Form CMS-855A Processing Alternatives

10.3.1.1.14 – Form CMS-855A Processing Alternatives (Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) The processing alternatives in this section 10.3.1.1.14 are in addition to, and not in lieu of, any other processing alternatives described in this chapter or another CMS directive. These processing alternatives also apply notwithstanding any instruction in this chapter to the contrary. As stated in section 10.3, however, some of the application data elements and verification procedures that have previously been subject to a processing exception/alternative may no longer be so or are moot under PECOS 2.0. (See section 10.3 for a discussion of such data and procedures.) In such situations, the contractor shall disregard the exception/alternative and follow the instructions in sections 10.3 through 10.3.1.1.10. A. General Principle (Subject to the exceptions listed below as well as the instructions in section 10.3, the following principle applies to all Form CMS-855A sections.) If a data element on the provider’s Form CMS-855A application is missing but the information is disclosed (1) elsewhere on the application or (2) in the supporting documentation submitted with the application, the contractor need not obtain the missing data via an updated Form CMS-855A page and a newly-signed certification statement; no further development – not even by telephone – is required. The following information, however, must be furnished in the appropriate section(s) of the Form CMS-855A, even if the data is identified elsewhere on the form or in the supporting documentation: (i) All organizational and individual ownership and managing control information on the Form CMS-855A (ii) Except as otherwise stated in section 10.6.6 of this chapter, any final adverse action data requested in the Final Adverse Legal Actions/Convictions section and the final adverse legal action history for any organization or individual listed in the Ownership Interest and/or Managing Control Information sections of the Form CMS-855A (iii) All legal business names (LBNs) (e.g., provider, chain home office) (NOTE: If an application is submitted with a valid NPI and CCN combination but (1) the LBN field is blank, (2) an incomplete or inaccurate LBN is submitted, or (3) the applicant includes a DBA name in the Practice Location Information section of the Form CMS-855A and the contractor can confirm the correct LBN based on the NPI-CCN combination provided, the contractor need not develop.) (iv) All tax identification numbers (TINs) (e.g., provider, owning organization) (v) NPI-legacy number combinations in the Practice Location Information section of the Form CMS-855A (NOTE: The contractor may use the shared systems, PECOS, or its provider files as a resource to determine the PTAN or NPI before developing with the provider.) (vi) Provider type (vii) The following data in the Change of Ownership (CHOW), Acquisitions/Mergers or Consolidations sections of the Form CMS-855A: • DBA name • Effective dates of sale/transfer/consolidation • Checkbox in the Identifying Information (CHOW Information) section indicating whether buyer will accept assets/liabilities • Names of units with separate legacy numbers/NPIs • All NPIs and legacy numbers (NOTE: The contractor may use the shared systems, PECOS, or its provider files as a resource to determine the CCN or NPI before developing with the provider). B. Supporting Documentation Resubmission If supporting documentation currently exists in the provider’s file, the provider need not submit that documentation again during the enrollment process. The contractor shall utilize the existing documentation for verification. In short, documentation submitted with a previously submitted enrollment application (or documentation currently uploaded in PECOS) qualifies as a processing alternative (unless stated otherwise in this chapter or any CMS directive). C. City, State, and ZIP Code If an address in any section of the Form CMS-855A (e.g., correspondence address, practice location) lacks a city, state, or zip + four, the contractor can verify the missing data in any manner it chooses. In addition, the contractor can obtain the “zip + four” from either the U.S. Postal Service or the Delivery Point Validation in PECOS. D. Licenses In situations where the provider is required to submit a copy of a particular professional or business license, certification, or registration but fails to do so, the contractor need not obtain such documentation from the provider if the contractor can verify the information independently. The contractor can do this by: (1) reviewing and printing confirmation pages from the applicable state web site; (2) requesting and receiving from the appropriate state body written confirmation of the provider’s status therewith; and (3) using any other third-party verification source. In addition, if the provider submits a copy of the applicable license, certification, or registration but fails to complete the appropriate section of the form, the section need not be completed if the data in question can be verified on the license/certification itself or via any of the three mechanisms above. The contractor shall, however, note the following: (i) The above-referenced written confirmation from a state body of the provider’s status can be in the form of a letter, fax, or e-mail, but it must be in writing. Documentation of a verbal conversation between the contractor and the body in question does not qualify as appropriate confirmation. (ii) The aforementioned licensure exception only applies to those documents that traditionally fall within the category of licenses, registrations, or certifications. It is inapplicable to materials such as adverse action documentation, bills of sale, etc. Furthermore, the exception is moot in cases where: (a) the state does not require a particular license/certification; or (b) the license/certification has not been obtained because a state survey has not yet been performed. E. Documentation of Missing Information Elsewhere The contractor shall document in PECOS that the missing information covered under this section 10.3.1.1.14 was found elsewhere in the enrollment package. However, this excludes information that must be verified at the current point in time (i.e., a license without a primary source verification method). F. Relationship to Opt-Out The contractor shall not utilize information submitted with opt-out applications for enrollment application processing or vice-versa.