(Delegated Officials) - Form CMS-855A

10.3.1.1.12 – Section 16 (Delegated Officials) - Form CMS-855A (Rev. 13355; Issued: 08-13-25; Effective: 05-05-25; Implementation: 05-05-25) A. General Requirements A delegated official is an individual to whom an authorized official listed in the Certification Statement section of the Form CMS-855A delegates the authority to report changes and updates to the provider’s enrollment record or to sign revalidation applications. The delegated official’s signature binds the organization both legally and financially, as if the signature were that of the authorized official. Before the delegation of authority is established, the only acceptable signature on the enrollment application to report updates or changes to the enrollment information is that of an authorized official currently on file with Medicare. The delegated official must be an individual with an “ownership or control interest” in (as that term is defined in § 1124(a)(3) of the Social Security Act) or be a W-2 managing employee of the provider. Section 1124(a)(3) defines an individual with an ownership or control interest as: • A five percent direct or indirect owner of the provider, • An officer or director of the provider (if the provider is a corporation), or • Someone with a partnership interest in the provider if the provider is a partnership The delegated official must be a delegated official of the provider, not of an owning organization, parent company, chain home office, or management company. One cannot use a status as a W-2 managing employee of the provider’s parent company, management company, or chain home office as a basis for the individual’s role as the provider’s delegated official. The provider must complete the Ownership Interest and Managing Control Information for Individuals section of the Form CMS-855A for all delegated officials. A delegated official has no authority to sign an initial application. However, the delegated official may (i) sign a revalidation application and (ii) sign off on changes/updates submitted in response to a contractor’s request to clarify or submit information needed to continue processing the provider's initial application. Delegated officials may not delegate their authority to any other individual. Only an authorized official may delegate the authority to make changes and/or updates to the provider's Medicare data or to sign revalidation applications. For purposes of the Delegated Officials information captured in the Delegated Official section only, the term "managing employee" means any individual (including a general manager, business manager, or administrator) who exercises operational or managerial control over the provider, or who conducts the day-to-day operations of the provider. However, this does not include persons who, either under contract or through some other arrangement, manage the day- to-day operations of the provider but who are not actual W-2 employees. For instance, suppose the provider hires Smith as an independent contractor to run its day-to-day-operations. Under the definition of "managing employee" in the Ownership Interest and Managing Control Information for Individuals section of the Form CMS-855A, Smith would have to be listed in that section. Yet under the Delegated Officials section definition (as described above), Smith cannot be a delegated official because Smith is not an actual W-2 employee of the provider. Independent contractors are not considered "managing employees" under the Delegated Officials section of the Form CMS-855A. B. W-2 Form Unless the contractor requests it to do so, the provider need not submit a copy of the owning/managing individual’s W-2 to verify an employment relationship. C. Number of Delegated Officials The provider can have as many delegated officials as it chooses. It also need not have any delegated officials at all. If the provider lists no delegated officials, however, the authorized official(s) remains the only individual(s) who can report changes and/or updates to the provider's enrollment data. D. Effective Date The effective date in PECOS for a delegated official should be the date of signature. E. SSN To be a delegated official, the person must have and submit an SSN. An individual may not use an ITIN in lieu of an SSN in this regard. F. Deletion of a Delegated Official For delegated official deletions, documentation verifying that the person no longer is or qualifies as a delegated official is not required. In addition, the delegated official’s signature is unnecessary. G. Delegated Official Not on File If the provider submits a change of information (e.g., change of address) and the delegated official signing the form is not on file, the contractor shall ensure that: (i) The person meets the definition of a delegated official, (ii) The provider completes the Individual Ownership and/or Managing Control section of the Form CMS-855A for that person, and (iii) An authorized official signs off on the addition of the delegated official. (NOTE: The original change request and the addition of the new official constitute a single change request (i.e., one change request encompassing two different actions) for purpose of enrollment processing and reporting)). H. Signature on Paper Application If the provider submits a paper Form CMS-855A change request, the contractor may accept a delegated official’s signature in the Certification Statement or Delegated Official section of the Form CMS-855A. I. Telephone Number The delegated official’s telephone number can be left blank. No further development is needed.