Blank Cms 855A Template

WHO SHOULD COMPLETE THIS APPLICATION

Institutional providers can apply for enrollment in the Medicare program or make a change in their enrollment information using either:

•The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or

•The paper enrollment application process (e.g., CMS 855A).

For additional information regarding the Medicare enrollment process, including Internet-based PECOS,

go to www.cms.gov/MedicareProviderSupEnroll.

Institutional providers who are enrolled in the Medicare program, but have not submitted the CMS 855A

г2003, are required to submit a Medicare enrollment application (i.e., Internet-based PECOS or the S 855A) as an initial application when reporting a change for the first time.

following health care organizations must complete this application to initiate the enrollment process:

If your provider type is not listed above, contact your designated fee-for-service contractor before you submit this application.

Complete this application if you are a health care organization and you:

•Plan to bill Medicare for Part A medical services, or

•Would like to report a change to your existing Part A enrollment data. A change must be reported within 90 days of the effective date of the change; per 42 C.F.R. 424.516(e), changes of ownership or control must be reported within 30 days of the effective date of the change.

BILLING NUMBER INFORMATION

The National Provider Identifier (NPI) is the standard unique health identifier for health care providers and is assigned by the National Plan and Provider Enumeration System (NPPES). Medicare healthcare

providers, except organ procurement organizations, must obtain an NPI prior to enrolling in Medicare or before submitting a change to your existing Medicare enrollment information. Applying

for an NPI is a process separate from Medicare enrollment. To obtain an NPI, you may apply online at https://NPPES.cms.hhs.gov. As an organizational health care provider, it is your responsibility to determine if you have “subparts.'' A subpart is a component of an organization that furnishes healthcare and is not itself a legal entity. If you do have subparts, you must determine if they should obtain their own unique NPIs. Before you complete this enrollment application, you need to make those determinations and obtain NPl(s) accordingly.

IMPORTANT: For NPI purposes, sole proprietors and sole proprietorships are considered to be

“Type 1” providers. Organizations (e.g., corporations, partnerships) are treated as “Type 2” entities. When reporting the NPI of a sole proprietor on this application, therefore, the individual’s Type 1 NPI should be reported; for organizations, the Type 2 NPI should be furnished.

For more information about subparts, visit www.cms.gov/NationalProvldentStand to view the “Medicare

Expectations Subparts Paper.”

The Medicare Identification Number, often referred to as the CMS Certification Number (CCN) or Medicare “legacy” number, is a generic term for any number other than the NPI that is used to identify a Medicare provider.

INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION

•Type or print all information so that it is legible. Do not use pencil.

•Report additional information within a section by copying and completing that section for each additional entry.

•Attach all required supporting documentation.

•Keep a copy of your completed Medicare enrollment package for your records.

•Send the completed application with original signatures and all required documentation to your designated Medicare fee-for-service contractor.

AVOID DELAYS IN YOUR ENROLLMENT

To avoid delays in the enrollment process, you should:

•Complete all required sections.

•Ensure that the legal business name shown in Section 2 matches the name on the tax documents.

•Ensure that the correspondence address shown in Section 2 is the provider’s address.

•Enter your NPI in the applicable sections.

•Enter all applicable dates.

•Ensure that the correct person signs the application.

•Send your application and all supporting documentation to the designated fee-for-service contractor.

OBTAINING MEDICARE APPROVAL

The usual process for becoming a certified Medicare provider is as follows:

1.The applicant completes and submits a CMS-855A enrollment application and all supporting documentation to its fee-for-service contractor.

2.The fee-for-service contractor reviews the application and makes a recommendation for approval or denial to the State survey agency, with a copy to the CMS Regional Office.

3.The State agency or approved accreditation organization conducts a survey. Based on the survey results, the State agency makes a recommendation for approval or denial (a certification of compliance or noncompliance) to the CMS Regional Office. Certain provider types may elect voluntary accreditation by a CMS-recognized accrediting organization in lieu of a State survey.

4.A CMS contractor conducts a second contractor review, as needed, to verify that a provider continues to meet the enrollment requirements prior to granting Medicare billing privileges.

5.The CMS Regional Office makes the final decision regarding program eligibility. The CMS Regional Office also works with the Office of Civil Rights to obtain necessary Civil Rights clearances. If approved, the provider must typically sign a provider agreement.

ADDITIONAL INFORMATION

For additional information regarding the Medicare enrollment process, visit www.cms.gov/

MedicareProviderSupEnroll.

The fee-for-service contractor may request, at any time during the enrollment process, documentation to support or validate information reported on the application. You are responsible for providing this documentation in a timely manner.

The information you provide on this application will not be shared. It is protected under 5 U.S.C. Section 552(b)(4) and/or (b)(6), respectively. For more information, see the last page of this application for the Privacy Act Statement.

MAIL YOUR APPLICATION

The Medicare fee-for-service contractor (also referred to as a fiscal intermediary or a Medicare administrative contractor) that services your State is responsible for processing your enrollment application. To locate the mailing address for your fee-for-service contractor, go to www.cms.gov/

MedicareProviderSupEnroll.

SECTION 1: BASIC INFORMATION

NEW ENROLLEES

If you are:

•Enrolling with a particular fee-for-service contractor for the first time.

•Undergoing a change of ownership where the new owner will not be accepting assignment of the Medicare assets and liabilities of the seller/former owner.

ENROLLED MEDICARE PROVIDERS

The following actions apply to Medicare providers already enrolled in the program:

Reactivation

To reactivate your Medicare billing privileges, submit this enrollment application. In addition, you must be able to submit a valid claim and meet all current requirements for your provider type before reactivation can occur.

Voluntary Termination

A provider should voluntarily terminate its Medicare enrollment when:

•It will no longer be rendering services to Medicare patients,

•It is planning to cease (or has ceased) operations,

•There has been an acquisition/merger and the new owner will not be using the identification number of the entity it has acquired,

•There has been a consolidation and the identification numbers of the consolidating providers will no longer be used, or

•There has been a change of ownership and the new owner will not be accepting assignment of the Medicare assets and liabilities of the seller/former owner, meaning that the number of the seller/former owner will no longer be used.

NOTE: A voluntary identification number termination cannot be used to circumvent any corrective action plan or any pending/ongoing investigation, nor can it be used to avoid a period of reasonable assurance, where a provider must operate for a certain period without recurrence of the deficiencies that were the basis for the termination. The provider will not be reinstated until the completion of the reasonable assurance period.

Change of Ownership (CHOW)

A CHOW typically occurs when a Medicare provider has been purchased (or leased) by another organization. The CHOW results in the transfer of the old owner's Medicare Identification Number and provider agreement (including any outstanding Medicare debt of the old owner) to the new owner. The regulatory citation for CHOWs can be found at 42 C.F.R. 489.18. If the purchaser (or lessee) elects not to accept a transfer of the provider agreement, then the old agreement should be terminated and the purchaser or lessee is considered a new applicant.

SECTION 1: BASIC INFORMATION (Continued)

Acquisition/Merger

An acquisition/merger occurs when a currently enrolled Medicare provider is purchasing or has been purchased by another enrolled provider. Only the purchaser’s Medicare Identification Number and tax identification number remain.

Acquisitions/mergers are different from CHOWs. In the case of an acquisition/merger, the seller/former owner’s Medicare Identification Number dissolves. In a CHOW, the seller/former owner’s provider number typically remains intact and is transferred to the new owner.

Consolidation

A consolidation occurs when two or more enrolled Medicare providers consolidate to form a new business entity.

Consolidations are different from acquisitions/mergers. In an acquisition/merger, two entities combine but the Medicare Identification Number and tax identification number (TIN) of the purchasing entity remain intact. In a consolidation, the TINs and Medicare Identification Numbers of the consolidating entities dissolve and a new TIN and Medicare Identification Number are assigned to the new, consolidated entity.

Because of the various situations in which a CHOW, acquisition/merger, or consolidation can occur, it is recommended that the provider contact its fee-for-service contractor or its CMS Regional Office if it is unsure as to whether such a transaction has occurred. The provider should also review the applicable federal regulation at 42 C.F.R. 489.18 for additional guidance.

Change of Information

A change of information should be submitted if you are changing, adding, or deleting information under your current tax identification number. Changes in your existing enrollment data must be reported to the Medicare fee-for-service contractor in accordance with 42 C.F.R. 424.516(e).

NOTE: Ownership changes that do not qualify as CHOWs, acquisitions/mergers, or consolidations should be reported here. The most common example involves stock transfers. For instance, assume that a business entity’s stock is owned by A, B, and C. A sells his stock to D. While this is an ownership change, it is generally not a formal CHOW under 42 C.F.R. 489.18. Thus, the ownership change from A to D should be reported as a change of information, not a CHOW. If you have any questions on whether an ownership change should be reported as a CHOW or a change of information, contact your fee-for- service contractor or CMS Regional Office.

If you are already enrolled in Medicare and are not receiving Medicare payments via EFT, any change to your enrollment information will require you to submit a CMS-588 application. All future payments will then be made via EFT.

Revalidation

CMS may require you to submit or update your enrollment information. The fee-for-service contractor will notify you when it is time for you to revalidate your enrollment information. Do not submit a revalidation application until you have been contacted by the fee-for-service contractor.

SECTION 1: BASIC INFORMATION (Continued)

A. Check one box and complete the required sections

SECTION 1: BASIC INFORMATION (Continued)

B. Check all that apply and complete the required sections:

REQUIRED SECTIONS

□Identifying Information1,2 (complete only those sections that are changing), 3,13, and either 15 (if you are the authorized official) or 16 (if you are the delegated official), and Section 6 for the signer if that authorized or delegated official has not been established for this provider.

□Adverse Legal Actions/Convictions 1,2B1,3,13, and either 15 (if you are the authorized official) or 16 (if you are the delegated official), and Section 6 for the signer if that authorized or delegated official has not been established for this provider.

□Practice Location Information, 1,2B1,3,4 (complete only those sections that are

□Chain Home Office Information 1,2B1,3,7,13, and either 15 (if you are the authorized official) or 16 (if you are the delegated official), and Section 6 for the signer if that authorized or delegated official has not been established for this provider.

□Billing Agency Information1,2B1,3,8 (complete only those sections that are changing), 13, and either 15 (if you are the authorized official) or 16 (if you are the delegated official), and Section 6 for the signer if that authorized or delegated official has not been established for this provider.

□Special Requirements for Home 1,2B1,3,12,13, and either 15 (if you are the authorized

SECTION 2: IDENTIFYING INFORMATION

______________________________________ NEW ENROLLEES_____________________________________

Submit separate CMS-855A enrollment applications if the types of providers for which this

application is being submitted are separately recognized provider types with different rules regarding Medicare participation. For example, if a provider functions as both a hospital and an end-stage renal disease (ESRD) facility, the provider must complete two separate enrollment applications (CMS-855A) — one tor the hospital and one for the ESRD facility. If a hospital performs multiple types of services, only one enrollment application (CMS-855A) is required.

For example, a hospital that has a swing-bed unit need only submit one enrollment application (CMS- 855A). This is because the provider is operating as a single provider type —a hospital—that happens to have a distinct part furnishing different/additional services.

SPECIAL ENROLLMENT NOTES

•If you are adding a psychiatric or rehabilitation unit to a hospital, check the appropriate subcategory under the “Hospital” heading. (A separate enrollment for the psychiatric/rehabilitation unit is not required). The unit should be listed as a practice location in Section 4.

•If you are adding a home health agency (HHA) branch, list it as a practice location in Section 4. A separate enrollment application is not necessary.

•If you are changing hospital types (e.g., general hospital to a psychiatric hospital), indicate this in Section 2. A new/separate enrollment is not necessary.

•If you are adding an HHA sub-unit (as opposed to a branch), this requires an initial enrollment application for the sub-unit.

•If the hospital will focus on certain specialized services, the applicant should analyze whether the facility will be a general hospital or will fall under the category of a specialty hospital. A specialty hospital is defined as a facility that is primarily engaged in cardiac, orthopedic, or surgical care. Based upon Diagnosis Related Group/Major Diagnosis Category (DRG/MDC) and type (medical/surgical), the applicant should project all inpatient discharges expected in the first year of the hospital's operation. Those applicants that project that 45% or more of the hospital's inpatient cases will fall in either cardiac (MDC-5), orthopedic (MDC-8), or surgical care should check the Hospital—Specialty Hospital block in Section 2A2.

•Physician-owned hospital means any participating hospital (as defined in 42 CFR § 489.24) in which a physician, or an immediate family member of a physician has an ownership or investment interest in the hospital. The ownership or investment interest may be through equity, debt, or other means, and includes an interest in an entity that holds an ownership or investment interest in the hospital. This definition does not include a hospital with physician ownership or investment interests that satisfy the requirements at 42 CFR § 411.356(a) or (b). (NOTE: Physician-owned hospitals have additional reporting requirements explained in Section 5 and Section 6 of this application.)