Independent Diagnostic Testing Facility (IDTF) Standards

Independent Diagnostic Testing Facility (IDTF) Standards 

A. IDTF Standards 
Consistent with 42 CFR §410.33(g), each IDTF must certify on its Form CMS-855B enrollment application that it meets the following standards and all other requirements:

1. Operates its business in compliance with all applicable Federal and State licensure and regulatory requirements for the health and safety of patients.

• The purpose of this standard is to ensure that suppliers are licensed in the business and specialties being provided to Medicare beneficiaries. Licenses are required by State and/or Federal agencies to make certain that guidelines and regulations are being followed and to ensure that businesses are furnishing quality services to Medicare beneficiaries.

• The responsibility for determining what licenses are required to operate a supplier’s business is the sole responsibility of the supplier. The contractor is not responsible for notifying any supplier of what licenses are required or that any changes have occurred in the licensure requirements. No exemptions to applicable State licensing requirements are permitted, except when granted by the State.

• The contractor shall not grant billing privileges to any business not appropriately licensed as required by the appropriate State or Federal agency. If a supplier is found providing services for which it is not properly licensed, billing privileges may be revoked and appropriate recoupment actions taken.

2. Provides complete and accurate information on its enrollment application. Changes in ownership, changes of location, changes in general supervision, and final adverse actions must be reported to the contractor within 30 calendar days of the change. All other changes to the enrollment application must be reported within 90 days.

NOTE: This 30-day requirement takes precedence over the certification in section 15 of the Form CMS-855B whereby the supplier agrees to notify Medicare of any changes to its enrollment data within 90 days of the effective date of the change. By signing the certification statement, the IDTF agrees to abide by all Medicare rules for its supplier type, including the 30-day rule in 42 CFR §410.33(g)(2).

3. Maintain a physical facility on an appropriate site. (For purposes of this standard, a post office box, commercial mailbox, hotel, or motel is not an appropriate site. The physical facility, including mobile units, must contain space for equipment appropriate to the services designated on the enrollment application, facilities for hand washing, adequate patient privacy accommodations, and the storage of both business records and current medical records within the office setting of the IDTF, or IDTF home office, not within the actual mobile unit.)

• IDTF suppliers that provide services remotely and do not see beneficiaries at their practice location are exempt from providing hand washing and adequate patient privacy accommodations.

• The requirements in 42 CFR §410.33(g)(3) take precedence over the guidelines in sections 15.5.4 and 15.5.4.2 of this chapter pertaining to the supplier’s practice location requirements.

• The physical location must have an address, including the suite identifier, which is recognized by the United States Postal Service (USPS).

4. Has all applicable diagnostic testing equipment available at the physical site excluding portable diagnostic testing equipment. The IDTF must—
(i) Maintain a catalog of portable diagnostic equipment, including diagnostic testing equipment serial numbers, at the physical site;
(ii) Make portable diagnostic testing equipment available for inspection within 2 business days of a CMS inspection request; and
(iii) Maintain a current inventory of the diagnostic testing equipment, including serial and registration numbers, and provide this information to the designated fee-for- service contractor upon request, and notify the contractor of any changes in equipment within 90 days.

5. Maintain a primary business phone under the name of the designated business. The IDTF must have its--
(i) Primary business phone located at the designated site of the business or within the home office of the mobile IDTF units.
(ii) Telephone or toll free telephone numbers available in a local directory and through directory assistance.

The requirements in 42 CFR §410.33(g)(5) take precedence over the guidelines in sections 15.5.4 and 15.5.4.2 of this chapter regarding the supplier’s telephone requirements.
IDTFs may not use “call forwarding” or an answering service as their primary method of receiving calls from beneficiaries during posted operating hours.

6. Have a comprehensive liability insurance policy of at least $300,000 per location that covers both the place of business and all customers and employees of the IDTF. The policy must be carried by a non-relative-owned company. Failure to maintain required insurance at all times will result in revocation of the IDTF’s billing privileges retroactive to the date the insurance lapsed. IDTF

Accreditation / Section 2 of the Form CMS-855A

Accreditation

If the provider checks “Yes,” the contractor shall ensure that the listed accrediting body is one that CMS recognizes in lieu of a State survey or other certification for the provider type in question. If the accrediting body is not recognized by CMS, the contractor shall advise the provider accordingly. (Note, however, that the provider may not intend to use the listed accreditation in lieu of the State survey and merely furnished the accrediting body in response to the question.)

Section 2 of the Form CMS-855A

A. Home Health Agency (HHA) Branches, Hospital Units, and Outpatient Physical Therapy/Outpatient Speech Pathology (OPT/OSP) Extension Sites

As explained in section 15.4.1.6, a branch is a location or site from which an HHA provides services within a portion of the total geographic area that the parent company serves. The branch is part of the HHA and is located sufficiently close to the parent agency such that it shares administration, supervision, and services with the parent. If an existing HHA wants to add a branch, it is considered a change of information on the Form CMS-855A.

An HHA subunit, meanwhile, is a semi-autonomous organization under the same governing body as the parent HHA and serves patients in a geographic area different from that of the parent. Due to its distance from the subunit, the parent is incapable of sharing administration, supervision and services with the subunit on a daily basis. If the HHA wants to add an HHA subunit, it must complete an initial enrollment application for the subunit. (The subunit also signs a separate provider agreement.)

If an enrolled hospital seeks to add a rehabilitation, psychiatric, or swing-bed unit, it should submit a Form CMS-855 change of information request and not an initial enrollment application. Similarly, if an OPT/OSP provider wants to add an extension site, a change of information request should be submitted.

If the contractor makes a recommendation for approval of the provider’s request to add an HHA
branch or a hospital unit, the contractor shall forward the package to the State agency as described in this chapter. However, the contractor shall emphasize to the provider that a recommendation for approval of the branch or hospital unit addition does not signify CMS’s approval of the new location. Only the RO can approve the addition.

With respect to the Provider Enrollment, Chain and Ownership System, the contractor shall create a separate enrollment record for the hospital unit. However, a separate enrollment record for each HHA branch and OPT/OSP extension site is not required. These locations can simply be listed on the main provider’s enrollment record.

B. Critical Access Hospitals
Critical access hospitals (CAHs) are not considered to be a hospital sub-type for enrollment purposes. Thus, if an existing hospital wishes to convert to a CAH, it must submit a Form CMS-855A as an initial enrollment.

C. Transplant Centers
For purposes of Medicare enrollment, a hospital transplant center is treated similarly to a hospital sub-unit. If the hospital wishes to add a transplant center, it must check the “other” box in section 2A2 of the CMS-855A, write “transplant center” on the space provided, and follow the standard instructions for adding a sub-unit. Unless CMS indicates otherwise, the contractor shall process the application in the same manner it would the addition of a hospital sub-unit; however, no separate enrollment in PECOS need be created for the transplant center.

Correspondence Address and E-mail Addresses

Correspondence Address and E-mail Addresses

A. Correspondence Address
The correspondence address must be one where the contractor can directly contact the applicant to resolve any issues once the provider is enrolled in the Medicare program. It cannot be the address of a billing agency, management services organization, chain home office, or the provider’s representative (e.g., attorney, financial advisor). It can, however, be a P.O. Box or, in the case of an individual practitioner, the person’s home address.

B. Correspondence Telephone Number
The provider may list any telephone number it wishes as the correspondence phone number. The number need not link to the listed correspondence address. If the provider fails to list a correspondence telephone number, the contractor shall develop for this information via the procedures outlined in this chapter.

C. E-mail Addresses
An e-mail address listed on the application can be a generic e-mail address. It need not be that of a specific individual. The contractor may accept a particular e-mail address if it has no reason to suspect that it does not belong to or is not somehow associated with the provider.

D. Contact Persons
Unless stated otherwise in this chapter or in another CMS directive - or unless the provider requests that the contractor communicate with only a specific individual (e.g., an authorized official) or via specific means (e.g., only via the correspondence e-mail address) - the contractor has the discretion to use the contact persons listed in section 13 of the Form CMS-855 for all written and oral communications (e.g., mail, e-mail, telephone) related to the provider’s Medicare enrollment. Such communication need not be restricted to a particular enrollment application of the provider’s that the contractor is currently processing. Nor is the contractor required (again, unless either CMS or the provider directs otherwise) to send certain materials to the correspondence mailing or e-mail address rather than the contact person’s mailing or e-mail address.

Licenses and Certifications

Licenses and Certifications

The extent to which the applicant must complete the licensure or certification information in section 2 of the Form CMS-855 depends upon the provider type involved. For instance, some states may require a particular provider to be “certified” but not “licensed,” or vice versa.
The provisions in this section 15.5.2.1 are subject to the “processing alternatives” described in sections 15.7.1.3.1 through 15.7.1.3.2 of this chapter.

A. Form CMS-855B and Form CMS-855I
The contractor shall verify that the supplier is licensed and/or certified to furnish services in:

• The state where the supplier is enrolling.

• Any other state within the contractor’s jurisdiction in which the supplier (per section 4 of the Form CMS-855) will maintain a practice location.

The only licenses that must be submitted with the application are those required by Medicare or the state to function as the supplier type in question. Licenses and permits that are not of a medical nature are not required, though business licenses needed for the applicant to operate as a health care facility or practice must be submitted. In addition, there may be instances where the supplier is not required to be licensed at all in a particular state; the contractor shall still ensure, however, that the supplier meets all applicable state and Medicare requirements.

The contractor shall also adhere to the following:

• State Surveys: Documents that can only be obtained after state surveys or accreditation need not be included as part of the application. (This typically occurs with ASCs and portable x-ray suppliers.) The supplier must, however, furnish those documents that can be submitted prior to the survey/accreditation.

The contractor shall include any licenses, certifications, and accreditations submitted by ASCs and portable x-ray suppliers in the enrollment package that is forwarded to the state and/or RO.
Once the contractor receives the approval letter or tie-in notice from the RO for the ASC or portable x-ray supplier, the contractor is encouraged, but not required, to contact the RO, state agency, or supplier for the applicable licensing and/or certification data and to enter it into PECOS.

• Notarization: If the applicant submits a license that is not notarized or "certified true," the contractor shall verify the license with the appropriate state agency. (A notarized copy of an original document has a stamp that says "official seal," along with the name of the notary public, the state, the county, and the date the notary's commission expires. A certified "true copy" of an original document has a raised seal that identifies the state and county in which it originated or is stored.)

• Temporary Licenses: If the supplier submits a temporary license, the contractor shall note the expiration date in PECOS. Should the supplier fail to submit the permanent license after the temporary license expiration date, the contractor shall initiate revocation procedures. (A temporary permit – one in which the applicant is not yet fully licensed and must complete a specified number of hours of practice in order to obtain the license – is not acceptable.)

• Revoked/Suspended Licenses: If the applicant had a previously revoked or suspended license reinstated, the applicant must submit a copy of the reinstatement notice with the application.

• Date of Enrollment – For suppliers other than ASCs and portable x-rays, the date of enrollment is the date the contractor approved the application. The enrollment date cannot be made retroactive. To illustrate, suppose the supplier met all the requirements needed to enroll in Medicare (other than the submission of a Form CMS-855I) on January 1. He sends his Form CMS-855I to the contractor on May 1, and the contractor approves the application on June 1. The date of enrollment is June 1, not January 1. (NOTE: The matter of the date of enrollment is separate from the question of the date from which the supplier may bill.)

• License Expiration/Revocation Dates for Non-Certified Suppliers – For expired licenses, the contractor shall enter into PECOS the day after the expiration as the expiration date. For revoked and suspended licenses, the contractor shall enter into PECOS the revocation date (not the day after) as the expiration date.
See section 15.7.5.1 of this chapter for special instructions related to periodic license reviews and certain program integrity matters.

B. Form CMS-855A

Documents that can only be obtained after state surveys or accreditation need not be included as part of the application, nor must the data be provided in section 2 of the Form CMS-855A. The provider shall, however, furnish those documents that can be submitted prior to the survey/accreditation. The contractor shall include all submitted licenses, certifications, and accreditations in the enrollment package that is forwarded to the state and/or RO.

Once the contractor receives the approval letter or tie-in notice from the RO, the contractor is encouraged, but not required, to contact the RO, state agency, or provider

Identifying Information (Section 2 of the Form CMS-855) / Section 2 of the Form CMS-855B / Section 2 of the Form CMS-855I

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.

Basic Information (Section 1 of the Form CMS-855) / Final Adverse Actions

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

Suppliers Not Eligible to Participate / Sections of the Forms CMS-855A, CMS-855B, and CMS-855I / Practice Location Information

 Suppliers Not Eligible to Participate

Below is a list of individuals and entities that frequently attempt to enroll in Medicare, but are not eligible to do so. If the contractor receives an enrollment application from any of these individuals or entities, the contractor shall deny the application.

• Acupuncturist
• Assisted Living Facility
• Birthing Center
• Certified Alcohol and Drug Counselor
• Certified Social Worker
• Drug and Alcohol Rehabilitation Counselor
• Hearing Aid Center/Dealer
• Licensed Alcoholic and Drug Counselor
• Licensed Massage Therapist
• Licensed Practical Nurse
• Licensed Professional Counselor
• Marriage Family Therapist
• Master of Social Work
• Mental Health Counselor
• National Certified Counselor
• Occupational Therapist Assistant
• Physical Therapist Assistant
• Registered Nurse
• Speech and Hearing Center
• Substance Abuse Facility

 Sections of the Forms CMS-855A, CMS-855B, and CMS-855I

A. Background
Sections 15.5.1 through 15.5.19.7 below discuss various data elements on the Form CMS-855A, Form CMS-855B, and Form CMS-855I. Not every data element on the forms is discussed in these sections; only those elements that warrant additional instructions are mentioned. Nonetheless, the contractor shall – unless stated otherwise in this chapter or in another CMS directive - adhere to all instructions in this chapter 15 in terms of the collection, processing, and verification of all data elements on the Form CMS-855 applications, regardless of whether the data element in question is discussed in sections 15.5.1 through 15.5.19.7.

For purposes of these sections, and unless otherwise indicated, the term “approval” includes recommendations for approval.

B. Precedence of Sections 15.7 through 15.7.1.6.2
Though the contractor shall follow the instructions in sections 15.5.1 through 15.5.19.7, any specific processing or verification instructions in sections 15.5.7 through 15.7.1.6.2 shall – unless stated otherwise in this chapter or in another CMS directive - take precedence over those in sections 15.5.1 through 15.5.19.7.
See sections 15.7.1.3.1 and 15.7.1.3.2 for information regarding “processing alternatives.”

Practice Location Information

Unless specifically indicated otherwise, the instructions in this section 15.5.4 apply to the Form CMS-855A, the Form CMS-855B, and the Form CMS-855I.
The instructions in section 15.5.4.1 apply only to the Form CMS-855A; the instructions in section 15.5.4.2 apply only to the Form CMS-855B; and the instructions in section 15.5.4.3 only apply to the Form CMS-855I.

A. Practice Location Verification
The contractor shall verify that the practice locations listed on the application actually exist. If a particular location cannot at first be verified, the contractor shall request clarifying information; for instance, the contractor can request that the applicant furnish letterhead showing the appropriate address.)

The contractor shall also verify that the reported telephone number is operational and connects to the practice location/business listed on the application. However, the contractor need not contact every location for applicants that are enrolling multiple locations; the contractor can verify each location’s telephone number with the contact person listed on the application and note the verification accordingly in the contractor’s verification documentation per section 15.7.3 of this chapter. (The telephone number must be one where patients and/or customers can reach the applicant to ask questions or register complaints.)

Medicaid State Agencies / Section 4 of the Form CMS-855A

Medicaid State Agencies

Medicaid State agencies do not have a National Provider Identifier and are not otherwise eligible to enroll in the Medicare program.

If a Medicaid State agency is enrolled or seeks enrollment as a provider or supplier in the Medicare program, the contractor shall deny or revoke its Medicare billing privileges using, respectively, §424.530(a)(5) (denials) and § 424.535(a)(3) (revocations) as the basis.

Section 4 of the Form CMS-855A

A. General Information
A hospital or other provider must list all addresses where it - and not a separately enrolled provider or supplier it owns or operates, such as a nursing home - furnishes services. The provider’s primary practice location should be the first location identified in section 4A and the contractor shall treat it as such – unless there is evidence indicating otherwise - for purposes of entry into the Provider Enrollment, Chain and Ownership System (PECOS). NOTE: Hospital departments located at the same address as the main facility need not be listed as practice locations on the Form CMS-855A.
If a practice location (e.g., hospital unit) has a CMS Certification Number (CCN) that is in any way different from that of the main provider, the contractor shall create a separate enrollment record in PECOS for that location; this does not apply, however, to home health agency (HHA) branches, outpatient physical therapy/outpatient speech pathology (OPT/OSP) extension sites and transplant centers.

An HHA should complete section 4A with its administrative address.
If the provider’s address and/or telephone number cannot be verified, the contractor shall request clarifying information from the provider. If the provider states that the facility and its phone number are not yet operational, the contractor may continue processing the application. However, it shall indicate in its recommendation letter that the address and telephone number of the facility could not be verified. For purposes of PECOS entry, the contractor can temporarily use the date the certification statement was signed as the effective date.

B. Verification of HHA Sites
If the contractor receives an application from an HHA that has the same general practice location address as another enrolled (or enrolling) HHA and the contractor has reason to suspect that the HHAs may be concurrently operating out of the same suite or office, the contractor shall notify the National Site Visit Contractor of this at the time the contractor orders the required site visit through PECOS.

C. Out-of-State Practice Locations
If a provider is adding a practice location in another State that is within the contractor’s jurisdiction, a separate, initial Form CMS-855A enrollment application is not required if the following 5 conditions are met:
• The location is not part of a separate organization (e.g., a separate corporation, partnership),
• The location does not have a separate tax identification number (TIN) and legal business name (LBN),
• The State in which the new location is being added does not require the location to be surveyed,
• The applicable RO does not require the new location or its owner to sign a separate provider agreement, and
• The location is not a federally qualified health center (FQHCs are required to separately enroll each site)

Consider the following examples:
1. The contractor’s jurisdiction consists of States X, Y and Z. Jones Skilled Nursing Facility (JSNF), Inc., is enrolled in State X with 3 sites. It wants to add a fourth site in State Y. The new site will be under JSNF, Inc. JSNF will not be establishing a separate corporation, LBN or TIN for the site, and - per the State and RO - a separate survey and provider agreement are not necessary. Since all 5 conditions above are met, JSNF can add the fourth location via a change of information request, rather than an initial application. The change request must include all information relevant to the new location (e.g., licensure, new managing employees). To the extent required, the contractor shall create a separate PECOS enrollment record for the State Y location.

2. The contractor’s jurisdiction consists of States X, Y and Z. JSNF, Inc., is enrolled in State X with 3 locations. It wants to add a fourth location in State Y, but under a newly created, separate legal entity - JSNF, LP. The fourth location must be enrolled via a separate, initial Form CMS-855A.
3. The contractor’s jurisdiction consists of States X, Y and Z. Jones Hospice (JH), Inc., is enrolled in State X with 1 location. It wants to add a second location in State Z under JH, Inc. However, it has been determined that a separate survey and certification of the new location are required. A separate, initial Form CMS-855A for the new location is required.

Advanced Diagnostic Imaging / Section 4 of the Form CMS-855B

Advanced Diagnostic Imaging

Section 135(a) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) amended section 1834(e) of the Social Security Act. It required the Secretary to designate organizations to accredit suppliers – including, but not limited to, physicians, non-physician practitioners and independent diagnostic testing facilities - that furnish the technical component (TC) of advanced diagnostic imaging services.

MIPPA specifically defines advanced diagnostic imaging procedures as including diagnostic magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine imaging such as positron emission tomography (PET). The law also authorizes the Secretary to specify other diagnostic imaging services in consultation with physician specialty organizations and other stakeholders. In order to furnish the TC of advanced diagnostic imaging services for Medicare beneficiaries, suppliers must be accredited by January 1, 2012. The effective date of the previously named regulation is January 1, 2012.

CMS approved three national accreditation organizations (AOs) – the American College of Radiology, the Intersocietal Accreditation Commission, and the Joint Commission - to provide accreditation services for suppliers of the TC of advanced diagnostic imaging procedures. The accreditation will apply only to the suppliers of the images, not to the physician's interpretation of the image. Also, this accreditation only applies to those who are paid under the Physician Fee Schedule.

All accreditation organizations have quality standards that address the safety of the equipment as well as the safety of the patients and staff. A provider submitting claims for the TC must be accredited by January 1, 2012 to be reimbursed for the claim if the service is performed on or after that date. Each of these designated AOs submits monthly reports to CMS that list the suppliers who have been or are accredited, as well as the beginning and end date of the accreditation and the respective modalities for which they receive accreditation.

Newly enrolling physicians and non-physician practitioners described above must complete the Internet-based PECOS or the appropriate CMS-855 and check the appropriate boxes for Advanced Diagnostic Imaging (ADI). Contractors shall accept applications from providers and suppliers who are accredited for the new ADI accreditation. The Medicare enrollment contractors shall verify the information sent on the application meets the current enrollment requirements.

The Medicare enrollment contractors shall verify the ADI supplier is listed as one of the accredited individuals/organizations found at www.cms.hhs.gov/Medicareprovidersupenroll and consistent with accreditation information found in section 2 of the CMS-855, and if the application is approved, will enter the information into the Provider Enrollment, Chain and Ownership System (PECOS).

Section 4 of the Form CMS-855B

A. Ambulatory Surgical Centers (ASCs) and Portable X-ray Suppliers

Mass Immunizers Who Roster Bill / Section 4 of the Form CMS-855I

Mass Immunizers Who Roster Bill

An entity or individual who wishes to furnish mass immunization services - but may not otherwise qualify as a Medicare provider - may be eligible to enroll as a “Mass Immunizer” via the Form CMS-855I (individuals) or the Form CMS-855B (entities). Such suppliers must meet the following requirements:

• They may not bill Medicare for any services other than pneumococcal pneumonia vaccines (PPVs), influenza virus vaccines, and their administration.

• They must submit claims through the roster billing process.

• The supplier, as well as all personnel who administer the shots, must meet all applicable state and local licensure or certification requirements.
The roster billing process was developed to enable Medicare beneficiaries to participate in mass PPV and influenza virus vaccination programs offered by public health clinics and other organizations.

In addition:

• The effective date provision in 42 CFR § 424.520(d) does not apply to the enrollment of mass immunizers. This is because the individual/entity is not enrolling as a physician, non-physician practitioner, physician group or non-physician practitioner group.

• In section 4 of the Form CMS-855, the supplier need not list each off-site location (e.g., county fair, shopping mall) at which it furnishes services. It need only list its base of operations (e.g., county health department headquarters, drug store location).

For more information on mass immunization roster billing, refer to:
• Publication 100-02, Benefit Policy Manual, chapter 15, section 50.4.4.2

• Publication 100-04, Claims Processing Manual, chapter 18, sections 10 through 10.3.2.3

Section 4 of the Form CMS-855I 

A. Solely-Owned Organizations
The former practice of having solely-owned practitioner organizations (as explained and defined in section 4A of the CMS-855I) complete a CMS-855B, a CMS-855R, and a CMS-855I has been discontinued. All pertinent data for these organizations can be furnished via the CMS-855I alone. The contractor, however, shall require the supplier to submit a CMS-855B, CMS-855I and CMS-855R if, during the verification process, it discovers that the supplier is not a solely-owned organization.

(NOTE: A solely-owned supplier type that normally completes the CMS-855B to enroll in Medicare must still do so. For example, a solely-owned LLC that is an ambulance company must complete the CMS-855B, even though section 4A makes mention of solely-owned LLCs. Use of section 4A of CMS-855I is limited to suppliers that perform physician or practitioner services.)
Sole proprietorships need not complete section 4A of the CMS-855I. By definition, a sole proprietorship is not a corporation, professional association, etc. Do not confuse a sole proprietor with a physician whose business is that of a corporation, LLC, etc., of which he/she is the sole owner.

In section 4A, the supplier may list a type of business organization other than a professional corporation, a professional association, or a limited liability company (e.g., closely-held corporation). This is acceptable so long as that business type is recognized by the State in which the supplier is located.

The contractor shall verify all data furnished in section 4A (e.g., legal business name, TIN, adverse legal actions). If section 4A is left blank, the contractor may assume that it does not pertain to the applicant.
A solely-owned physician or practitioner organization that utilizes section 4A to enroll in Medicare can generally submit change of information requests to Medicare via the CMS-855I. However, if the change involves data not captured on the CMS-855I, the change must be made on the applicable CMS form (i.e., CMS-855B, CMS-855R).

B. Individual Affiliations
If the applicant indicates that he/she intends to render all or part of his/her services in a group setting, the contractor shall ensure that the applicant (or the group) has submitted a CMS-855R for each group to which the individual plans to reassign benefits. The contractor shall also verify that the group is enrolled in Medicare. If it is not, the contractor shall enroll the group prior to approving the reassignment.

C. Practice Location Information
A practitioner who only renders services in patients' homes (i.e., house calls) must supply his/her home address in section 4C. In addition, if a practitioner renders services in a retirement or assisted living community, section 4C must include the name and address of that community. In either case, the contractor shall verify that the address is a physical address. Post office boxes and drop boxes are not acceptable.

D. Sole Proprietor Use of EIN
The practitioner must obtain a separate EIN if he/she wants to receive reassigned benefits as a sole proprietor.

E. NPI Information for Groups
If a supplier group/organization is already established in PECOS (i.e., status of "approved), the physician or non-physician practitioner is not required to submit the NPI in 4B2 of the 855I. In short, if group/organization is already established in PECOS, the group/organization does not need to include an NPI in section 4B2. The only NPI that the physician or non-physician practitioner must supply is the NPI found in section 4C.

NOTE: Physicians and non-physician practitioners are required to supply the NPI in section 4B2 of the CMS-855I for groups/organizations not established in PECOS with a status of "approved."

F. Out-of-State Practice Locations
If a supplier is adding a practice location in another State, a separate, initial Form CMS-855I enrollment application is required for that location even if:
• The location is part of the same organization (e.g., a solely-owned corporation),
• The location has the same tax identification number (TIN) and legal business name (LBN), and
• The location is in the same contractor jurisdiction.

To illustrate, suppose the contractor’s jurisdiction consists of States X, Y and Z. Dr. Jones, a sole proprietor, is enrolled in State X with 2 locations. He wants to add a third location in State Y under his social security number and his sole proprietorship’s employer identification number. A separate, initial Form CMS-855I application is required for the State Y location.

Diabetes Self-Management Training (DSMT) / Owning and Managing Organizations

Diabetes Self-Management Training (DSMT)

A. Background

Diabetes self-management training (DSMT) is not a separately recognized provider type, such as a physician or nurse practitioner. A person or entity cannot enroll in Medicare for the sole purpose of performing DSMT. Rather, DSMT is an extra service that an enrolled provider or supplier can bill for, assuming it meets all of the necessary DSMT requirements.

All DSMT programs must be accredited as meeting quality standards by a CMS-approved national accreditation organization. Currently, CMS recognizes the American Diabetes Association (ADA) and the American Association of Diabetes Educators (AADE) as approved national accreditation organizations.

A Medicare-enrolled provider or non-DMEPOS supplier that wishes to bill for DSMT may simply submit the appropriate accreditation certificate to its contractor. No Form CMS-855 is required, unless the provider or supplier is not in the Provider Enrollment, Chain and Ownership System (PECOS), in which case a complete Form CMS-855 application must be submitted.

If the supplier is exclusively a DMEPOS supplier, it must complete and submit a Form CMS-855B application to its local Part A/B Medicare Administrative Contractor (A/B MAC).

This is because A/B MACs, rather than Durable Medical Equipment Medicare Administrative Contractors, pay DSMT claims. Thus, the DMEPOS supplier must separately enroll with its A/B MAC, even if it has already completed a Form CMS-855S. If an A/B MAC receives an application from a DMEPOS supplier that would like to bill for DMST, it shall verify with the National Supplier Clearinghouse that the applicant is currently enrolled and eligible to bill the Medicare program.

For more information on DSMT, refer to:
• 42 CFR Part 410 (subpart H)
• Publication 100-02, Medicare Benefit Policy Manual, chapter 15, sections 300 – 300.5.1

Owning and Managing Organizations
(This section only applies to section 5 of the Form CMS-855A and Form CMS-855B. It does not apply to the Form CMS-855I.)
 
All organizations that have any of the following must be listed in section 5A of the Form CMS-855:
 
1. A 5 percent or greater direct or indirect ownership interest in the provider. The following illustrates the difference between direct and indirect ownership:
EXAMPLE: The supplier listed in section 2 of the Form CMS-855B is an ambulance company that is wholly (100 percent) owned by Company A. Company A is considered to be a direct owner of the supplier (the ambulance company), in that it actually owns the assets of the business. Now assume that Company B owns 100 percent of Company A. Company B is considered an indirect owner - but an owner, nevertheless - of the supplier. In other words, a direct owner has an actual ownership interest in the supplier, whereas an indirect owner has an ownership interest in an organization that owns the supplier. See the instructions for section 5 of the Form CMS-855 for additional information on indirect ownership.
 
2. Mortgage or security interest
For purposes of enrollment, ownership also includes "financial control." Financial control exists when:
(a) An organization or individual is the owner of a whole or part interest in any mortgage, deed of trust, note, or other obligation secured (in whole or in part) by the provider or any of the property or assets of the provider, and
(b) The interest is equal to or exceeds 5 percent of the total property and assets of the provider. 
name (LBN), and

• The location is in the same contractor jurisdiction.
To illustrate, suppose the contractor’s jurisdiction consists of States X, Y and Z. Dr. Jones, a sole proprietor, is enrolled in State X with 2 locations. He wants to add a third location in State Y under his social security number and his sole proprietorship’s employer identification number. A separate, initial Form CMS-855I application is required for the State Y location.

Manufacturers of Replacement Parts/Supplies for Prosthetic Implants or Implantable Durable Medical Equipment (DME) Surgically Inserted at an ASC

Manufacturers of Replacement Parts/Supplies for Prosthetic Implants or Implantable Durable Medical Equipment (DME) Surgically Inserted at an ASC

Since Part A/B Medicare Administrative Contractors (A/B MACs) make payments for implantable prosthetics and DME to hospitals, physicians or ASCs, A/B MACs shall not enroll manufacturers of implantable or non-implantable and prosthetics DME into the Medicare program. A manufacturer of non-implantable prosthetics and DME and replacement parts and supplies for prosthetic implants and surgically implantable DME may enroll in the Medicare program as a supplier with the National Supplier Clearinghouse if it meets the definition of a supplier as well as the requirements in 42 CFR § 424.57.

Owning and Managing Organizations
1. A 5 percent or greater direct or indirect ownership interest in the provider.
The following illustrates the difference between direct and indirect ownership:
EXAMPLE: The supplier listed in section 2 of the Form CMS-855B is an ambulance company that is wholly (100 percent) owned by Company A. Company A is considered to be a direct owner of the supplier (the ambulance company), in that it actually owns the assets of the business. Now assume that Company B owns 100 percent of Company A. Company B is considered an indirect owner - but an owner, nevertheless - of the supplier. In other words, a direct owner has an actual ownership interest in the supplier, whereas an indirect owner has an ownership interest in an organization that owns the supplier.
See the instructions for section 5 of the Form CMS-855 for additional information on indirect ownership.
2. Mortgage or security interest
For purposes of enrollment, ownership also includes "financial control." Financial control exists when:
(a) An organization or individual is the owner of a whole or part interest in any mortgage, deed of trust, note, or other obligation secured (in whole or in part) by the provider or any of the property or assets of the provider, and
(b) The interest is equal to or exceeds 5 percent of the total property and assets of the provider.
All entities with at least a 5 percent mortgage, deed of trust or other security interest in the provider must be reported in section 5. This frequently will include banks, other financial institutions, and investment firms,
3. Any general partnership interest in the provider, regardless of the percentage. This includes: (1) all interests in a non-limited partnership, and (2) all general partnership interests in a limited partnership.
4. For limited partnerships, any limited partnership interest that is 10 percent or greater.
5. Managing control of the provider or supplier

A managing organization is one that exercises operational or managerial control over the provider, or conducts the day-to-day operations of the provider. The organization need not have an ownership interest in the provider in order to qualify as a managing organization. For instance, the entity could be a management services organization under contract with the provider to furnish management services for one of the provider's practice locations.

The organizations referred to above generally fall into one or more of the following categories:
• Corporations
• Partnerships and limited partnerships
• Limited liability companies
• Charitable and religious organizations
• Governmental/tribal organizations
• Banks and financial institutions
• Investment firms
• Holding companies
• Trusts and trustees
• Medical providers/suppliers
• Consulting firms
• Management services companies
• Medical staffing companies
• Non-profit entities

In section 5(A)(2) of the Form CMS-855, the provider must indicate the type(s) of organizational categories the reported entity falls into. The following principles also apply with respect to section 5:

a. Diagrams – In addition to completing section 5(A):
• The provider must submit an organizational structure diagram/flowchart identifying all of the entities listed in section 5 and their relationships with the provider and each other. (This applies to the Form CMS-855A, CMS-855B and CMS-855S.)
• If the provider is a skilled nursing facility (SNF), it must submit a diagram/flowchart identifying the organizational structures of all of its owners, including those that were not required to be listed in section 5 or 6. This must be submitted in addition to the diagram/flowchart in the previous bullet.
These diagrams/flowcharts must be submitted for initial enrollments, revalidations, Form CMS-855 reactivations, and upon any contractor request.

b. Percentage of Interest (section 5(B)) – The provider need not:
• Disclose a percentage of managerial control
• Submit documentation verifying the percentage of ownership, partnership interest or security/mortgage interest, unless the contractor requests it.

c. Section 2 - Any entity listed as the provider in section 2 of the Form CMS-855 need not be reported in section 5A. The only exception involves governmental entities, which must be identified in section 5A even if they are already listed in section 2.

d. Governmental and Tribal Organization Letter - For governmental and tribal organizations, the letter referred to in the Form CMS-855 instructions for section 5 must be signed by an appointed or elected official of the governmental or tribal entity who has the authority to legally and financially bind the governmental or tribal entity to the laws, regulations, and program instructions of Medicare. This governmental or tribal official is not required to be an authorized official, or vice versa.

e. Non-Profit Organizations - Many non-profit organizations are charitable or religious in nature, and are operated and/or managed by a Board of Trustees or other governing body. The actual name of the Board of Trustees or other governing body must be listed in section 5A of the Form CMS-855. The provider must submit a copy of its 501(c)(3) approval notification for non-profit status. If it does not possess such documentation but nevertheless claims it is a non-profit entity, the provider may submit any other documentation that supports its claim (e.g., written documentation from the State).
Governmental and tribal entities need not submit a copy of a 501(c)(3) if it is otherwise obvious to the contractor that the entity is a governmental or tribal entity. The contractor can assume that the governmental or tribal entity is non-profit.

f. IRS CP-575 - Owning/managing organizations need not furnish an IRS CP-575 document unless requested by the contractor (e.g., the contractor discovers a potential discrepancy between the organization’s reported legal business name and tax identification number.

g. Documentation – Proof of ownership, managerial control, security interest, etc., need not be submitted unless the contractor requests it. This also means that articles of incorporation, partnership agreements, etc., need not be submitted absent a contractor’s request.

h. Partnerships – Only partnership interests in the enrolling provider need be disclosed in section 5. Partnership interests in the provider’s indirect owners need not be reported. However, if the partnership interest in the indirect owner results in a greater than 5 percent indirect ownership interest in the enrolling provider, this indirect ownership interest would have to be disclosed in section 5.
i. Disregarded Entities – In general, a “disregarded entity” is a term the IRS uses for an LLC that – for federal tax purposes only – is effectively indistinguishable from its single owner/member. The LLC’s income and expenses are shown on the owner’s personal tax return. The LLC itself does not pay taxes.

If an enrolling provider claims that it is a disregarded entity, the contractor need not obtain written confirmation of this from the provider notwithstanding the instruction in section 17 of the Form CMS-855 that such confirmation is required. As a disregarded entity does not receive a CP-575 form from the IRS confirming its legal business name (LBN) and tax identification number (TIN), the contractor may accept from the enrolling provider any government form (such as a W-9) that lists its LBN and TIN. The disregarded entity’s LBN and TIN shall be listed in section 2B1 of the Form CMS-855.

Speech Language Pathologists in Private Practice / Tax Identification Numbers (TINs) of Owning and Managing Organizations and Individuals

Speech Language Pathologists in Private Practice

Effective July 1, 2009, in order to qualify as an outpatient speech-language pathologist in private practice, an individual must meet the following requirements:

(i) Be legally authorized (if applicable, licensed, certified, or registered) to engage in the private practice of speech-language pathology by the state in which he or she practices, and practice only within the scope of his or her license and/or certification.

(ii) Engage in the private practice of speech-language pathology as an individual, in one of the following practice types:

(A) An unincorporated solo practice

(B) An unincorporated partnership or unincorporated group practice

(C) An unincorporated solo practice, partnership, or group practice, or a professional corporation or other incorporated speech-language pathology practice

(D) An employee of a physician group

(E) An employee of a group that is not a professional corporation

For more information on speech language pathologists in private practice, refer to Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, section 230.

Tax Identification Numbers (TINs) of Owning and Managing Organizations and Individuals

Registered Dietitians / Chain Organizations

Registered Dietitians

Federal regulations at 42 CFR § 410.134 state that a registered dietitian (or nutrition professional) is an individual who, on or after December 22, 2000:

1. Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose;

2. Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional; and

3. Is licensed or certified as a dietitian or nutrition professional by the state in which the services are performed. In a state that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a “registered dietitian”' by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (1) and (2) above.

There are two exceptions to these requirements:
• A dietitian or nutritionist licensed or certified in a state as of December 21, 2000, is not required to meet the requirements of (1) and (2) above.

Chain Organizations
(This section only applies to the Form CMS-855A.)
All providers that are currently part of a chain organization or are joining a chain organization must complete section 7 with information about the chain home office. Under 42 CFR §421.404, a “home office” means the entity that provides centralized management and administrative services to the providers or suppliers under common ownership and common control, such as centralized

Psychologists Practicing Independently / Billing Agencies / Special Requirements for Home Health Agencies (HHAs)

Psychologists Practicing Independently

Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, section 80.2 states that a psychologist practices independently when:

• He/she render services on his/her own responsibility, free of the administrative and professional control of an employer, such as a physician, institution or agency;

• The persons he/she treats are his/her own patients;

• He/she has the right to bill directly, collect and retain the fee for his/her services; and

• The psychologist is state-licensed or certified in the state where furnishing services. A psychologist practicing in an office located in an institution may be considered an independently practicing psychologist when both of the following conditions are met:

• The office is confined to a separately-identified part of the facility that is used solely as the psychologist’s office and cannot be construed as extending throughout the entire institution; and

• The psychologist conducts a private practice (i.e., services are rendered to patients from outside the institution as well as to institutional patients).

Independently practicing psychologists have a more limited benefit under the Medicare program than clinical psychologists. With a degree starting at the master’s level of psychology, independently practicing psychologists are authorized to bill the program directly solely for diagnostic psychological and neuropsychological tests that have been ordered by a physician, clinical psychologist or nonphysician practitioner who is authorized to order diagnostic tests.

Independently practicing psychologists are not authorized to supervise diagnostic psychological and neuropsychological tests. Any tests performed by an independently practicing psychologist must fall under the psychologist’s state scope of practice.

 Billing Agencies
(Unless otherwise stated, this section applies to the Form CMS-855A, the Form CMS-855B, and the Form CMS-855I.)
A billing agency is an entity that furnishes billing and collection services on behalf of a provider or supplier. A billing agency is not enrolled in the Medicare program. A billing agency submits claims to Medicare in the name and billing number of the provider or supplier that furnished the service or services. In order to receive payment directly from Medicare on behalf of a provider or supplier, a billing agency must meet the conditions described in § 1842(b)(6)(D) of the Social Security Act.
The provider shall complete section 8 of the Form CMS-855 with information about all billing agents it utilizes. As all Medicare payments must be made via electronic funds transfer, the contractor need not verify the provider’s compliance with the “Payment to Agent” rules in CMS Publication 100-04, chapter 1, section 30.2. The only exception is if the contractor discovers that the “special payments” address in section 4 of the provider’s Form CMS-855 application belongs to the billing agent or agency. In this situation, the contractor may obtain a copy of the billing agreement if it has reason to believe that the arrangement violates the “Payment to Agent” rules.
If the chain organization listed in section 7 of the Form CMS-855A also serves as the provider’s billing agent, the chain must be listed in section 8 as well.
For further information on billing agencies, see CMS Publication 100-04, chapter 1, section 30.2.4.

Special Requirements for Home Health Agencies (HHAs) 

Physician Assistants (PAs) / Authorized Officials / Form CMS-855I Signatories / Form CMS-855A and Form CMS-855B Signatories

Physician Assistants (PAs)

Federal regulations at 42 CFR § 410.74(c), 42 CFR § 410.150(a)(15), and Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, section 190 require that a physician assistant (PA) must meet the following Medicare requirements:

1. Have graduated from a physician assistant educational program that is accredited by the Accreditation Review Commission on Education for the Physician Assistant (its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and the Committee on Allied Health Education and Accreditation (CAHEA)); or

2. Have passed the national certification examination that is administered by the National Commission on Certification of Physician Assistants (NCCPA); and

3. Be licensed by the state to practice as a physician assistant.

As indicated in Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, section 190(D):

• Payment for the PA’s services may only be made to the PA’s employer, not to the PA himself/herself. In other words, the PA cannot individually enroll in Medicare and receive direct payment for his or her services. This also means that the PA does not reassign his or her benefits to the employer, since the employer must receive direct payment anyway.

• The PA’s employer can be either an individual or an organization. If the employer is a professional corporation or other duly qualified legal entity (e.g., limited liability company) in a state that permits PA ownership in the entity (e.g., as a stockholder, member), the entity may bill for PA services even if a PA is a stockholder or officer of the entity – so long as the entity is eligible to enroll as a provider or supplier in the Medicare program. PAs may not otherwise organize or incorporate and bill for their services directly to the Medicare program, including as, but not limited to, sole proprietorships or general partnerships. Accordingly, a qualified employer is not a group of PAs that incorporate to bill for its services. Moreover, leasing agencies and staffing companies do not qualify under the Medicare program as providers or suppliers of services.


• PAs also have the option under their benefit to furnish services as an independent contractor (1099 employment arrangement) in which case the contractor serves as the PA’s employer and Medicare payment is made directly to the contractor.



Authorized Officials

Unless indicated otherwise below or in another CMS directive, the instructions in sections 15.5.15.1 and 15.5.15.2 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.

Form CMS-855I Signatories

The enrolling or enrolled physician or non-physician practitioner is the only person who can sign the Form CMS-855I. (This applies to initial enrollments, changes of information, reactivations, etc.) This includes solely-owned entities listed in section 4A of the Form CMS-855I. A physician or non-physician practitioner may not delegate the authority to sign the Form CMS-855I on his/her behalf to any other person.

Form CMS-855A and Form CMS-855B Signatories

For Form CMS-855A and CMS-855B initial applications, the certification state

Physicians / Delegated Officials

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.

Physical Therapists in Private Practice

Physical Therapists in Private Practice

A. Private Practice
Section 42 CFR 410.60(c)(ii), (iii), and (iv) state that a physical therapist in private practice must:
(1) Engage in the private practice of physical therapy on a regular basis as an individual, in one of the following practice types:
(a) An unincorporated solo practice.
(b) A partnership or unincorporated group practice.
(c) An unincorporated solo practice, partnership, or group practice, or a professional corporation or other incorporated physical therapy practice.
(d) An employee of a physician group.
(e) An employee of a group that is not a professional corporation
AND
(2) Bill Medicare only for services furnished in his or her private practice office space, or in the patient's home.
(a) A therapist's private practice office space refers to the location(s) where the
practice is operated, in the state(s) where the therapist (and practice, if applicable) is legally authorized to furnish services, during the hours that the therapist engages in practice at that location. When services are furnished in private practice office space, such space must be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice.
(b) A patient's home does not include any institution that is a hospital, a CAH, or a SNF.
AND
(3) Treat individuals who are patients of the practice and for whom the practice collects fees for the services furnished.

B. Regulatory Definition
Section 42 CFR § 484.4 defines a physical therapist as a person who is licensed, if applicable, by the state in which practicing (unless licensure does not apply) and who meets one of the following requirements:

(1)(a) Graduated after successful completion of a physical therapist education program approved by one of the following:
(i) The Commission on Accreditation in Physical Therapy Education (CAPTE).
(ii) Successor organizations of CAPTE.
(iii) An education program outside the United States determined to be substantially equivalent to physical therapist entry-level education in the United States by a credentials evaluation organization approved by the American Physical Therapy Association or an organization identified in 8 CFR § 212.15(e) as it relates to physical therapists; and
(b) Passed an examination for physical therapists approved by the state in which physical therapy services are provided.
OR
(2) On or before December 31, 2009--

(a) Graduated after successful completion of a physical therapy curriculum approved by the Commission on Accreditation in Physical Therapy Education (CAPTE); or
(b) Meets both of the following:

(i) Graduated after successful completion of an education program determined to be substantially equivalent to physical therapist entry level education in the United States by a
credentialed evaluation organization approved by the American Physical Therapy Association or identified in 8 CFR § 212.15(e) as it relates to physical therapists.

(ii) Passed an examination for physical therapists approved by the state in which physical therapy services are provided.
OR
(3) Before January 1, 2008--

(a) Graduated from a physical therapy curriculum approved by one of the following:
(i) The American Physical Therapy Association.
(ii) The Committee on Allied Health Education and Accreditation of the American Medical Association.
(iii) The Council on Medical Education of the American Medical Association and the American Physical Therapy Association.

OR

(4) On or before December 31, 1977 was licensed or qualified as a physical therapist and meets both of the following:
(1) Has 2 years of appropriate experience as a physical therapist.
(2) Has achieved a satisfactory grade on a proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service.

OR

(5) Before January 1, 1966--
(1) Was admitted to membership by the American Physical Therapy Association; or
(2) Was admitted to registration by the American Registry of Physical Therapists; or
(3) Has graduated from a physical therapy curriculum in a 4-year college or university approved by a state department of education.

Occupational Therapists in Private Practice

Occupational Therapists in Private Practice

A. Private Practice
Section 42 CFR 410.59(c)(ii), (iii), and (iv) state that an occupational therapist in private practice must:
(1) Engage in the private practice of occupational therapy on a regular basis as an individual, in one of the following practice types:
(a) An unincorporated solo practice.
(b) A partnership or unincorporated group practice.
(c) An unincorporated solo practice, partnership, or group practice, or a professional corporation or other incorporated occupational therapy practice.
(d) An employee of a physician group.
(e) An employee of a group that is not a professional corporation.
AND
(2) Bill Medicare only for services furnished in his or her private practice office space, or in the patient's home.
(a) A therapist's private practice office space refers to the location(s) where the
practice is operated, in the state(s) where the therapist (and practice, if applicable) is legally authorized to furnish services, during the hours that the therapist engages in practice at that location. When services are furnished in private practice office space, such space must be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice.
(b) A patient's home does not include any institution that is a hospital, a CAH, or a SNF.
AND
(3) Treat individuals who are patients of the practice and for whom the practice collects fees for the services furnished.

B. Regulatory Definition
Section 42 CFR § 484.4 defines an occupational therapist as an individual who:
(1)(a) Is licensed or otherwise regulated, if applicable, as an occupational therapist by the state in which practicing, unless licensure does not apply;
(b) Graduated after successful completion of an occupational therapist education program accredited by the Accreditation Council for Occupational Therapy Education (ACOTE) of the American Occupational Therapy Association, Inc. (AOTA), or successor organizations of ACOTE; and
(c) Is eligible to take, or has successfully completed the entry-level certification examination for occupational therapists developed and administered by the National Board for Certification in Occupational Therapy, Inc. (NBCOT).
OR
(2) On or before December 31, 2009--
(a) Is licensed or otherwise regulated, if applicable, as an occupational therapist by the state in which practicing; or
(b) When licensure or other regulation does not apply--
(i) Graduated after successful completion of an occupational therapist education program accredited by the Accreditation Council for Occupational Therapy Education (ACOTE) of the American Occupational Therapy Association, Inc. (AOTA) or successor organizations of ACOTE; and
(ii) Is eligible to take, or has successfully completed the entry-level certification examination for occupational therapists developed and administered by the National Board for Certification in Occupational Therapy, Inc., (NBCOT).
OR
(3) On or before January 1, 2008--
(a) Graduated after successful completion of an occupational therapy program accredited jointly by the committee on Allied Health Education and Accreditation of the American Medical Association and the American Occupational Therapy Association; or
(b) Is eligible for the National Registration Examination of the American Occupational Therapy Association or the National Board for Certification in Occupational Therapy.
OR
(4) On or before December 31, 1977--
(a) Had 2 years of appropriate experience as an occupational therapist; and (b) Had achieved a satisfactory grade on an occupational therapist proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service.

C. Education Outside the United States

Nurse Practitioners / Supervising Physicians

Nurse Practitioners

Federal regulations at 42 CFR § 410.75(b) state that a nurse practitioner must be a registered professional nurse who is authorized by the state in which the services are furnished to practice as a nurse practitioner in accordance with state law. The individual must also meet one of the following criteria:

(1) Obtained Medicare billing privileges as a nurse practitioner for the first time on or after January 1, 2003, and meets the following requirements:
(i) Is certified as a nurse practitioner by a recognized national certifying body that has established standards for nurse practitioners.
(ii) Possesses a master’s degree in nursing or a Doctor of Nursing Practice (DNP) doctoral degree.

(2) Obtained Medicare billing privileges as a nurse practitioner for the first time before January 1, 2003, and meets the standards in (1)(i) above.

(3) Obtained Medicare billing privileges as a nurse practitioner for the first time before January 1, 2001.

Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, section 200 lists the following organizations as CMS-recognized national certifying bodies for nurse practitioners at the advanced practice level:

• American Academy of Nurse Practitioners;
• American Nurses Credentialing Center;
• National Certification Corporation for Obstetric, Gynecologic and Neonatal Nursing Specialties;
• Pediatric Nursing Certification Board (previously named the National Certification Board of Pediatric Nurse Practitioners and Nurses);
• Oncology Nurses Certification Corporation;
• AACN Certification Corporation; and
• National Board on Certification of Hospice and Palliative Nurses

Supervising Physicians 

A. General Principles