Identifying Information (Section 2 of the Form CMS-855)
Unless specifically indicated otherwise, the instructions in sections 15.5.1 through 15.5.2.3 below apply to the Form CMS-855A, the Form CMS-855B, and the Form CMS-855I.
The instructions in section 15.5.2.4 apply only to the Form CMS-855A; the instructions in section 15.5.2.5 apply only to the Form CMS-855B; and the instructions in section 15.5.2.6 only apply to the Form CMS-855I.
Section 2 of the Form CMS-855B
Any supplier that indicates it is an OT/PT group must complete the questionnaire in section 2J. In doing so:
• If the group indicates that it renders services in patients’ homes, the contractor shall verify that the group has an established private practice where it can be contacted directly and where it maintains patients' records.
• If the group answers “yes” to question 2, 3, 4, or 5, the contractor shall request a copy of the lease agreement giving the group exclusive use of the facilities for PT/OT services only if it has reason to question the accuracy of the group’s response. If the contractor makes this request and the provider cannot furnish a copy of the lease, the contractor shall deny the application.
Section 2 of the Form CMS-855I
A. Specialties
On the CMS-855I, the physician must indicate his/her supplier specialties, showing "P" for primary and "S" for secondary. Non-physician practitioners must indicate their supplier type.
The contractor shall deny the application if the individual fails to meet the requirements of his/her physician specialty or supplier type.
B. Education for Non-Physician Practitioners
The contractor shall verify all required educational information for non-physician practitioners. While the non-physician practitioner must meet all Federal and State requirements, he/she need not provide documentation of courses or degrees taken to satisfy these requirements unless specifically requested to do so by the contractor. To the maximum extent possible, the contractor shall use means other than the practitioner’s submission of documentation- such as a State or school Web site - to validate the person’s educational qualifications.
A physician need not submit a copy of his/her degree unless specifically requested to do so by the contractor. To the maximum extent possible, the contractor shall use means other than the physician’s submission of documentation- such as a State or school Web site - to validate the person’s educational status.
C. Resident/Intern Status
If the applicant is a "resident" in an "approved medical residency program" (as these two terms are defined at 42 CFR §413.75(b)), the contractor shall refer to Pub. 100-02, chapter 15, section 30.3 for further instructions. (The contractor may also want to refer to 42 CFR §415.200, which states that services furnished by residents in approved programs are not "physician services.”)
The physician should indicate the exact date that its residency program, internship, or fellowship was completed, so that the appropriate effective date can be issued.
An intern cannot enroll in the Medicare program. (For purposes of this requirement, the term “intern” means an individual who is not licensed by the State because he/she is still in post-graduate year (PGY) 1.) Also, an individual in a residency or fellowship program cannot be reimbursed for services performed as part of that program.
D. Physician Assistants
As stated in the instructions on page 3 of the CMS-855I, physician assistants (PAs) who are enrolling in Medicare need only complete sections 1, 2, 3, 13, 15, and 17 of the CMS- 855I. The physician assistant must furnish his/her NPI in section 1 of the application, and must list his/her employers in section 2E.
The contractor must verify that the employers listed are: (1) enrolled in Medicare, and (2) not excluded or debarred from the Medicare program. (An employer can only receive payment for a PA’s services if both are enrolled in Medicare.) All employers must also have an established record in PECOS. If an employer is excluded or debarred, the contractor shall deny the application.
Since PAs cannot reassign their benefits – even though they are reimbursed through their employer – they should not complete a CMS-855R.
E. Psychologists Billing Independently
The contractor shall ensure that all persons who check “Psychologist Billing Independently” in section 2D2 of the CMS-855I answer all questions in section 2I. If the supplier answers “no” to question 1, 2, 3, 4a, or 4b, the contractor shall deny the application.
F. Occupational/Physical Therapist in Private Practice (OT/PT)
All OT/PTs in private practice must respond to the questions in section 2J of the CMS-855I. If the OT/PT plans to provide his/her services as: (1) a member of an established OT/PT group, (2) an employee of a physician-directed group, or (3) an employee of a non-professional corporation, and that person wishes to reassign his/her benefits to that group, this section does not apply. Such information will be captured on the group’s CMS-855B application.
If the OT/PT checks that he/she renders all of his/her services in patients' homes, the contractor shall verify that he/she has an established private practice where he/she can be contacted directly and where he/she maintains patient records. (This can be the person’s home address, though all Medicare rules and instructions regarding the maintenance of patient records apply.) In addition, section 4D of the CMS-855I should indicate where services are rendered (e.g., county, State, city of the patients' homes). Post office boxes are not acceptable.
If the individual answers “yes” to question 2, 3, 4, or 5, the contractor shall request a copy of the lease agreement giving him/her exclusive use of the facilities for PT/OT services only if it has reason to question the accuracy of his/her response. If the contractor makes this request and the provider cannot furnish a copy of the lease, the contractor shall deny the application.
Unless specifically indicated otherwise, the instructions in sections 15.5.1 through 15.5.2.3 below apply to the Form CMS-855A, the Form CMS-855B, and the Form CMS-855I.
The instructions in section 15.5.2.4 apply only to the Form CMS-855A; the instructions in section 15.5.2.5 apply only to the Form CMS-855B; and the instructions in section 15.5.2.6 only apply to the Form CMS-855I.
Section 2 of the Form CMS-855B
Any supplier that indicates it is an OT/PT group must complete the questionnaire in section 2J. In doing so:
• If the group indicates that it renders services in patients’ homes, the contractor shall verify that the group has an established private practice where it can be contacted directly and where it maintains patients' records.
• If the group answers “yes” to question 2, 3, 4, or 5, the contractor shall request a copy of the lease agreement giving the group exclusive use of the facilities for PT/OT services only if it has reason to question the accuracy of the group’s response. If the contractor makes this request and the provider cannot furnish a copy of the lease, the contractor shall deny the application.
Section 2 of the Form CMS-855I
A. Specialties
On the CMS-855I, the physician must indicate his/her supplier specialties, showing "P" for primary and "S" for secondary. Non-physician practitioners must indicate their supplier type.
The contractor shall deny the application if the individual fails to meet the requirements of his/her physician specialty or supplier type.
B. Education for Non-Physician Practitioners
The contractor shall verify all required educational information for non-physician practitioners. While the non-physician practitioner must meet all Federal and State requirements, he/she need not provide documentation of courses or degrees taken to satisfy these requirements unless specifically requested to do so by the contractor. To the maximum extent possible, the contractor shall use means other than the practitioner’s submission of documentation- such as a State or school Web site - to validate the person’s educational qualifications.
A physician need not submit a copy of his/her degree unless specifically requested to do so by the contractor. To the maximum extent possible, the contractor shall use means other than the physician’s submission of documentation- such as a State or school Web site - to validate the person’s educational status.
C. Resident/Intern Status
If the applicant is a "resident" in an "approved medical residency program" (as these two terms are defined at 42 CFR §413.75(b)), the contractor shall refer to Pub. 100-02, chapter 15, section 30.3 for further instructions. (The contractor may also want to refer to 42 CFR §415.200, which states that services furnished by residents in approved programs are not "physician services.”)
The physician should indicate the exact date that its residency program, internship, or fellowship was completed, so that the appropriate effective date can be issued.
An intern cannot enroll in the Medicare program. (For purposes of this requirement, the term “intern” means an individual who is not licensed by the State because he/she is still in post-graduate year (PGY) 1.) Also, an individual in a residency or fellowship program cannot be reimbursed for services performed as part of that program.
D. Physician Assistants
As stated in the instructions on page 3 of the CMS-855I, physician assistants (PAs) who are enrolling in Medicare need only complete sections 1, 2, 3, 13, 15, and 17 of the CMS- 855I. The physician assistant must furnish his/her NPI in section 1 of the application, and must list his/her employers in section 2E.
The contractor must verify that the employers listed are: (1) enrolled in Medicare, and (2) not excluded or debarred from the Medicare program. (An employer can only receive payment for a PA’s services if both are enrolled in Medicare.) All employers must also have an established record in PECOS. If an employer is excluded or debarred, the contractor shall deny the application.
Since PAs cannot reassign their benefits – even though they are reimbursed through their employer – they should not complete a CMS-855R.
E. Psychologists Billing Independently
The contractor shall ensure that all persons who check “Psychologist Billing Independently” in section 2D2 of the CMS-855I answer all questions in section 2I. If the supplier answers “no” to question 1, 2, 3, 4a, or 4b, the contractor shall deny the application.
F. Occupational/Physical Therapist in Private Practice (OT/PT)
All OT/PTs in private practice must respond to the questions in section 2J of the CMS-855I. If the OT/PT plans to provide his/her services as: (1) a member of an established OT/PT group, (2) an employee of a physician-directed group, or (3) an employee of a non-professional corporation, and that person wishes to reassign his/her benefits to that group, this section does not apply. Such information will be captured on the group’s CMS-855B application.
If the OT/PT checks that he/she renders all of his/her services in patients' homes, the contractor shall verify that he/she has an established private practice where he/she can be contacted directly and where he/she maintains patient records. (This can be the person’s home address, though all Medicare rules and instructions regarding the maintenance of patient records apply.) In addition, section 4D of the CMS-855I should indicate where services are rendered (e.g., county, State, city of the patients' homes). Post office boxes are not acceptable.
If the individual answers “yes” to question 2, 3, 4, or 5, the contractor shall request a copy of the lease agreement giving him/her exclusive use of the facilities for PT/OT services only if it has reason to question the accuracy of his/her response. If the contractor makes this request and the provider cannot furnish a copy of the lease, the contractor shall deny the application.
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