboratory, imaging services, or covered ordered/certified home health services is required to:
• Maintain documentation for 7 years from the date of service, and
• Upon the request of CMS or a Medicare contractor, provide access to that documentation.
The documentation to be maintained includes written and electronic documents (including the National Provider Identifier (NPI) of the physician who ordered/certified the home health services and the NPI of the physician - or, when permitted, other eligible professional - who ordered items of DMEPOS or clinical laboratory or imaging services) relating to written orders and certifications and requests for payments for items of DMEPOS and clinical laboratory, imaging, and home health services.
Consistent with §424.516(f)(1), please mail to us copies of the orders for the items or services that were furnished to the following beneficiaries on the dates specified: (Contractors shall insert the beneficiaries’ names (up to 5 may be listed, unless CMS specifies otherwise), appropriate identification information, and the dates on which the provider or supplier furnished the items/services in question.
The contractor has the discretion to determine the cases/services that are included in this documentation request as well as the type(s) of documentation to be requested.) The documentation must be received at the following address no later than 30 calendar days after the date of this letter: (Cite appropriate address) Failure to timely submit this documentation may result in the revocation of your enrollment pursuant to 42 CFR §424.535(a)(10).”
G. Model Language for §424.516(f)(2) Situations
The contractor shall use the model language below if it is requesting documentation from a provider or supplier furnishing the items or services addressed in § 424.516(f)(2). “Dear Physician / Professional: Under 42 CFR §424.516(f)(2), a physician who orders/certifies home health services and the physician - or, when permitted, other eligible professional - who orders items of DMEPOS or clinical laboratory or imaging services is required to maintain documentation for 7 years from the date of service and to provide access to that documentation pursuant to a CMS or Medicare contractor request.
The documentation to be maintained includes written and electronic documents relating to written orders and certifications and requests for payments for items of DMEPOS and clinical laboratory, imaging, and home health services. Consistent with §424.516(f)(2), please mail to us copies of the orders for items or services that you issued for the following beneficiaries on the dates specified: (Contractors shall insert the beneficiaries’ names (up to 5 may be listed, unless CMS specifies otherwise), appropriate identification information, and the dates on which the orders were made. The contractor has the discretion to determine the cases/services that are included in this documentation request as well as the type(s) of documentation to be requested.)
The documentation must be received at the following address no later than 30 calendar days after the date of this letter: (Cite appropriate address) Failure to timely submit this documentation may result in the revocation of your enrollment pursuant to 42 CFR §424.535(a)(10).” (For individuals enrolled via the Form CMS-855O, the contractor shall instead use the following language: “Failure to timely submit this documentation may result in the revocation of your Form CMS-855O enrollment.”)
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