Form CMS-855O Processing Alternatives and Miscellaneous

10.3.1.5.4 – Form CMS-855O Processing Alternatives and Miscellaneous Policies (Rev. 13355; Issued: 08-13-25; Effective: 05-05-25; Implementation: 05-05-25) A. Processing Alternatives The alternatives in this section 10.3.1.5.4(A) are applicable to all sections of the Form CMS- 855O, unless otherwise specified. 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 10.3.1.5.3. 1. General Alternatives (i) If blank, “Type of Other Name” can be captured orally. (ii) If the contractor knows that a particular state does not require licensure/certification and the “Not Applicable” boxes are not checked in the Personal Identifying Information (License/ Certification/Registration Information) section, no further development is needed. (iii) When processing a non-physician practitioner’s (NPP) application, the contractor need not 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. 2. Information Disclosed Elsewhere If a data element on the Form CMS-855O 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-855O 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-855O, even if the data is identified elsewhere on the form or in the supporting documentation: (i) Except as otherwise stated in section 10.6.6 of this chapter, any final adverse action data requested in the Final Adverse Legal Actions section (ii) Legal names (iii) Tax identification number (TIN) (iv) NPI-legacy number combinations in the Identifying Information section (if applicable) (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 supplier.) (v) Data in the Basic Information section 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. 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 in another CMS directive. Also, the contractor shall document in PECOS that the missing information 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)). In addition, the contractor shall not utilize information submitted along with opt-out applications for enrollment application processing or vice-versa. 3. City, State, and ZIP Code If a particular address lacks a city or state, 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 Delivery Point Validation in PECOS. 4. Sectional Processing Alternatives The processing alternatives in this section 10.3.1.5.4 are in addition to, and not in lieu of, all other processing alternatives in section 10.3.1.5, et seq. B. Unsolicited Additional Information If the supplier submits additional/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 constitutes a separate change request rather than an update to the original change request. The contractor may process both changes simultaneously; however, the change that was submitted first shall be processed to completion prior to the second one being processed to completion. C. Conversion from Form CMS-855O to Form CMS-855I – PECOS Requirements Internet-based PECOS permits an individual supplier to convert a current Form CMS-855O application to a Form CMS-855I enrollment and vice versa. Such suppliers shall follow the current process for creating a new application. When PECOS detects existing approved enrollments, the supplier will be prompted to select from a list of those enrollments that will be used to pre-populate the information for the new application. The supplier must confirm the desire to withdraw the existing enrollments before the new application may be submitted. The enrollments to be withdrawn are displayed in a new section of the ADR in PECOS Administrative Interface (AI). The contractor shall review this information and take the appropriate action to voluntarily withdraw the enrollments listed. The contractor shall begin processing the Form CMS-855I enrollment but leave it in “In Review” status while withdrawing the other enrollments. (For paper applications, a logging and tracking (L&T) submittal reason of Voluntary Termination shall be used to withdraw the Form CMS-855O enrollment.) The effective date of the withdrawn enrollments shall be one day prior to the effective date of the Form CMS-855I enrollment. If the Form CMS-855O enrollment requiring withdrawal is outside of the contractor’s jurisdiction, the contractor shall notify the other contractor via the PCV or email using the “Associate Profile Contact List,” stating that the enrollment needs to be voluntarily withdrawn. The second contractor shall take action based on the email and retain the email as documentation. If the supplier submits a paper Form CMS-855I and a current Form CMS-855O enrollment exists within the contractor jurisdiction, the contractor shall voluntarily withdraw the Form CMS-855O enrollment. If the current Form CMS-855O enrollment is outside of the contractor’s jurisdiction, the contractor shall notify the other contractor via the PCV or e-mail (using the “Associate Profile Contact List”) that the enrollment needs to be voluntary withdrawn. The second contractor shall take action based on the email and retain the email as documentation. If the supplier submits a paper Form CMS-855O to voluntarily withdraw enrollment as well as a paper Form CMS-855I to begin billing Medicare, the contractor shall not contact the supplier to confirm the submissions unless the contractor has reason to believe that what was submitted was not the supplier’s intention. If it is determined that the supplier submitted applications to convert the existing Form CMS-855O enrollment into a Form CMS-855I enrollment in error (either via paper or PECOS), the contractor shall return the application (thus returning the enrollment record back to its previous state) because it is not needed and/or is inapplicable to the situation. D. Form CMS-855O Processing Guide Go to https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only- Manuals-IOMs- Items/CMS019033.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending to view the CMS-855O Processing Guide, which constitutes a general Form CMS-855O processing guide for suppliers and contractors. The procedures described in the Guide, which include processing alternatives and processing instructions for the Form CMS-855O, take precedence over all other instructions in this chapter concerning the processing of Form CMS-855O applications.