(Personal Identifying Information) – Form CMS-855I

10.3.1.3.2 - Section 2 (Personal Identifying Information) – Form CMS-855I (Rev. 13355; Issued: 08-13-25; Effective: 05-05-25; Implementation: 05-05-25) A. Licensure Information 1. General Instructions (The extent to which the applicant must complete the licensure information depends upon the supplier type involved. Requirements will vary by supplier type and by location; for instance, some states may require a particular supplier type to be “certified” but not “licensed,” or vice versa. (The license and certification “Not Applicable” checkboxes are for instances where a state does not require licensure).) The only licenses that must be submitted with the application are those required by Medicare or the state to function as the supplier type in question. Licenses and permits that are not of a medical nature are not required. In addition, and as mentioned above, instances can occur where the supplier need not be licensed at all in a particular state; the contractor shall still ensure, however, that the supplier meets all applicable state and Medicare requirements. The contractor shall verify that the supplier is licensed and/or certified to furnish services in: • The state in which the supplier is enrolling. • Any other state within the contractor’s jurisdiction in which the supplier (per the “Practice Location Information” section of the Form CMS-855I) will maintain a practice location. The contractor shall also ensure that the individual answers “Yes” or “No” to the Section 2(B)(1) question regarding compact licenses if individual indicates that the individual is licensed. (See subsection (A)(6) below for more information on compact licenses.) 2. 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 states "official seal," along with the name of the notary public, the state, the county, and the expiration date of the notary's commission. 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.) 3. Temporary Licenses If the supplier submits a temporary license, the contractor shall note the expiration date in PECOS. Should the supplier fail to submit the permanent license after the temporary license expiration date, the contractor shall initiate revocation procedures. (A temporary permit – one in which the applicant is not yet fully licensed and must complete a specified number of hours of practice to obtain the license – is not acceptable.) 4. Revoked/Suspended Licenses If the applicant had a previously revoked or suspended license reinstated, the applicant must submit a copy of the reinstatement notice with the application. 5. License Expiration/Revocation Dates for Non-Certified Suppliers For expired licenses, the contractor shall enter in PECOS the day after the expiration as the expiration date. For revoked and suspended licenses, the contractor shall enter in PECOS the revocation date (not the day after) as the expiration date. (See section 10.6.19(T) of this chapter for special instructions related to periodic license reviews.) 6. Interstate License Compacts A new trend in medicine has arisen involving interstate license compacts. While physician compacts streamline the licensure process for physicians who want to practice in multiple states, a separate license from each state in which the physician intends to practice is still issued (if all requirements are met). CMS will continue to rely on the license issued by the state medical board to help confirm compliance with federal requirements. In a similar vein, certain non-physician practitioner (NPP) compacts allow the NPP to work in a compact member state (other than the individual’s home state) without going through the normal process for licensure in the remote state. NPPs working under the authorization of such a compact must meet both the licensure requirements outlined in the primary state of residence and those established by the compact laws adopted by the legislatures of the interstate compact states. At present, there are interstate compacts involving physicians, physical therapists, occupational therapists, speech language pathologists, and psychologists (though none for nurse practitioners). More are possible. Licenses obtained through an interstate license compact for the above supplier types shall be treated as valid, full licenses for the purposes of meeting federal requirements. The contractor shall thus accept Form CMS-855I applications from applicants reporting a license obtained via an interstate license compact. In addition, the contractor shall attempt to verify the interstate license obtained through the compact using the state licensing board website(s) or compact website (if one exists); if neither technique can confirm the interstate license, the contractor shall request documentation from the supplier that validates said data. B. Correspondence Address, Medical Record Correspondence Address, and Telephone Number 1. Correspondence Address The correspondence address must be one where 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, or the supplier’s representative (e.g., attorney, financial advisor). It can, however, be a P.O. Box or, in the case of an individual practitioner, the person’s home address. The contractor need not verify the correspondence address. 2. Medical Records Correspondence Address The medical records correspondence address must be one where the contractor can directly contact the applicant regarding medical records once the supplier is enrolled in Medicare. It cannot be the address of a billing agency, management services organization, or the supplier’s representative (e.g., attorney, financial advisor). It can, however, be a P.O. Box or, in the case of an individual practitioner, the person’s home address. Note that: (1) the contractor need not verify the medical records correspondence address; and (2) the medical records correspondence address does not apply to individuals reassigning all benefits. 3. Telephone Number The supplier may list any telephone number as the correspondence or medical record correspondence phone number. The number need not link to the listed correspondence address. If the supplier fails to list a correspondence or medical record 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 need not verify the telephone number. C. 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. D. Specialties A physician must indicate the supplier specialty via a checkmark, an “X,” or other symbol; if the physician has more than one specialty, these specialties must be indicated, showing "P" for primary and "S" for secondary. (Non-physician practitioners must indicate their supplier type.) The contractor shall verify that any supplier identifying a secondary specialty on the Form CMS- 855I application has the appropriate medical license. The contractor shall validate the license using the state’s medical license website. If an active license is not found, the contractor shall develop via telephone, fax, email, or mail to confirm the supplier’s intent and to obtain a copy of the license, if applicable. The contractor shall deny the application if the individual fails to meet the requirements of the physician specialty (primary and/or secondary) or supplier type. Notwithstanding the foregoing instructions in this subsection (D), if a Form CMS-855I enrollment application is submitted to report a primary or secondary specialty change, the contractor shall not contact the physician, practitioner, or contact person directly to confirm either the change itself or the individual’s intent to change specialty. E. Education 1. Non-Physician Practitioners - The contractor shall verify all required educational information for non-physician practitioners. While the non-physician practitioner must meet all federal and state requirements, the individual need not provide documentation of courses or degrees taken to satisfy these requirements unless the contractor requests it. To the maximum extent possible, the contractor shall use means other than the practitioner’s submission of documentation---such as a state or school web site---to validate the person’s educational qualifications. 2. Physicians - A physician need not submit a copy of the degree unless the contractor requests it. To the maximum extent possible, the contractor shall use means other than the physician’s submission of documentation---such as a state or school web site--to validate the person’s educational status. F. Relocation to a New State: License Reviews When a practitioner submits a Form CMS-855I application to either (1) add a practice location in a new state or (2) relocate to a new state entirely, the contractor that received the application shall review state licensing board information for the “prior” state to determine: • Whether the practitioner had a medical license revoked, suspended, or inactive (due to retirement, death, or voluntary surrender of license), or otherwise lost a license, and • If the practitioner has indeed lost a medical license, whether this was reported via the Form CMS-855I within the timeframe specified in 42 CFR § 424.520. If the practitioner is currently enrolled and did not report the adverse action to Medicare in a timely manner, the contractor shall---unless another directive in this chapter instructs otherwise, such as section 10.6.6----revoke the practitioner’s Medicare enrollment and establish the appropriate reenrollment bar length. If the practitioner is submitting an initial enrollment application (e.g., is moving to a new state and contractor jurisdiction) and did not report the adverse action in Section 3 of the CMS-855I, the contractor shall--- unless another directive in this chapter instructs otherwise---- deny the enrollment application.