(Identifying Information) - Form CMS-855A

10.3.1.1.2 – Section 2 (Identifying Information) - Form CMS-855A (Rev. 12639; Issued: 05-16-24; Effective: 06-17-24; Implementation: 06-17-24) A. Licenses, Certification, and Accreditation Information The extent to which the provider must furnish licensure, certification, or accreditation information in Section 2 depends upon the provider type involved. Requirements vary by provider type and by location; for instance, some states may require a particular provider to be “certified” but not “licensed,” or vice versa. The only licenses the provider must submit with the application are those required by Medicare or the state to function as the provider type in question. Licenses and permits that are not of a medical nature are not required. If the contractor knows that a particular state does not require licensure/certification and the “Not Applicable” boxes in the Identifying Information section of the Form CMS-855A are not checked, no further development is needed. Regarding accreditation under the Identifying Information section of the Form CMS-855A, if the provider checks “Yes,” the contractor shall ensure that the listed accrediting body is one that CMS recognizes in lieu of a state survey or other certification for the provider type in question. If CMS does not recognize the accrediting body, the contractor shall advise the provider accordingly. (Note, however, that the provider may not intend to use the listed accreditation in lieu of the state survey; it may have merely furnished the accrediting body in response to the question.) Documents that are attainable only after state surveys or accreditation need not be included as part of the application, and the provider need not furnish the data requested in the Identifying Information section of the Form CMS-855A. However, the provider shall furnish those documents it can submit prior to the survey/accreditation. The contractor shall include all submitted licenses, certifications, and accreditations in the enrollment package it sends to the state. (See section 10.3.1.1.14 of this chapter for information about processing alternatives involving licensure submissions.) B. Correspondence Address and Telephone Number The correspondence address must be one at which the contractor can directly contact the provider to resolve any issues once the provider is enrolled in Medicare. It cannot be the address of a billing agency, management services organization, chain home office, or the provider’s representative (e.g., attorney, financial advisor); however, it can be a P.O. Box. The contractor need not verify the correspondence address. The provider may list any telephone number it wishes as the correspondence phone number. The number need not link to the listed correspondence address. If the provider fails to list a correspondence telephone number and it is required for the application submission, the contractor shall develop for this information via the procedures outlined in this chapter (e.g., the PCV for PECOS applications). The contractor shall accept a particular phone number if it has no reason to suspect that it does not belong to or is not somehow associated with the provider. The contractor is not required to verify the telephone number. Unless CMS specifies otherwise, any change in the provider’s phone number or address that the provider did not cause (i.e., area code change, municipality renames the provider’s street) must still be updated via the Form CMS-855A. C. E-mail Addresses Regarding the correspondence e-mail address in the Correspondence Address and Telephone Number Section of the Form CMS-855A, this e-mail address can be a generic one. It need not be that of a specific individual. The contractor may accept a particular e-mail address if it has no reason to suspect that it does not belong to or is not somehow associated with the provider. D. Medical Record Correspondence (MRC) Address This is the address at which MRC (such as medical record review requests) is sent to the provider. In collecting and processing this data, the contractor shall follow the same basic instructions as those concerning the correspondence address outlined in sections 10.3.1.1.2(B) and (C) above (e.g., acceptance of generic e-mail address and telephone number; cannot be billing agency address; etc.). All processing alternatives that apply to correspondence address data also apply to MRC information. E. Other Identifying Information Other than the tax identification number (TIN) and legal business name (LBN), the contractor may capture all information in the Correspondence Address and Telephone Number Section of the Form CMS-855A by telephone, the PCV (if applicable), e-mail, fax, or a review of the provider’s web site.