CMS-10357.Instrument Elements

INFORMATION COLLECTION INSTRUMENTS

CMS-6028-P: Letter Requesting Waiver of Medicare/Medicaid Enrollment Application Fee; Submission of Fingerprints; Submission of Medicaid Identifying Information; Medicaid Site Visit and Rescreening

1. Medicare Enrollment Application Fee Waiver Request

Certain providers and suppliers enrolling in Medicare will be required to submit a fee with their application. If the applicant believes it has a hardship that justifies a waiver of the fee, it may submit a letter describing said hardship. No standard form letter will be created and no specific format will be required. However, the provider’s letter, which will accompany its enrollment application, must:

• Identify the provider

• Explain why a waiver of the application fee should be granted

2. Fingerprints

Certain providers and suppliers enrolling in Medicare and Medicaid will be required to submit standard FD-258 fingerprint cards for their owners, authorized officials, delegated officials, and managing employees. A copy of a sample FD-258 card is attached.

3. Collection of SSNs and DOBs for Medicaid and CHIP providers

The State Medicaid agency must require that all persons with an ownership or control interest in a Medicaid provider submit their SSNs and DOBs. For most, if not all, State Medicaid agencies, these two data elements will be collected via the respective Medicaid provider enrollment form for that particular State.

IV. Site Visits for Medicaid-only or CHIP-only providers

A State Medicaid agency must conduct on-site visits for providers it determines to be "moderate" or "high" categorical risk. No standard form to record the visit results will be created for use by every Medicaid agency nationwide. Each State will record the results via its own chosen mechanism.

V. Rescreening of Medicaid Providers Every 5 Years:

A State Medicaid agency must screen all providers at least every 5 years. This is consistent with the Medicare requirement in current 42 CFR § 424.515 that providers and suppliers revalidate their enrollment information at least every 5 years. No standard form to rescreen these providers will be created for use by every Medicaid agency nationwide. Again, each State will undertake its rescreening activities via its own chosen mechanisms.