Basic Information (Section 1 of the Form CMS-855)
Unless otherwise stated in this chapter or in another CMS directive, the provider may only check one reason for submittal. Suppose a supplier is changing its tax identification number via the Form CMS-855B. The supplier must submit two applications: (1) an initial Form CMS-855B as a new supplier, and (2) a Form CMS-855B voluntary termination. Both transactions cannot be reported on the same application.
A provider shall enroll as an initial applicant if it is:
• Seeking to reestablish itself in the Medicare program after reinstatement from an exclusion or debarment or after the expiration of a reenrollment bar, or
• A hospital requesting enrollment via the Form CMS-855B to bill for practitioner services for hospital departments, outpatient locations and/or hospital clinics.
Final Adverse Actions
Unless stated otherwise, the instructions in this section 15.5.3 apply to the following sections of the Form CMS-855:
• Section 3
• Section 4A of the CMS-855I
• Section 5
• Section 6
A. Disclosure of Final Adverse Action
If a final adverse action is disclosed on the Form CMS-855, 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.
In addition:
1. Reinstatements
- If the person or entity in question was excluded or debarred but has since been reinstated, the contractor shall confirm the reinstatement through the OIG or, in the case of debarment, through the federal agency that took the action. It shall also ensure that the provider submits written proof of the reinstatement (e.g., reinstatement letter).
2. Revocation Reversals – Medicare revocations that were reversed on appeal need not be reported on the Form CMS-855.
3. Scope of Disclosure – All final adverse actions that occurred under the LBN and TIN of the disclosing entity (e.g., applicant; section 5 owner) must be reported. This includes Medicare revocations that: (1) were initiated by a different Medicare contractor in another contractor jurisdiction, and (2) involve a different provider or supplier type. Consider the following examples:
Example (a) - Smith Pharmacy, Inc. had 22 separately enrolled locations in 2009. Each location was under Smith’s LBN and TIN. In 2010, two locations were revoked, leaving 20 locations. Smith submits a Form CMS-855S application for a new location on Jones Street. The two revocations in 2010 must be reported on the Jones Street application. Suppose, however, that each of Smith’s locations had its own LBN and TIN. The Jones Street application need not disclose the two revocations from 2010.
Example (b) - An HHA, hospice, and hospital are enrolling under Corporation X’s LBN and TIN. X is listed as the provider in section 2 of each applicant’s Form CMS-855A. All three successfully enroll. Six months later, Company X’s billing privileges for the HHA are revoked. Both the hospice and the hospital must report the revocation via a Form CMS-855A change request because the revocation occurred under the provider’s LBN and TIN. Assume now that X seeks to enroll an ASC under X’s LBN and TIN. The HHA revocation would have to be reported in section 3 of the ASC’s initial Form CMS-855B.
Example (c) – Company Y is listed as the provider/supplier for two HHAs and two suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). These four providers/suppliers are under Y’s LBN and TIN. Each provider/supplier is located in a different State.
All are enrolled. Y’s billing privileges for one of the DMEPOS suppliers are revoked. Y now seeks to enroll an ASC in a fifth State. Y must disclose the DMEPOS revocation on the ASC’s initial Form CMS-855, even though the revocation: (1) was done by a Medicare contractor other than that with which the ASC seeks enrollment, and (2) occurred in a state different from that in which the ASC is located.
Example (d) – Company Alpha is listed as an owner in section 5 of the Form CMS-855A. Alpha operates two health care providers – Y and Z - under its LBN and TIN. Y was subject to a General Services Administration debarment, which ended in 2009. The debarment would have to be reported in section 5, since it occurred under Z’s LBN and TIN.
4. Timeframe – With the exception of the felony convictions identified in #1 under “Convictions” in section 3 of the Form CMS-855, all final adverse actions must be reported regardless of when they occurred.
5. Corporate Integrity Agreements (CIAs) – CIAs need not be disclosed on the Form CMS-855.
6. Evidence to Indicate Adverse Action – There may be instances where the provider or supplier states in section 3, 4A of the Form CMS-855I, 5, and/or 6 that the person or entity has never had a final adverse action imposed against him/her/it, but the contractor finds evidence to indicate otherwise. In such cases, the contractor shall contact its CMS Provider Enrollment Business Function Lead (PEBFL) for guidance.
B. Prior Approval
If a current exclusion or debarment is disclosed on the Form CMS-855, the contractor shall deny the application in accordance with the instructions in this chapter; prior approval from CMS Central Office’s provider enrollment unit (COPEU) is unnecessary. If any other final adverse action is listed, the contractor shall refer the matter to its PEBFL for review. When referring the action to its PEBFL (which shall be done via e-mail or fax), the contractor shall include the following information: (1) provider/supplier name and NPI; (2) version of the Form CMS-855 involved; (3) reason for provider/supplier’s submission of the application; (4) a summary of the adverse legal facts; and (5) whether the provider/supplier has previously disclosed this or any other final adverse action.
(If the contractor learns via any means other than the submission of a Form CMS-855 (e.g., from law enforcement, notice from another contractor) that an enrolled provider or supplier has had any final adverse action (regardless of type) imposed against it, the contractor shall refer the matter to its PEBFL for guidance.)
C. Review of PECOS
If the contractor denies an application or revokes a provider based on a final adverse action, the contactor shall search PECOS (or, if the provider is not in PECOS, the contractor’s internal system) to determine:
• Whether the person/entity with the adverse action has any other associations (e.g., is listed in PECOS as an owner of three Medicare-enrolled providers), or
• If the denial/revocation resulted from an adverse action imposed against an owner, managing employee, director, etc., of the provider, whether the person/entity in question has any other associations (e.g., a managing employee of the provider is identified as an owner of two other Medicare-enrolled HHAs).
If such an association is found and, per 42 CFR § 424.535, there are grounds for revoking the billing privileges of the other provider, the contractor shall initiate revocation proceedings with respect to the latter.
If the “other provider” is enrolled with a different contractor, the contractor shall notify the latter - via fax or e-mail – of the situation, at which time the latter shall take the revocation action. To illustrate, suppose John Smith attempted to enroll with Contractor X as a physician. Smith is currently listed as an owner of Jones Group Practice, which is enrolled with Contractor Y. Contractor X discovers that Smith was recently convicted of a felony. X therefore denies Smith’s application. X must also notify Y of the felony conviction; Y shall then revoke Jones’ billing privileges per 42 CFR § 424.535(a)(3).
D. Chain Home Offices, Billing Agencies, and HHA Nursing Registries
If the contractor discovers that an entity listed in section 7, 8, or 12 of the Form CMS-855 has had a final adverse action imposed against it, the contractor shall contact its PEBFL for guidance.
E. System for Award Management (SAM)
When an entity or individual is listed as debarred in the SAM (formerly, the General Services Administration Excluded Parties List System), the SAM record may identify associated entities and persons that are also debarred. To illustrate, suppose John Smith is identified as debarred. The SAM record may also list individuals and entities associated with John Smith that are debarred as well, such as “John Smith Company,” “Smith Consulting,” “Jane Smith,” and “Joe Smith.”
If the contractor learns via the Form CMS-855 verification process, a Zone Program Integrity Contractor (ZPIC) referral, or other similar means that a particular person or entity is debarred, the contractor shall search the person/entity in the SAM to see if the SAM record discloses any associated parties that are debarred. If associated parties are listed, the contractor – after verifying, via the instructions in this chapter, that the associated party is indeed debarred – shall check PECOS to determine whether the party is listed in any capacity. If the party is listed, the contractor shall take all applicable steps outlined in this chapter with respect to revocation proceedings against the party and against any persons/entities with whom the party is associated. For instance, using our example above, if the contractor confirms that Jane Smith is debarred and PECOS shows Jane Smith as an owner of Entity X, the contractor shall, as applicable, initiate revocation proceedings against X.
Unless otherwise stated in this chapter or in another CMS directive, the provider may only check one reason for submittal. Suppose a supplier is changing its tax identification number via the Form CMS-855B. The supplier must submit two applications: (1) an initial Form CMS-855B as a new supplier, and (2) a Form CMS-855B voluntary termination. Both transactions cannot be reported on the same application.
A provider shall enroll as an initial applicant if it is:
• Seeking to reestablish itself in the Medicare program after reinstatement from an exclusion or debarment or after the expiration of a reenrollment bar, or
• A hospital requesting enrollment via the Form CMS-855B to bill for practitioner services for hospital departments, outpatient locations and/or hospital clinics.
Final Adverse Actions
Unless stated otherwise, the instructions in this section 15.5.3 apply to the following sections of the Form CMS-855:
• Section 3
• Section 4A of the CMS-855I
• Section 5
• Section 6
A. Disclosure of Final Adverse Action
If a final adverse action is disclosed on the Form CMS-855, 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.
In addition:
1. Reinstatements
- If the person or entity in question was excluded or debarred but has since been reinstated, the contractor shall confirm the reinstatement through the OIG or, in the case of debarment, through the federal agency that took the action. It shall also ensure that the provider submits written proof of the reinstatement (e.g., reinstatement letter).
2. Revocation Reversals – Medicare revocations that were reversed on appeal need not be reported on the Form CMS-855.
3. Scope of Disclosure – All final adverse actions that occurred under the LBN and TIN of the disclosing entity (e.g., applicant; section 5 owner) must be reported. This includes Medicare revocations that: (1) were initiated by a different Medicare contractor in another contractor jurisdiction, and (2) involve a different provider or supplier type. Consider the following examples:
Example (a) - Smith Pharmacy, Inc. had 22 separately enrolled locations in 2009. Each location was under Smith’s LBN and TIN. In 2010, two locations were revoked, leaving 20 locations. Smith submits a Form CMS-855S application for a new location on Jones Street. The two revocations in 2010 must be reported on the Jones Street application. Suppose, however, that each of Smith’s locations had its own LBN and TIN. The Jones Street application need not disclose the two revocations from 2010.
Example (b) - An HHA, hospice, and hospital are enrolling under Corporation X’s LBN and TIN. X is listed as the provider in section 2 of each applicant’s Form CMS-855A. All three successfully enroll. Six months later, Company X’s billing privileges for the HHA are revoked. Both the hospice and the hospital must report the revocation via a Form CMS-855A change request because the revocation occurred under the provider’s LBN and TIN. Assume now that X seeks to enroll an ASC under X’s LBN and TIN. The HHA revocation would have to be reported in section 3 of the ASC’s initial Form CMS-855B.
Example (c) – Company Y is listed as the provider/supplier for two HHAs and two suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). These four providers/suppliers are under Y’s LBN and TIN. Each provider/supplier is located in a different State.
All are enrolled. Y’s billing privileges for one of the DMEPOS suppliers are revoked. Y now seeks to enroll an ASC in a fifth State. Y must disclose the DMEPOS revocation on the ASC’s initial Form CMS-855, even though the revocation: (1) was done by a Medicare contractor other than that with which the ASC seeks enrollment, and (2) occurred in a state different from that in which the ASC is located.
Example (d) – Company Alpha is listed as an owner in section 5 of the Form CMS-855A. Alpha operates two health care providers – Y and Z - under its LBN and TIN. Y was subject to a General Services Administration debarment, which ended in 2009. The debarment would have to be reported in section 5, since it occurred under Z’s LBN and TIN.
4. Timeframe – With the exception of the felony convictions identified in #1 under “Convictions” in section 3 of the Form CMS-855, all final adverse actions must be reported regardless of when they occurred.
5. Corporate Integrity Agreements (CIAs) – CIAs need not be disclosed on the Form CMS-855.
6. Evidence to Indicate Adverse Action – There may be instances where the provider or supplier states in section 3, 4A of the Form CMS-855I, 5, and/or 6 that the person or entity has never had a final adverse action imposed against him/her/it, but the contractor finds evidence to indicate otherwise. In such cases, the contractor shall contact its CMS Provider Enrollment Business Function Lead (PEBFL) for guidance.
B. Prior Approval
If a current exclusion or debarment is disclosed on the Form CMS-855, the contractor shall deny the application in accordance with the instructions in this chapter; prior approval from CMS Central Office’s provider enrollment unit (COPEU) is unnecessary. If any other final adverse action is listed, the contractor shall refer the matter to its PEBFL for review. When referring the action to its PEBFL (which shall be done via e-mail or fax), the contractor shall include the following information: (1) provider/supplier name and NPI; (2) version of the Form CMS-855 involved; (3) reason for provider/supplier’s submission of the application; (4) a summary of the adverse legal facts; and (5) whether the provider/supplier has previously disclosed this or any other final adverse action.
(If the contractor learns via any means other than the submission of a Form CMS-855 (e.g., from law enforcement, notice from another contractor) that an enrolled provider or supplier has had any final adverse action (regardless of type) imposed against it, the contractor shall refer the matter to its PEBFL for guidance.)
C. Review of PECOS
If the contractor denies an application or revokes a provider based on a final adverse action, the contactor shall search PECOS (or, if the provider is not in PECOS, the contractor’s internal system) to determine:
• Whether the person/entity with the adverse action has any other associations (e.g., is listed in PECOS as an owner of three Medicare-enrolled providers), or
• If the denial/revocation resulted from an adverse action imposed against an owner, managing employee, director, etc., of the provider, whether the person/entity in question has any other associations (e.g., a managing employee of the provider is identified as an owner of two other Medicare-enrolled HHAs).
If such an association is found and, per 42 CFR § 424.535, there are grounds for revoking the billing privileges of the other provider, the contractor shall initiate revocation proceedings with respect to the latter.
If the “other provider” is enrolled with a different contractor, the contractor shall notify the latter - via fax or e-mail – of the situation, at which time the latter shall take the revocation action. To illustrate, suppose John Smith attempted to enroll with Contractor X as a physician. Smith is currently listed as an owner of Jones Group Practice, which is enrolled with Contractor Y. Contractor X discovers that Smith was recently convicted of a felony. X therefore denies Smith’s application. X must also notify Y of the felony conviction; Y shall then revoke Jones’ billing privileges per 42 CFR § 424.535(a)(3).
D. Chain Home Offices, Billing Agencies, and HHA Nursing Registries
If the contractor discovers that an entity listed in section 7, 8, or 12 of the Form CMS-855 has had a final adverse action imposed against it, the contractor shall contact its PEBFL for guidance.
E. System for Award Management (SAM)
When an entity or individual is listed as debarred in the SAM (formerly, the General Services Administration Excluded Parties List System), the SAM record may identify associated entities and persons that are also debarred. To illustrate, suppose John Smith is identified as debarred. The SAM record may also list individuals and entities associated with John Smith that are debarred as well, such as “John Smith Company,” “Smith Consulting,” “Jane Smith,” and “Joe Smith.”
If the contractor learns via the Form CMS-855 verification process, a Zone Program Integrity Contractor (ZPIC) referral, or other similar means that a particular person or entity is debarred, the contractor shall search the person/entity in the SAM to see if the SAM record discloses any associated parties that are debarred. If associated parties are listed, the contractor – after verifying, via the instructions in this chapter, that the associated party is indeed debarred – shall check PECOS to determine whether the party is listed in any capacity. If the party is listed, the contractor shall take all applicable steps outlined in this chapter with respect to revocation proceedings against the party and against any persons/entities with whom the party is associated. For instance, using our example above, if the contractor confirms that Jane Smith is debarred and PECOS shows Jane Smith as an owner of Entity X, the contractor shall, as applicable, initiate revocation proceedings against X.
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