If the contractor determines that a provider is having claim payment issues due solely to an incorrect NPI-Provider Transaction Access Number (PTAN) combination or NPI-CMS Certification Number (CCN) combination entered into the Provider Enrollment, Chain and Ownership System (PECOS), the contractor shall request that the provider submit the correct NPI-legacy combination via a Form CMS-855 change of information. The change request can be faxed, although the contractor shall verify the faxed signature against the provider’s or authorized official’s signature on file before any changes are made in PECOS.
The contractor shall not use this process to resolve any enrollment issue other than the correction of the NPI-legacy identifier combination. Moreover, the contractor shall not use this process for providers that have not submitted a complete Form CMS-855 enrollment application during or after May 2006. For instance, assume a provider first enrolled in Medicare in December 2005 and has not submitted a complete enrollment application after that date. The provider would be unable to utilize the process described in this section.
Processing Alternatives – Form CMS-855B and Form CMS-855I
A. General Processing Alternatives
The following general alternatives are applicable to all sections of the Form CMS-855B and the CMS-855I, unless otherwise specified:
1. Information Disclosed Elsewhere - If a data element on the supplier’s Form CMS-855 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-855 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-855, even if the data is identified elsewhere on the form or in the supporting documentation:
a. Any final adverse action data requested in sections 3, 4A (Form CMS-855I only), 5B (Form CMS-855B only), and 6B of the Form CMS-855
b. Legal business names (LBN) or legal names
c. Tax identification numbers (TIN)
d. NPI-legacy number combinations in Section 4 of the Form CMS-855
e. Supplier/practitioner type (section 2A of the Form CMS-855B and section 2D of the Form CMS-855I)
Data available on a previously submitted CMS-855 enrollment application, or information currently in PECOS, does not qualify as a processing alternative. In addition, per section 15.7.3 of this chapter, the contractor shall document in the provider file that the missing information was found elsewhere in the enrollment package.
2. Licenses
In situations where 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 provider if the contractor can verify the information independently. This may 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 provider 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 those documents that traditionally fall within the category of licenses, registrations, certifications, or degrees. It does not apply to items such as adverse action documentation, paramedic intercept services documents, etc. Furthermore, the exception is moot in cases where: (1) a particular license/certification is not required by the state, or (2) the license/certification has not been obtained because a state survey has not yet been performed (i.e., for certified suppliers).
3. City, State, and ZIP Code - If an address (e.g., correspondence address, practice location) 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 Finalist in PECOS.
4. 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 check “no” to question 1(a) in Section 2C of the Form CMS-855I.
5. Clinical Laboratory Improvement Act (CLIA) and Drug Enforcement Agency (DEA) - CLIA and
DEA certificates need not be submitted if the applicable CLIA and DEA information was furnished on the Form CMS-855. Likewise, if the aforementioned certificates are furnished but the applicable Form CMS-855 sections are blank, no further development is needed.
6. Practice Locations - Each practice location is to be verified. However, there is no need to separately contact each location on the application. Such verification can be done via the contact person listed on the application; the contact person’s verification shall be documented in the provider file pursuant to section 15.7.3 of this chapter.
B. Sectional Processing Alternatives
The processing alternatives in this subsection B are in addition to, and not in lieu of, those in subsection A.
The contractor shall not use this process to resolve any enrollment issue other than the correction of the NPI-legacy identifier combination. Moreover, the contractor shall not use this process for providers that have not submitted a complete Form CMS-855 enrollment application during or after May 2006. For instance, assume a provider first enrolled in Medicare in December 2005 and has not submitted a complete enrollment application after that date. The provider would be unable to utilize the process described in this section.
Processing Alternatives – Form CMS-855B and Form CMS-855I
A. General Processing Alternatives
The following general alternatives are applicable to all sections of the Form CMS-855B and the CMS-855I, unless otherwise specified:
1. Information Disclosed Elsewhere - If a data element on the supplier’s Form CMS-855 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-855 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-855, even if the data is identified elsewhere on the form or in the supporting documentation:
a. Any final adverse action data requested in sections 3, 4A (Form CMS-855I only), 5B (Form CMS-855B only), and 6B of the Form CMS-855
b. Legal business names (LBN) or legal names
c. Tax identification numbers (TIN)
d. NPI-legacy number combinations in Section 4 of the Form CMS-855
e. Supplier/practitioner type (section 2A of the Form CMS-855B and section 2D of the Form CMS-855I)
Data available on a previously submitted CMS-855 enrollment application, or information currently in PECOS, does not qualify as a processing alternative. In addition, per section 15.7.3 of this chapter, the contractor shall document in the provider file that the missing information was found elsewhere in the enrollment package.
2. Licenses
In situations where 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 provider if the contractor can verify the information independently. This may 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 provider 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 those documents that traditionally fall within the category of licenses, registrations, certifications, or degrees. It does not apply to items such as adverse action documentation, paramedic intercept services documents, etc. Furthermore, the exception is moot in cases where: (1) a particular license/certification is not required by the state, or (2) the license/certification has not been obtained because a state survey has not yet been performed (i.e., for certified suppliers).
3. City, State, and ZIP Code - If an address (e.g., correspondence address, practice location) 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 Finalist in PECOS.
4. 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 check “no” to question 1(a) in Section 2C of the Form CMS-855I.
5. Clinical Laboratory Improvement Act (CLIA) and Drug Enforcement Agency (DEA) - CLIA and
DEA certificates need not be submitted if the applicable CLIA and DEA information was furnished on the Form CMS-855. Likewise, if the aforementioned certificates are furnished but the applicable Form CMS-855 sections are blank, no further development is needed.
6. Practice Locations - Each practice location is to be verified. However, there is no need to separately contact each location on the application. Such verification can be done via the contact person listed on the application; the contact person’s verification shall be documented in the provider file pursuant to section 15.7.3 of this chapter.
B. Sectional Processing Alternatives
The processing alternatives in this subsection B are in addition to, and not in lieu of, those in subsection A.
No comments:
Post a Comment