The contractor shall consult other Medicare manuals for more information on how these providers and suppliers bill Medicare, their conditions of coverage, their conditions of participation, etc.
Provider and supplier specialty codes can be found at Publication 100-04, chapter 26, sections 10.8 through 10.8.3.
Verification of Data/Processing Alternatives
A. Verification - General
1. Means of Verification
Unless stated otherwise in this chapter or in another CMS directive, the contractor shall verify and validate – via the most cost-effective methods available - all information furnished by the provider on or with its application. The general purpose of the verification process is to ensure that all of the data furnished on the Form CMS-855 is accurate.
Examples of verification techniques include, but are not limited to:
• Site visits
• Third-party data validation sources
• State professional licensure and certification Web sites (e.g., medical board sites)
• Federal licensure and certification Web sites (if applicable)
• State business Web sites (e.g., to validate “doing business as” name)
• Yellow Pages (e.g., to verify certain phone numbers)
The list of verification techniques identified in this section 15.7.1.3 is not exhaustive. If the contractor is aware of another means of validation that is as cost-effective and accurate as those listed, it is free to use such means. However, all Social Security Numbers (SSNs) and National Provider Identifiers (NPIs) listed on the application will continue to be verified through PECOS. The contractor shall not request an SSN card to verify an individual’s identity or SSN.
2. Procedures
Unless stated otherwise in this chapter or in another CMS directive, the following principles apply:
(1) A data element is considered “verified” when, after attempting at least one means of validation, the contractor is confident that the data is accurate. (The contractor shall use its best judgment when making this assessment.)
(2) The contractor need only make one verification attempt (i.e., need only use one validation technique) before either:
(a) Requesting clarifying information (as described in sections 15.7.1.4 through 15.7.1.6.2) if the data element cannot be verified. (However, the contractor is encouraged to make a second attempt using a different validation means prior to requesting clarification.)
OR
(b) Concluding that the furnished data is accurate.
3. Concurrent Reviews
If the contractor receives multiple Form CMS-855s for related entities, it can perform concurrent reviews of similar data. For instance, suppose a chain home office submits initial Form CMS-855As for four of its chain providers. The ownership information (sections 5 and 6) and chain home office data (section 7) is the same for all four providers. The contractor need only verify the ownership and home office data once; it need not do it four times – once for each provider. However, the contractor shall document in each provider’s file that a single verification check was made for all four applications.
For purposes of this requirement: (1) there must be an organizational, employment, or other business relationship between the entities, and (2) the applications must have been submitted within a few weeks of each other. As an illustration, assume that Group Practice A submits an initial Form CMS-855B on January 1. Group Practice B submits one on October 1. Section 6 indicates that Joe Smith is a co-owner of both practices, though both entities have many other owners that are not similar. In this case, the contractor must verify Mr. Smith’s data in both January and October. It cannot use the January verification and apply it to Group B’s application because: (1) the applications were submitted nine months apart, and (2) there is no evidence that the entities are related.
4. Contacting Other Contractor
During the verification process, the contractor may need to contact another Medicare contractor for information regarding the provider. The latter contractor shall respond to the former contractor’s request within three business days absent extenuating circumstances.
B. Processing Alternatives
Sections 15.7.1.3.1 through 15.7.1.3.4 outline special processing rules (“processing alternatives”) that are intended to reduce the burden on contractors and providers while simultaneously maintaining the integrity of the enrollment process. These provisions take precedence over all other instructions outlined in this chapter 15.
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