Certification Statement - Form CMS-855A

10.3.1.1.10 – Certification Statement - Form CMS-855A (Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) A. Certification Statement – General Policies (Unless otherwise specified, the instructions in this section 10.3.1.1.10(A) apply to: (1) signatures on the paper Form CMS-855A; and (2) electronic signatures for web applications.) For paper applications, handwritten (wet) signatures in ink and digital/electronic signatures (digital or electronic signatures such as those created by digital signature options created in software, such as Adobe) are acceptable. For web applications, electronic signatures are required; the contractor may contact its PEOG BFL for questions regarding electronic signatures. B. Paper Submissions A signed certification statement shall accompany the paper Form CMS-855A application. If the provider submits an invalid certification statement or no certification statement at all, the contractor shall still process the application. The contractor shall solicit an appropriate certification statement as part of the development process – preferably via the PCV, e-mail or fax. This includes certification statements that are: (a) unsigned; (b) undated; (c) signed (as reflected by the date of signature) more than 120 days prior to the date on which the contractor received the application); (d) missing; or (e) stamped. The contractor shall send one development request to include a list of all of the missing required data/documentation, including the certification statement. The contractor may reject the provider’s application if the provider fails to furnish the missing information on the enrollment application - including all necessary documentation - within 30 calendar days from the date the contractor requested the missing information or documentation. Unless stated otherwise in this chapter or in another CMS directive: (i) The contractor shall begin processing the application upon receipt and shall develop for missing certification statements and all other missing information (including an application fee) upon review. (ii) The contractor may return a certification statement via scanned email or fax. (iii) Signature dates cannot be more than 120 days prior to the receipt date of the application. (iv) For paper applications that require development, the dated signature of at least one of the provider’s authorized or delegated officials must be on the certification statement that must be sent in within 30 days. Obtaining the signatures of the other authorized and delegated officials is not required. (v) For paper changes of information (as the term “changes of information” is defined in section 10.4.4 of this chapter), if the certification statement is signed by an individual not on file with the contractor as an authorized or delegated official of the provider, the contractor may accept the certification statement. However, it shall develop for information on the person consistent with the procedures in this chapter. (vi) The contractor need not compare the signature on the Form CMS-855A with the same authorized or delegated official’s signature on file to ensure that it is the same person. (vii) The contractor shall not request the submission of a driver’s license or passport to verify a person’s signature or identity. C. PECOS Submissions Unless stated otherwise in this chapter or in another CMS directive: (i) The contractor shall (a) begin processing the application upon receipt via PECOS; (b) perform all required manual validations; and (c) develop for any needed clarifying or missing information or documentation consistent with section 10.3 above and all other applicable instructions in this chapter. (ii) If the provider submits an invalid certification statement, the contractor shall treat this as missing information and develop for a correct certification statement – preferably via the PCV, e-mail, or fax. (This includes certification statements that are signed by a person unauthorized to do so under 42 CFR Part 424, subpart P.) The contractor shall send one development request to include a list of all of the data/documentation to be furnished or clarified, including, as applicable, the certification statement. The contractor may reject the provider’s application if the provider fails to furnish said data/documentation within 30 calendar days from the date of the contractor’s request. (iii) For PECOS applications that require development, at least one of the provider’s authorized or delegated officials must sign any certification statement that must accompany the provider’s response. Obtaining the signatures of the other authorized and delegated officials is not required. (iv) For PECOS changes of information, if the certification statement is signed by an individual who is not on file with the contractor as an authorized or delegated official of the provider, the contractor may accept the certification statement. However, it shall develop for information on the person in question consistent with the procedures in this chapter. (v) The contractor need not compare the signature thereon with the same authorized or delegated official’s signature on file to ensure that it is the same person. (vi) The contractor shall not request the submission of a driver’s license or passport to verify a person’s signature or identity. D. Certification Statement Development If, as already mentioned, the provider submits an invalid certification statement (as described in subsections (B) and (C) above), the contractor shall develop for a correct certification statement and send a development letter to the provider. The provider must submit the requested certification statement as follows: (i) Paper applications -- Via scanned email, fax, or mail. Only the actual signature page is required; the provider need not submit the additional page containing the certification terms. (This also applies to the provider’s initial submission of a certification statement. Such instances require the submission of only the signature page and not the certification terms.) (ii) Web applications – Via electronic signature. (iii)