If you have not submitted a Medicare enrollment application in a while, you are likely to notice some changes in the information you are required to provide. Effective July 1, 2011, the Centers for Medicare and Medicaid Services (CMS) released newly revamped versions of the Medicare enrollment applications on Forms CMS-855A, 855B, 855R and 855I. In addition, CMS added a new form—the CMS-855O—for ordering and referring physicians and nonphysician practitioners (NPPs) who need to obtain a Medicare number for limited purposes.
The changes were issued as a follow-up to a final rule published by CMS on February 2, 2011 (at 76 FR 5862), pursuant to which CMS implemented various provisions of The Patient Protection and Affordable Care Act (PPACA). The final rule addresses a number of topics, including new heightened screening procedures for providers and suppliers in the Medicare and Medicaid programs and Children’s Health Insurance Program (CHIP).
The purpose of the CMS-855 Medicare enrollment application forms is to gather information from each provider and supplier that tells CMS who the individual/entity is, whether it meets the qualifications to be a Medicare participating provider or supplier, where it provides services, who its owners and other key people are (officers, directors and managing employees) and other information necessary to establish correct claims payments. Many of the changes to the CMS-855 applications expand on the “who” component by asking for more detailed information on the identity of the applicant, its qualifications to provide certain services and the identity of its owners and key people.
Some of the notable changes on the Form CMS-855 application forms include the following (this list is not exhaustive):
- A check box was added in Section 2A that will identify whether a hospital has physician-owners. If yes, a new six-page Attachment 1 has been added to capture very detailed information on the organizations and individuals who have direct or indirect ownership or control interests in physician-owned hospitals. These changes were implemented in response to the new restrictions made to the Stark Law’s exception for physician ownership in hospitals enacted under the PPACA.
- In Section 2B, providers now have to indicate their year-end cost report date. Sections 5 and 6 of the Form, which report five percent or greater direct and indirect organizational and individual owners, as well as directors/officers and managing employees, have been completely revamped, including a new requirement that the provider report the exact percentage of all five percent or greater direct and indirect ownership interests and the effective date on which the ownership interests were acquired.
- The revised CMS-855A now explicitly requires disclosure of any entity whose mortgage or other security interest in the provider is equal to five percent or more of the total property and assets of the provider. This includes investment funds, holding companies, banks and financial institutions, and charitable and religious organizations. In addition, the provider must submit an organizational diagram identifying all of the owning or controlling entities and their relationship to each other and the provider.
- Sections 5 and 6 now also require the provider identify any contractual services (including management and billing services) furnished by the provider’s owners and managing organizations/employees.
In addition, institutional providers are now required to pay an application fee in connection with initial Medicare applications, revalidations and the addition of practice locations. The application fee for 2011 is $505, which is subject to an annual cost of living adjustment. Institutions may submit a hardship exception request at the time of filing to request an exception from this fee.
- In Section 2, ambulatory surgical facilities now have to provide information regarding their accreditation.
- Also in Section 2, CMS now requests accreditation information for all groups and organizations that provide advanced diagnostic imaging services, including CT, MRI, nuclear medicine and PET.
- In Section 6, individual owners, directors/officers, authorized officials and managing employees must now report their titles, place (state) of birth and effective date of ownership or control.
- In Section 2A, physicians and NPPs are now asked whether they will accept new Medicare patients. This information will be published in the “Medicare Physician and Healthcare Provider Directory.”
- For those practitioners that bill for advanced diagnostic imaging services (CT, MRI, nuclear medicine and PET), information on accreditation for these modalities is now required.
- In Section 6, managing employees must now report their titles, place (state) of birth and effective date of managing control.
- Suppliers that are terminating a reassignment must now list a contact person for the application in Section 7 of the form. This is intended to reduce the time it takes to process the termination.
ALL legal entities (e.g., corporations, LLCs, partnerships, etc.) enrolling as providers and suppliers are now required to submit the following supporting documents regardless of which CMS-855 enrollment application is submitted:
- Written confirmation from the IRS of the entity’s Tax Identification Number (TIN).
- If applicable, written confirmation from the IRS confirming that a limited liability company (LLC) is automatically classified as a Disregarded Entity (e.g., Form 8832).
- If a nonprofit organization, copy of the IRS determination letter evidencing 501(c)(3) status.
CMS has also added a statement to the CMS-855A, 855B and 855I application forms that the Medicare Administrative Contractor may request additional supporting documents not otherwise listed in the application forms to ensure compliance with enrollment requirements.
In addition to the updates on the 855A, 855B, 855R and 855I enrollment applications, CMS has added a new form called the “CMS-855O.” This form is to be used by ordering and referring physicians and NPPs who need a Medicare number in order to populate the ordering and referring data field on the CMS-1500 claims submission form. This form was added to allow a physician or NPP the opportunity to obtain a Medicare identification number (without being approved for billing privileges) for the sole purpose of ordering and referring Medicare beneficiaries to Medicare-approved providers and suppliers.
Providers and suppliers should be aware that in order to maintain Medicare billing privileges, a provider or supplier (other than a DMEPOS supplier) must resubmit and recertify the accuracy of its Medicare enrollment information every five years. This process has become known as “revalidation.” CMS or the local Medicare Administrative Contractor will contact the provider/supplier when it is due for revalidation. The provider/supplier then has 60 days to complete the required enrollment application and provide all required supporting documentation.
CMS announced in a recent Medicare Learning Network article (available at http://www.cms.gov/MLNMattersArticles/Downloads/SE1126.pdf) that all provider/suppliers enrolled prior to March 25, 2011, must be revalidated between now and March 23, 2013. Failure to submit the requested enrollment form within the 60-day timeframe may result in the deactivation of the provider/supplier’s Medicare billing privileges.
The Medicare enrollment process has become increasingly complicated. Completing the forms themselves is more and more difficult. Failure to complete the enrollment forms correctly or within the required timeframes can result in the loss of Medicare billing privileges, which can be devastating for any provider/supplier. Providers and suppliers are encouraged to seek the assistance of an attorney or other individual who is experienced with the Medicare enrollment process when submitting any Medicare enrollment materials.