(Identifying Information) - Form CMS-855B

10.3.1.2.2 – Section 2 (Identifying Information) - Form CMS-855B (Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) A. License, Certification, and Accreditation Information 1. Background Regarding licensure information in the Identifying Information Section of the Form CMS-855B, the extent to which the applicant must furnish licensure, certification, or accreditation data depends upon the supplier type involved. Requirements will vary by supplier type and by location; for instance, some states may require a particular supplier to be “certified” but not “licensed” (or vice versa). The only licenses that the supplier must submit with the application are those that Medicare and/or the state requires to function as the supplier type in question. Licenses and permits not of a medical nature are not required. In some instances, licensure may not be required in a particular state at all, though the contractor in this case shall still ensure that the supplier meets all applicable state and Medicare requirements. If the contractor knows that a particular state does not require licensure/certification and the “Not Applicable” boxes are not checked in the Identifying Information Section of the Form CMS- 855B, no further development is needed. 2. Jurisdictions and Practice Locations Except as otherwise stated in this chapter or in another CMS directive, the contractor shall verify that the supplier is licensed and/or certified to furnish services in: (i) The state where the supplier is enrolling; and (ii) Any other state within the contractor’s jurisdiction in which the supplier (per the “Practice Location Information” section of the Form CMS-855B) will maintain a practice location 3. Permissible Independent Verification In situations where the supplier 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 supplier 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 supplier’s status therewith; and (3) using any other third-party verification source. In addition, if the supplier 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 supplier’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, paramedic intercept agreements, 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. 4. Additional Policies a. License Reinstatement - If the applicant had a previously revoked or suspended license reinstated (and unless CMS states otherwise in this chapter or elsewhere), the applicant must submit a copy of the reinstatement notice with the application. b. License expiration/revocation dates for non-certified suppliers - For expired licenses, the contractor shall enter into PECOS the date after the expiration as the expiration date. For revoked and suspended licenses, the contractor shall enter into PECOS the revocation date (not the day after) as the expiration date. B. Clinical Laboratory Improvement Act (CLIA) and Drug Enforcement Agency (DEA) CLIA and DEA certificates are not required. If the applicable CLIA and DEA certificates are not furnished or the applicable Form CMS-855B sections are blank, no further development is needed. See section 10.6.19 et seq. of this chapter for special instructions regarding periodic license reviews. C. Supplier Identification Information – Business Information Unless otherwise stated in this chapter or in another CMS directive, the contractor may capture all information in the Identifying Information Section (with the exception of the TIN and LBN) by telephone, fax, e-mail, the PCV, or a review of the supplier’s web site. D. Physical Therapy/Occupational Therapy Groups A PT/OT group must complete the questionnaire in the Identifying Information Section for PT/OT groups. In doing so: (i) If the group indicates that it renders services in patients’ homes, the contractor shall verify that the group has an established private practice where it can be contacted directly and where it maintains patients' records. (ii) If the group answers “yes” to question 2, 3, 4, or 5, the contractor shall request a copy of the lease agreement giving the group exclusive use of the facilities for PT/OT services only if it has reason to question the accuracy of the group’s response. If the contractor makes this request and the supplier cannot furnish a copy of the lease, the contractor shall deny the application. E. State Surveys Documents that can only be obtained after state surveys or accreditation need not be included as part of the application. (This typically occurs with ASCs and portable x-ray suppliers.) The supplier must, however, furnish those documents that can be submitted prior to the survey/accreditation. The contractor shall include any licenses, certifications, and accreditations submitted by suppliers in the enrollment package that is forwarded to the state. Once the contractor receives the approval recommendation notice from the state, the contractor is encouraged (but not required) to contact the state or the supplier for the applicable licensing and/or certification data and to enter it into PECOS. F. Notarization If the applicant submits a license that is not notarized or "certified true," the contractor shall verify the license with the appropriate state agency. (A notarized copy of an original document has a stamp that says "official seal," along with the name of the notary public, the state, the county, and the date the notary's commission expires. A certified "true copy" of an original document has a raised seal that identifies the state and county in which it originated or is stored.) G. Correspondence Address and Telephone Number The correspondence address in the Correspondence Address and Telephone Number Section of the Form CMS-855B must be one at which the contractor can directly contact the applicant to resolve any issues once the supplier 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). It can, however, be a P.O. Box. The contractor need not verify the correspondence address. The supplier may list any telephone number it wishes as the correspondence phone number. The number need not link to the listed correspondence address. If the supplier fails to list a correspondence telephone number and it is required for the application submission, the contractor shall develop for this information – preferably via the PCV, e-mail, or fax. 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 supplier. The contractor is not required to verify the telephone number. H. E-mail Addresses An e-mail address listed on the application can be a generic e-mail address. 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 supplier.