Physicians
As described in § 1861(r)(1) of the Social Security Act and in 42 CFR § 410.20(b), a physician must be legally authorized to practice medicine by the state in which he/she performs such services in order to enroll in the Medicare program and to retain Medicare billing privileges. Such individuals include:
1. Doctors of:
• Medicine or osteopathy
• Dental surgery or dental medicine
• Podiatric medicine
• Optometry
2. A chiropractor who meets the qualifications specified in 42 CFR § 410.22.
Refer to Pub. 100-04, Medicare Claims Processing Manual, Chapter 19, section 40.1.2 for special licensure rules regarding practitioners who work in or reassign benefits to hospitals or freestanding ambulatory care clinics operated by the Indian Health Service or by an Indian tribe or tribal organization.
Delegated Officials
(Unless indicated otherwise below or in another CMS directive, the instructions in this section apply to (1) signatures on the paper Form CMS-855, (2) signatures on the certification statement for Internet-based Provider Enrollment, Chain and Ownership System (PECOS) applications, and (3) electronic signatures. (NOTE: This section only applies to the Form CMS-855A and the Form CMS-855B.))
A delegated official is an individual to whom an authorized official listed in section 15 of the Form CMS-855 delegates the authority to report changes and updates to the provider’s enrollment record or to sign revalidation applications. The delegated official must be an individual with an “ownership or control interest” in (as that term is defined in §1124(a)(3) of the Social Security Act), or be a W-2 managing employee of the provider.
Section 1124(a)(3) defines an individual with an ownership or control interest as:
• A five percent direct or indirect owner of the provider,
• An officer or director of the provider (if the provider is a corporation), or
• Someone with a partnership interest in the provider, if the provider is a partnership
The delegated official must be a delegated official of the provider, not of an owning organization, parent company, chain home office, or management company. One cannot use his/her status as a W-2 managing employee of the provider’s parent company, management company, or chain home office as a basis for his/her role as the provider’s delegated official.
The contractor shall note the following about delegated officials:
1. Authority - A delegated official has no authority to sign an initial application. However, the delegated official may (i) sign a revalidation application and (ii) sign off on changes/updates submitted in response to a contractor’s request to clarify or submit information needed to continue processing the provider's initial application.
2. Section 6 – Section 6 of the Form CMS-855 must be completed for all delegated officials.
3. Managing Employees - For purposes of section 16 only, the term "managing employee" means any individual, including a general manager, business manager, or administrator, who exercises operational or managerial control over the provider, or who conducts the day-to-day operations of the provider. However, this does not include persons who, either under contract or through some other arrangement, manage the day-to-day operations of the provider but who are not actual W-2 employees. For instance, suppose the provider hires Joe Smith as an independent contractor to run its day-to-day-operations. Under the definition of "managing employee" in section 6 of the Form CMS-855, Smith would have to be listed in that section. Yet under the section 16 definition (as described above), Smith cannot be a delegated official because he is not an actual W-2 employee of the provider. Independent contractors are not considered "managing employees" under section 16 of
the Form CMS-855.
4. W-2 Form – Unless the contractor requests it to do so, the provider is not required to submit a copy of the owning/managing individual’s W-2 to verify an employment relationship.
5. Number of Delegated Officials - The provider can have as many delegated officials as it chooses. Conversely, the provider is not required to have any delegated officials. Should no delegated officials be listed, the authorized official(s) remains the only individual(s) who can report changes and/or updates to the provider's enrollment data.
6. Effective Date - The effective date in PECOS for section 16 of the Form CMS-855 should be the date of signature.
7. Social Security Number - To be a delegated official, the person must have and must submit his/her social security number. An Individual Taxpayer Identification Number (ITIN) cannot be used in lieu of an SSN in this regard.
8. Deletion - If a delegated official is being deleted, documentation verifying that the person no longer is or qualifies as a delegated official is not required. Also, the signature of the deleted official is not needed.
9. Further Delegation - Delegated officials may not delegate their authority to any other individual. Only an authorized official may delegate the authority to make changes and/or updates to the provider's Medicare data or to sign revalidation applications.
10. Delegated Official Not on File - If the provider submits a change of information (e.g., change of address) and the delegated official signing the form is not on file, the contractor shall ensure that (1) the person meets the definition of a delegated official, (2) section 6 of the Form CMS-855 is completed for that person, and (3) an existing authorized official signs off on the addition of the delegated official. (NOTE: The original change request and the addition of the new official shall be treated as a single change request (i.e., one change request encompassing two different actions) for purpose of enrollment processing and reporting.)
11. Signature on Paper Application - If the provider submits a paper Form CMS-855 change request,
the contractor may accept the signature of a delegated official in Section 15 or 16 of the Form CMS-855.
12. Certification Statement Development – When the contractor develops for missing or additional information and the provider must submit a newly-signed certification statement, only the actual signature page is required; the additional page containing the certification terms need not be submitted unless the contractor requests it. This does not apply, however, to the provider’s initial submission of a certification statement for a particular application; such instances require the submission of both the signature page and the page containing the certification terms. To illustrate, suppose the provider submits an initial CMS-855 application with an undated certification statement.
The provider must furnish a newly-dated (and signed) certification statement and the certification terms page; it does so on March 1. On March 15, the contractor determines that information on section 4 of the provider’s application is incorrect and must be revised. When submitting the revised section 4 page, the provider need only furnish a newly-signed signature page; the certification terms page need not be submitted unless the contractor requests it.
As described in § 1861(r)(1) of the Social Security Act and in 42 CFR § 410.20(b), a physician must be legally authorized to practice medicine by the state in which he/she performs such services in order to enroll in the Medicare program and to retain Medicare billing privileges. Such individuals include:
1. Doctors of:
• Medicine or osteopathy
• Dental surgery or dental medicine
• Podiatric medicine
• Optometry
2. A chiropractor who meets the qualifications specified in 42 CFR § 410.22.
Refer to Pub. 100-04, Medicare Claims Processing Manual, Chapter 19, section 40.1.2 for special licensure rules regarding practitioners who work in or reassign benefits to hospitals or freestanding ambulatory care clinics operated by the Indian Health Service or by an Indian tribe or tribal organization.
Delegated Officials
(Unless indicated otherwise below or in another CMS directive, the instructions in this section apply to (1) signatures on the paper Form CMS-855, (2) signatures on the certification statement for Internet-based Provider Enrollment, Chain and Ownership System (PECOS) applications, and (3) electronic signatures. (NOTE: This section only applies to the Form CMS-855A and the Form CMS-855B.))
A delegated official is an individual to whom an authorized official listed in section 15 of the Form CMS-855 delegates the authority to report changes and updates to the provider’s enrollment record or to sign revalidation applications. The delegated official must be an individual with an “ownership or control interest” in (as that term is defined in §1124(a)(3) of the Social Security Act), or be a W-2 managing employee of the provider.
Section 1124(a)(3) defines an individual with an ownership or control interest as:
• A five percent direct or indirect owner of the provider,
• An officer or director of the provider (if the provider is a corporation), or
• Someone with a partnership interest in the provider, if the provider is a partnership
The delegated official must be a delegated official of the provider, not of an owning organization, parent company, chain home office, or management company. One cannot use his/her status as a W-2 managing employee of the provider’s parent company, management company, or chain home office as a basis for his/her role as the provider’s delegated official.
The contractor shall note the following about delegated officials:
1. Authority - A delegated official has no authority to sign an initial application. However, the delegated official may (i) sign a revalidation application and (ii) sign off on changes/updates submitted in response to a contractor’s request to clarify or submit information needed to continue processing the provider's initial application.
2. Section 6 – Section 6 of the Form CMS-855 must be completed for all delegated officials.
3. Managing Employees - For purposes of section 16 only, the term "managing employee" means any individual, including a general manager, business manager, or administrator, who exercises operational or managerial control over the provider, or who conducts the day-to-day operations of the provider. However, this does not include persons who, either under contract or through some other arrangement, manage the day-to-day operations of the provider but who are not actual W-2 employees. For instance, suppose the provider hires Joe Smith as an independent contractor to run its day-to-day-operations. Under the definition of "managing employee" in section 6 of the Form CMS-855, Smith would have to be listed in that section. Yet under the section 16 definition (as described above), Smith cannot be a delegated official because he is not an actual W-2 employee of the provider. Independent contractors are not considered "managing employees" under section 16 of
the Form CMS-855.
4. W-2 Form – Unless the contractor requests it to do so, the provider is not required to submit a copy of the owning/managing individual’s W-2 to verify an employment relationship.
5. Number of Delegated Officials - The provider can have as many delegated officials as it chooses. Conversely, the provider is not required to have any delegated officials. Should no delegated officials be listed, the authorized official(s) remains the only individual(s) who can report changes and/or updates to the provider's enrollment data.
6. Effective Date - The effective date in PECOS for section 16 of the Form CMS-855 should be the date of signature.
7. Social Security Number - To be a delegated official, the person must have and must submit his/her social security number. An Individual Taxpayer Identification Number (ITIN) cannot be used in lieu of an SSN in this regard.
8. Deletion - If a delegated official is being deleted, documentation verifying that the person no longer is or qualifies as a delegated official is not required. Also, the signature of the deleted official is not needed.
9. Further Delegation - Delegated officials may not delegate their authority to any other individual. Only an authorized official may delegate the authority to make changes and/or updates to the provider's Medicare data or to sign revalidation applications.
10. Delegated Official Not on File - If the provider submits a change of information (e.g., change of address) and the delegated official signing the form is not on file, the contractor shall ensure that (1) the person meets the definition of a delegated official, (2) section 6 of the Form CMS-855 is completed for that person, and (3) an existing authorized official signs off on the addition of the delegated official. (NOTE: The original change request and the addition of the new official shall be treated as a single change request (i.e., one change request encompassing two different actions) for purpose of enrollment processing and reporting.)
11. Signature on Paper Application - If the provider submits a paper Form CMS-855 change request,
the contractor may accept the signature of a delegated official in Section 15 or 16 of the Form CMS-855.
12. Certification Statement Development – When the contractor develops for missing or additional information and the provider must submit a newly-signed certification statement, only the actual signature page is required; the additional page containing the certification terms need not be submitted unless the contractor requests it. This does not apply, however, to the provider’s initial submission of a certification statement for a particular application; such instances require the submission of both the signature page and the page containing the certification terms. To illustrate, suppose the provider submits an initial CMS-855 application with an undated certification statement.
The provider must furnish a newly-dated (and signed) certification statement and the certification terms page; it does so on March 1. On March 15, the contractor determines that information on section 4 of the provider’s application is incorrect and must be revised. When submitting the revised section 4 page, the provider need only furnish a newly-signed signature page; the certification terms page need not be submitted unless the contractor requests it.
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