Processing Guide-855O

Disclaimer: The information contained in this guide is to assist providers/suppliers in completing the Form CMS-855O application and MACs in processing Form CMS-855O application. Processing the CMS-855O Medicare Enrollment Application – Enrollment for Eligible Ordering, Certifying Physicians, and Other Eligible Professionals Disclaimer: The information contained in this guide is to assist providers/suppliers in completing the Form CMS-855O application and MACs in processing Form CMS-855O application. Contents General Information ........................................................................................................................................... 3 Section 1: Basic Information ............................................................................................................................... 4 A - Reason for Submitting this Application ..................................................................................................... 5 B - Reason you are Enrolling to Order and Certify .......................................................................................... 5 Section 2: Identifying Information ..................................................................................................................... 6 A – Personal Information ................................................................................................................................ 6 B – Educational Information ........................................................................................................................... 6 C – License/Certification/Registration Information ........................................................................................ 7 Section 3: Final Adverse Legal Action ................................................................................................................ 8 Section 4: Medical Specialty Information ........................................................................................................... 8 A – Physician Specialty .................................................................................................................................... 8 B – Eligible Professional or Other Eligible Professional or Other Non-Physician Type Specialty Type ........... 8 Section 5: Important Address Information ........................................................................................................ 9 Section 6: Contact Person Information .............................................................................................................. 9 Section 7: Penalties for Falsifying Information on this Application ................................................................. 10 Section 8: Certification Statement and Signature ............................................................................................ 10 Page 11 Instructions for CMS-855O Medicare Enrollment Application – Enrollment for Eligible Ordering, Certifying and Prescribing Physicians, and Other Eligible Professionals General Information Most physicians and eligible professionals (as defined in section 1848(K)(3)(B) of the Social Security Act) enroll in the Medicare program to be reimbursed for the covered services they furnish to Medicare beneficiaries. However, with the implementation of Section 6405 of the Affordable Care Act, CMS requires certain physicians and eligible professionals (hereafter referred to as providers) to enroll in the Medicare program for the sole purpose of ordering or certifying items or services for Medicare beneficiaries. These providers do not and will not send claims to a Medicare Administrative MAC (MAC) for the services they furnish. The providers who may enroll in Medicare solely for the purpose of ordering and certifying include those who are: • Doctors of Medicine or Osteopathy • Doctors of Dental Medicine • Doctors of Dental Surgery • Doctors of Podiatric Medicine • Doctors of Optometry • Physician Assistants • Certified Clinical Nurse Specialists • Nurse Practitioners • Clinical Psychologists • Certified Nurse Midwifes • Clinical Social Workers • Licensed Residents (as defined in 42 C.F.R. section 413.75(b)) in an approved medical residency program • Retired Physicians who are licensed These providers can enroll for the sole purpose of ordering or certifying items or services for Medicare beneficiaries by completing the Form CMS-855O via paper or the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) process. To obtain additional information on Internet-based PECOS, refer to http://www.cms.gov/Medicare/Provider- Enrollment-and- Certification/MedicareProviderSupEnroll/InternetbasedPECOS.html. In lieu of Internet-based PECOS, the most current version of the Form CMS-855O (January 2017) shall be completed by the providers. If an outdated version of the application is submitted, the MACs shall return any Form CMS-855O applications submitted on the previous version (01/13) to the provider/supplier with a letter explaining the CMS-855O has been updated and the supplier must submit the current version of the CMS-855O (01/17). To obtain the current version of the form, refer to http://www.cms.gov/MedicareProviderSupEnroll. It is important to observe that providers that complete the Form CMS-855O do not and will not send claims to their MAC for services they furnish. These providers are not given Medicare Page 11 Instructions for CMS-855O Medicare Enrollment Application – Enrollment for Eligible Ordering, Certifying and Prescribing Physicians, and Other Eligible Professionals billing privileges for the purpose of submitting claims to Medicare directly for services that they furnish to beneficiaries. The ordering and certifying effective date is the date the MAC receives the CMS-855O application. NOTE: Only one Form CMS-855O submission is required which will allow the provider to order, certify nationwide. Multiple Form CMS-855O submissions are not required. The provider need not submit a Form CMS-460, a Form CMS-588, or an application fee with his or her Form CMS-855O. Providers shall submit their CMS-855O applications to the MAC that serves there geographic jurisdiction. To find out the MAC that serves your jurisdiction, refer to https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/MedicareProviderSupEnroll/Downloads/contact_list.pdf. However, since the CMS-855O is a national enrollment, providers who relocate to another state are not required to dis-enroll in the current state and re-enroll in the new state. The MAC that maintains the CMS-855O enrollment in the Provider Enrollment Chain and Ownership System (PECOS) is responsible for processing the change of information, even if the provider is relocating to a state outside of their jurisdiction. If any new licenses and/or certifications are obtained as a result of the provider’s relocation, the MACs shall ensure that the updated information is captured in the provider’s enrollment record. Once enrolled, the provider will be listed on a CMS database located at http://Data.cms.gov and will be deemed eligible to order and certify services and items for Medicare beneficiaries. If the provider’s Form CMS-855O has been approved and he/she later wants to obtain Medicare billing privileges, the provider must complete the Form CMS-855I in order to receive Medicare billing privileges. If the provider has an approved Opt Out affidavit and now wants to be ordering/certifying only, the provider will need to notify the MAC they wish to term the Opt Out status, prior to completing the CMS-855O. Please be aware that the Opt Out period must be exhausted prior to enrollment. Section 1: Basic Information All information on the Form CMS-855O is required with the exception of fields specifically marked as “optional”. The following general alternatives are applicable to all sections of the Form CMS-855O, unless otherwise specified: Page 11 Instructions for CMS-855O Medicare Enrollment Application – Enrollment for Eligible Ordering, Certifying and Prescribing Physicians, and Other Eligible Professionals 1. Information Disclosed Elsewhere - If a data element on the supplier’s 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 MAC 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: a. Any final adverse action data requested in section 3 b. Legal names c. Social Security Number (SSN) d. NPI-legacy number combinations in section 2 (if applicable) A - Reason for Submitting this Application This section identifies the reason for the application submission. With the exception of the voluntarily withdrawing checkbox, any blank checkboxes in Section 1 can be verified through any means chosen by the MAC (e.g., e-mail, telephone, fax).  You are enrolling for the sole purpose of ordering/certifying o Provider checks this box if he/she is enrolling for the sole purpose of ordering and certifying items and/or services to beneficiaries in the Medicare program. o All sections of the application must be completed.  You are currently enrolled solely to order and certify and are updating your information o Provider checks this box if he/she is enrolled for the sole purpose of ordering and certifying items and/or services to beneficiaries in the Medicare program but is making a change in their enrollment information. o Section 2A must be completed with the physician or eligible professional’s personal information and all other applicable sections, including section 8.  You are voluntarily withdrawing your Medicare enrollment to solely order and certify o Provider checks this box if he/she no longer wants to be enrolled for the sole purpose of ordering and certifying items and/or services to beneficiaries in the Medicare program. o Section 2A must be completed with the physician or eligible professional’s personal information and all other applicable sections, including section 8. B - Reason you are Enrolling Solely to Order or Certify This section identifies the reason the provider is registering solely to order, certify. Only one reason should be checked. If a reason is not identified, the MAC can verify the information Page 11 Instructions for CMS-855O Medicare Enrollment Application – Enrollment for Eligible Ordering, Certifying and Prescribing Physicians, and Other Eligible Professionals through any means chosen (e.g., e-mail, telephone, fax). Section 2: Identifying Information A – Personal Information The provider must provide all applicable information in this section. The MAC shall verify all of the information on the Form CMS-855O to include:  The name, date of birth and social security number coincides with the information on the individuals Social Security record. This information will be validated against the Social Security Administration (SSA).  The Medicare Identification Number (or PTAN) (if issued) of the provider should be listed in the Medicare Identification Number field. If the provider is submitting an initial enrollment application a PTAN need not be listed; the provider can enter the word “n/a” in this field or leave the field blank since providers who enroll to order and certify will not be assigned a PTAN.  NPI of the provider should be reflected in the National Provider Identifier field; it should match the information provided to the National Plan and Provider Enumeration System (NPPES) and must be a Type 1 NPI. NPPES can be accessed by visiting https://nppes.cms.hhs.gov/NPPES/Welcome.do.  If any of the required information is not supplied, the MAC shall send a development request to the provider/contact person to obtain the missing data except for “Type of Other Name” and “Gender” which can be captured orally.  Reviewing the Medicare Exclusion Database (MED) and System for Award Management (SAM) to ensure that the provider is not excluded or debarred. If, at any time during the verification process, the MAC needs additional or clarifying information from the provider, it shall follow existing CMS instructions for obtaining said data (e.g., sending a developmental letter). The information must be furnished to the MAC within 30 calendar days of the MAC’s request. B – Educational Information The provider must provide their Medical School/Professional School information in this section along with their year of graduation. If the Form CMS-855O 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 already exists in PECOS, no further development is needed by the MAC. If the information is not given, found in the supporting documentation or PECOS, the MAC shall send a development request to the provider/contact person to obtain the missing data. To the maximum extent possible, the MAC may use means other than the provider’s submission of documentation- such as a State or school Web site - to verify the Medical Page 11 Instructions for CMS-855O Medicare Enrollment Application – Enrollment for Eligible Ordering, Certifying and Prescribing Physicians, and Other Eligible Professionals School/Professional School information. C – License/Certification/Registration Information The provider shall complete this section listing their applicable license, certifications and registrations. The MAC shall verify that the provider meets the requirements for his/her supplier type, is licensed and/or certified to furnish services and is of a supplier type that can legally order or certify. 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. When processing a non-physician practitioner’s (NPP) application, the MAC need not automatically request a copy of the NPP’s degree or diploma (if it is not submitted) if his or her 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. If the provider submits a copy of the applicable license, certification, registration or degree but fails to complete the applicable section of Form CMS-855O, the section need not be completed if the data in question can be verified on the license/certification/registration itself or via any of the mechanisms at the MACs disposal. If the MAC is aware that a particular state does not require license/certification and the “Not Applicable” boxes are not checked in Section 2C, no further development is needed. MACs shall process form CMS-855O applications where the provider has relocated to another state. Since the form CMS-855O is a national enrollment, providers who relocate to another state are not required to dis-enroll in the current state and re-enroll in the new state. The MAC that maintains the form CMS-855O enrollment in the Provider Enrollment Chain and Ownership System (PECOS) is responsible for processing the change of information, even if the provider is relocating to a state outside of their jurisdiction. If any new licenses and/or certifications are obtained as a result of the provider’s relocation, the MACs shall ensure that the updated information is captured in the provider’s enrollment record. The provider shall enter their Drug Enforcement Agency (DEA) Registration Information, if applicable. If the DEA fields are not completed at all on the application, meaning no information was entered into this section, MACs shall assume that the DEA information is not applicable and are not required to develop. If the provider partially completed the section, MACs shall obtain the missing information elsewhere on the CMS-855 application, in the supporting documentation, if available, or using the DEA sources available to them; otherwise, the MAC is required to develop. DEA certificates need not be submitted if the applicable DEA information was furnished on the Form CMS-855O application. Similarly, if the aforementioned certificates are furnished but the applicable CMS-855 sections are blank, no further development is needed by the MAC. Section 3: Final Adverse Legal Action This section captures information on final adverse legal actions, such as convictions, exclusions, Page 11 Instructions for CMS-855O Medicare Enrollment Application – Enrollment for Eligible Ordering, Certifying and Prescribing Physicians, and Other Eligible Professionals revocations, and suspensions. The provider shall refer to the instructions in Section 3 for the types of final adverse legal actions that must be reported. All applicable final adverse actions must be reported in this section regardless of whether any records were expunged or any appeals are pending. If a final adverse legal action is disclosed in this section, the provider must furnish documentation concerning the type and date of the action, what court(s) and law enforcement authorities were involved, and how the adverse action was resolved. The documentation must be furnished regardless of whether the adverse action occurred in a state different from that in which the provider seeks enrollment or is enrolled. With the exception of any federal/state felony convictions within the preceding 10 years, identified in Section 3A1, all final adverse actions must be reported regardless of when they occurred. If the final adverse legal action is not reported but uncovered during the screening of the application, the MAC shall follow previous established guidance to address the missing information. Section 4: Medical Specialty Information This section captures the physician, eligible professional or other non-physician type specialty of the provider. Please refer to the General Information section for a list of the providers who are eligible to order and certify items and services to Medicare beneficiaries. A – Physician Specialty The provider shall select their primary specialty in this section. Only one specialty shall be selected. The provider must meet all state requirements for the type of specialty checked. If a physician specialty is not identified, the MAC shall send a development request to the provider/contact person to obtain the missing data. B – Eligible Professional or Other Non-Physician Type Specialty The provider shall select their Eligible Professional or Other Non-Physician Type Specialty in this section. Only one specialty shall be selected. Eligible Professional or Other Non-Physician Type Specialty must meet specific licensing, certification, educational and work experience requirements for the type of specialty selected. If a Eligible Professional or Other Non- Physician Type Specialty is not identified, the MAC shall send a development request to the provider/contact person to obtain the missing data. Section 5: Important Address Information The correspondence address must be one where the MAC can directly contact the applicant to resolve any issues once the provider is enrolled in the Medicare program. 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 or, in the case of an individual practitioner, the person’s home address. The MAC may accept a particular correspondence address if it has no reason to suspect that it does not belong to or is not somehow associated with the provider. If a particular address lacks a city or state, the MAC can Page 11 Instructions for CMS-855O Medicare Enrollment Application – Enrollment for Eligible Ordering, Certifying and Prescribing Physicians, and Other Eligible Professionals verify the missing data in any manner it chooses. In addition, the MAC can obtain the zip + four from either the U.S. Postal Service or address validation functionality in PECOS. The provider may list any telephone number it wishes as the correspondence phone number. The number need not link to the listed correspondence address. The MAC may accept this telephone number if it has no reason to suspect that it does not belong to or is not somehow associated with the provider. If the provider fails to list a correspondence telephone number and it is required for the application submission, the MAC shall develop for this information – preferably via email or fax. The provider may list an email address, however, email is not required. The email address listed on the application can be a generic email address. It need not be that of a specific individual. The MAC may accept a particular email address if it has no reason to suspect that it does not belong to or is not somehow associated with the provider. Section 6: Contact Person Information This section captures information regarding the person who should be contacted regarding this application. Multiple contact persons are allowed to be captured and the provider/contact person may copy this page and include in the Form CMS-855O submission to the MAC. The MAC has the discretion to use the contact persons listed in section 6 of the Form CMS-855O for all written and oral communications (e.g., mail, email, telephone) related to the provider’s Medicare enrollment. Such communication need not be restricted to a particular enrollment application of the provider that the MAC is currently processing. Nor is the MAC required (again, unless either CMS or the provider directs otherwise) to send certain materials to the correspondence mailing or email address rather than the contact person’s mailing or email address. MACs shall validate that the: • Contact person provided his/her first name, middle initial, and last name with any suffixes as well as the address, city/town, state, zip code, telephone and fax number (optional). • Contact person supplied an email address, although this is not required. • Contact Person listed his or her relationship or affiliation to the individual practitioner or clinic/group/organization, although this is not required. • Communications regarding the processing of the Form CMS-855O shall be sent to the contact person listed. If multiple contact persons are listed, the MAC shall contact the first contact person listed on the application. If they are not available, the MAC shall contact the other person(s) listed, unless the provider indicates otherwise via any means. • If no contact person is listed in this section, the MAC shall contact the provider in Section 2 or another contact person on file. The MAC need not develop for the information in this section. • If a contact person is listed, any other missing data (e.g., address, e-mail) can be captured via telephone. This instruction applies only to Section 5. Page 11 Instructions for CMS-855O Medicare Enrollment Application – Enrollment for Eligible Ordering, Certifying and Prescribing Physicians, and Other Eligible Professionals If this section is completely blank, the MAC need not develop for this information and can simply contact the physician or practitioner. Section 7: Penalties for Falsifying Information on this Application This section explains the penalties for deliberately furnishing false information in this application to gain or maintain enrollment in the Medicare program. Section 8: Certification Statement and Signature The provider is the only person who can sign this application. The authority to sign the application on behalf of the provider may not be delegated to any other person. The certification statement contains certain standards that must be met for initial and continuous enrollment in the Medicare program solely to order and certify items and services for Medicare beneficiaries. Note: Exceptions to the above policy may apply in the case of death, an executor of the estate, may sign on behalf of the deceased provider. All signatures must be original and signed in ink (blue ink preferred). Applications with signatures deemed not original will not be processed. Stamped, faxed or copied signatures will not be accepted. A signed certification statement shall accompany the paper Form CMS-855O. If the provider submits an invalid certification statement or fails to submit a certification statement, the MAC shall still proceed with processing the application. An appropriate certification statement shall be solicited as part of the development process. This includes certification statements that are: (a) unsigned; (b) undated; (c) contains a copied or stamped signature; (d) was signed (as reflected by the date of signature) more than 120 days prior to the date on which the MAC received the application); (e) for paper Form CMS-855O submissions, someone other than the physician or non-physician practitioner signed the form, except as noted above; or (f) missing certification statements. The MAC shall send one development request to include a list of all of the missing required data/documentation, including the certification statement. The MAC may reject the provider’s application if the provider fails to furnish the missing information on the enrollment application - including all necessary documentation - within 30 calendar days from the date the MAC requested the missing information or documentation. Unless otherwise stated:  The certification statement may be returned via scanned email, fax or mail to the MAC (as long as an original certification statement signature exist on file).  The MAC is not required to compare the signature thereon with the same provider’s signature on file to ensure that it is the same person. The MAC shall not request the submission of a driver’s license or passport to verify a signature. Page 11 Instructions for CMS-855O Medicare Enrollment Application – Enrollment for Eligible Ordering, Certifying and Prescribing Physicians, and Other Eligible Professionals Note: Web-based application must be accompanied by an e-signature or web certification in order for the MAC to begin processing the application.