Additional Processing Information and Alternatives – Form CMS-

10.3.1.3.7 - Additional Processing Information and Alternatives – Form CMS- 855I (Rev. 13355; Issued: 08-13-25; Effective: 05-05-25; Implementation: 05-05-25) A. Processing a Form CMS-855I Ownership Change of Information Application When a sole owner practitioner has sold the practitioner’s group to another individual practitioner and the EIN remains unchanged, the contractor shall process the transaction as a change of information via the Form CMS-855I to change the group’s owner. In doing so, the contractor shall: (i) Verify that the EIN is solely owned by the new owner. (ii) Make no change to the PTAN or effective date. (iii) If applicable, require the prior sole owner individual to submit a voluntary termination application to terminate the person’s individual enrollment/reassignment. B. Unsolicited Additional Information If the supplier submits missing/clarifying data or documentation on its own volition (i.e., without being contacted by the contractor), the contractor shall include this additional data/documentation in its overall application review. Any new or changed information that a supplier submits prior to the date the contractor finishes processing a previously submitted change request shall be processed as a separate change request rather than an update to the original change request. The contractor may process both changes simultaneously, but the change that was submitted first shall be processed to completion prior to the second one being processed to completion. C. Processing Alternatives As stated in section 10.3, 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 section 10.3 and sections 10.3.1.3 through 10.3.1.3.6. 1. Information Disclosed Elsewhere If a data element on the supplier’s Form CMS-855I 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-855I 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-855I, even if the data is identified elsewhere on the form or in the supporting documentation: a. Except as otherwise stated in section 10.6.6 of this chapter, any final adverse action data requested in sections 3, 4A, and 6B of the Form CMS-855I b Legal business names (LBN) or legal names (Note: If an application is submitted with a valid NPI-PTAN 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 Business Information section of the Form CMS-855I --- and the contractor can confirm the correct LBN based on the NPI-PTAN combination provided, the contractor need not develop. (This also applies to the Employer’s Name for PAs in the Personal Identifying Information (PA Information) section of the Form CMS-855I).) c. Tax identification numbers (TIN) d. NPI-legacy number combinations in the Business Information section of the Form CMS-855I. (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 supplier.) e. Practitioner type in the Personal Identifying Information section of the Form CMS-855I If the supporting documentation currently exists in the supplier’s file, the supplier need not submit that documentation again during the enrollment process. The contractor shall utilize the existing documentation for verification. Unless stated otherwise in this chapter or another CMS directive, documentation submitted with a previously submitted enrollment application (or documentation currently uploaded in PECOS) qualifies as a processing alternative. Also, the contractor shall document in PECOS that the missing information was found elsewhere in the enrollment package. (This excludes information that must be verified at the current point in time (i.e., a license without a primary source verification method).) In addition, the contractor shall not utilize information submitted along with opt-out applications for enrollment application processing or vice-versa. 2. Licenses If the supplier is required to submit a copy of a particular professional or business license, certification, registration, or degree but fails to do so, the contractor need not obtain such documentation from the supplier if the contractor can verify the information independently. This can be done by: (1) reviewing and printing confirming pages from the applicable state, professional, or school web site; (2) requesting and receiving from the appropriate state, professional, or educational body written confirmation of the supplier’s status therewith; or (3) utilizing another third-party verification source. Similarly, if the supplier submits a copy of the applicable license, certification, registration, or degree but fails to complete the applicable 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 described above. (The above-referenced written confirmation 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.) This exception only applies to documents that traditionally fall within the category of licenses, registrations, certifications, or degrees. It is inapplicable to items such as adverse action documentation, etc. Furthermore, the exception is moot in cases where the state does not require a particular license/certification. 3. Drug Enforcement Agency Certificates (DEA) DEA certificates are not required. If the applicable DEA certificate is not furnished or the applicable Form CMS-855I section is blank, no further development is needed. 4. City, State, and ZIP Code If an address (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. 5. Inapplicable Questions The supplier need not check “no” for questions that obviously do not apply to its supplier type. For instance, a nurse practitioner need not complete the Personal Identifying Information (Resident Information) section of the Form CMS-855I. 6. Additional Alternatives (i) If blank, the “Type of Other Name” can be captured orally. (ii) If the contractor is aware that a particular state does not require licensure/certification and the “Not Applicable” boxes are not checked in the Personal Identifying Information section, no further development is needed. (iii) Personal Identifying Information (Physician Specialty) section - If the supplier uses a checkmark, an “X,” or other symbol to identify the primary and secondary specialties (as opposed to a “P” or “S”), no additional development is needed. (iv) When processing a non-physician practitioner’s (NPP) application, the contractor need not automatically request a copy of the NPP’s degree or diploma (if it is not submitted) if education can be verified through other authorized means. Requesting a copy of the degree or diploma should only be done if educational information cannot otherwise be verified. (v) Medical or Professional School and Year of Graduation – If the Form CMS-855I lacks the medical or professional school and/or the year of graduation but the information is disclosed in the supporting documentation submitted with the application or it already exists in PECOS, no further development is needed.