|
|
Medicare Part A
(* = off-site link)
- Latest News & Updates
- Transition Info...
- Medical Policy...
- Reference Library...
- Provider Information...
- Reimbursement & Settlement...
- Self-Service Tools...
- Outreach & Education...
- EDI...
- Provider/CMS Links...
Electronic Mailing Lists
General
- Where do I get the CMS 855A application?
- What if I do not have the Internet and need an 855 Form?
- Can I make photocopies of my completed 855A form?
- Is my facility Accredited or Non-Accredited?
- Is my facility Provider Based?
- Who are the owners of my organization?
- Who is the managing/directing employee?
- What is the IRS Form CP 575?
- What if I just have a change to a billing address?
- Does a prior owner have to complete a CMS 855A during the change of ownership?
- Who should be the contact person?
- Who should sign the application?
- How much information should I disclose?
- What should I do if I have further questions completing the application?
- What constitutes an Authorized Official on a CMS-855 enrollment form?
- What is a delegated Official?
- If you have the information on one part of the CMS-855A enrollment application or on an attachment, and I forgot to write it in another section, why can't you just fill it in for me?
- Why do you require a new signature page each time I make a change to the CMS-855 form I sent in?
Where do I get the CMS 855A application?
The 855A is available to be downloaded from the CMS website at : http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp.
Date Reviewed/Revised: 07/08/2008
What if I do not have the Internet and need an 855 Form?
Call Provider Enrollment Services at: 1-866-488-0549, option 2. We can send you a paper copy of the 855A Enrollment Form.
Date Reviewed/Revised: 07/08/2008
Can I make photocopies of my completed 855A form?
Photocopies of the CMS 855A are permitted and can be used to submit multiple information that is required for certain sections; however an original signature must always be present in Section 15 when the application is submitted.
Date Reviewed/Revised: 07/08/2008
Is my facility Accredited or Non-Accredited?
CMS recognizes the JACHO accreditation organization. If your facility has been accredited by this organization, please mark the box accordingly.
Date Reviewed/Revised: 07/08/2008
Is my facility Provider Based?
Entities operating under the control of a parent organization are provider based. (Ex. File consolidated Cost report, share common staff, common governing board, and is located near parent provider).
Date Reviewed/Revised: 07/08/2008
Who are the owners of my organization?
All owners with 5% or more controlling interest must be listed. If another corporation owns your facility, then disclose information about that corporation. If your facility is non-profit with no defined owners, state this in Section 6 and complete section for all board members.
Date Reviewed/Revised: 07/08/2008
Who is the managing/directing employee?
A managing/directing employee is defined as any employee who has day-to-day control over the organization, including hiring and firing capacity. This section should include, but is not limited to, general manager(s), business manager(s), administrator(s), director(s) and board of directors. For large business organizations, only the top 20 compensated managing/directing personnel should be listed. Social Security numbers must be provided for all persons listed in this section.
Date Reviewed/Revised: 07/08/2008
-
The IRS Form CP 75 is the letter you received from the IRS granting your Employer Identification Number. In lieu of the IRS Form CP 575, the applicant may use any official correspondence from the IRS showing the name of the entity as shown on the application and the EIN, (i.e., the quarterly tax payment coupon).
Date Reviewed/Revised: 07/08/2008
What if I just have a change to a billing address?
Any information that was originally provided on the CMS 855A that is changed must be submitted to Provider Enrollment Services via an 855A. Changes of information of this type cannot be accepted via a letter.
Date Reviewed/Revised: 07/08/2008
Does a prior owner have to complete a CMS 855A during the change of ownership?
Yes, a prior must submit a CMS 855A along with the new owner's application. The new owner's application will not be processed without it. Contact Highmark Medicare Services for the information necessary for the prior owner (aka ‘seller’) to complete.
Date Reviewed/Revised: 07/08/2008
Who should be the contact person?
The contact person should be the person who is responsible for ensuring completion of the enrollment process for your facility. If the application is returned for any reason, it will be returned to the contact person listed.
Date Reviewed/Revised: 07/08/2008
Who should sign the application?
An authorized official must sign and date the initial CMS 855A enrollment application on behalf of the provider. This is an appointed official to whom the provider has granted the legal authority to enroll it in the Medicare program to make changes and/or updates to the provider’s status in the Medicare program and to commit the provider to fully abide by the laws, regulations, and program instructions of Medicare. The authorized official must be the provider’s general partner, chairman of the board, chief financial office, chief executive office, president, direct owner of 5% or more of the provider, or must hold a position of similar status and authority within the provider’s organization.
NOTE: A delegated official (assigned by the authorized official) may sign and date the CMS 855A in order to make changes and/or updates to the provider’s Medicare status.
Date Reviewed/Revised: 07/08/2008
How much information should I disclose?
Provide as much relevant information as possible. A thorough review of the information will be done and any discrepancies could delay the processing of the application.
Date Reviewed/Revised: 07/08/2008
What should I do if I have further questions completing the application?
First review the instructions at the beginning of the CMS 855A for clarification. If you still need assistance, you may contact Provider Enrollment Services at 1-866-488-0549, option 2.
Date Reviewed/Revised: 07/08/2008
What constitutes an Authorized Official on a CMS-855 enrollment form?
An authorized official is defined as an appointed official (e.g. chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization’s status in the Medicare program, and to commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program. The authorized official must be an owner or officer of the enrolling facility and not only of an owning organization. CMS has clarified that the chain home office administrator of the chain organization to which the provider is affiliated does not automatically qualify as the authorized official by virtue of this role. The authorized official must have a position or ownership with the enrolled/enrolling facility. The organization can have as many authorized officials as it wants as long as the person meets the definition. In addition to meeting the requirements listed in this paragraph, a new authorized official must be listed in Section 6 – Ownership Interest and/or Managing Control Information (individuals) of the CMS-855A application.
Date Posted: 08/15/2007, Date Reviewed/Revised: 07/08/2008
-
A delegated official means an individual who is delegated, by the “authorized official,” the authority to report changes and updates to the enrollment record. The delegated official must be either an individual with ownership or control interest in (as that term is defined in Section 1124(a)(3) of the Social Security Act), or be a W-2 managing employee of the provider or supplier. The delegated official must be directly employed or have ownership of the provider itself and not only of an owning organization. CMS has clarified that the chain home office administrator of the chain organization to which the provider is affiliated does not automatically qualify as the delegated official by virtue of this role. The delegated official must have a position with the enrolled/enrolling facility. An organization can have as many delegated officials as it wants as long as the person meets the definition. In addition to meeting the requirements listed, a new delegated official must be reported in Section 6 of the CMS-855A application.
Date Posted: 08/15/2007, Date Reviewed/Revised: 07/08/2008
-
The CMS-855A enrollment form is a legal document, and as such contractors are prohibited from altering it in any way. All the needed information must be completed in each section, even if it is a repetition of previously reported data or appears on an attachment.
Date Posted: 08/15/2007, Date Reviewed/Revised: 07/08/2008
Why do you require a new signature page each time I make a change to the CMS-855 form I sent in?
The CMS-855A enrollment form is a legal document, and your signature attests to the accuracy of the information submitted on the form. If during the processing of an application the contractor needs additional information, CMS requires that a new signature page with a current date is submitted along with the page with the changed information. This protects you by ensuring the integrity of the documentation for your enrollment with Medicare.
Date Posted: 08/15/2007, Date Reviewed/Revised: 07/08/2008