JUSTIFICATION_for_REQUESTING_SOC_SEC_NOS_MED_JA 03212013

JUSTIFICATION/RATIONALE FOR REQUESTING SOCIAL SECURITY NUMBERS FROM PHYSICIAN APPLICANTS TO THE SECTION 1011 (FEDERAL REIMBURSEMENT OF EMERGENCY HEALTH SERVICES FURNISHED TO UNDOCUMENTED ALIENS) PROGRAM

(CMS FORM #10115, OMB FORM #0938-0929)

1. Why do you need to use the Social Security Number (SSN)?

The SSN is used by the Centers for Medicare & Medicaid Services (CMS) to determine provider applicant eligibility (physicians only) to participate in, and receive funds from, the Section 1011 program. Section 1011(d) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) requires the Secretary to establish a process under which eligible providers may request Section 1011 payments and requires the inclusion of measures to ensure that inappropriate, excessive, or fraudulent payments are not made. Section 1011 further requires certification by the eligible provider of the veracity of the request for Section 1011 payment. To implement these provisions, the CMS must verify that the applicant is who they claim to be, verify the applicant’s participation in Medicare, and verify that there are no sanctions against the provider that would preclude them from participating in a federal program.

The Provider Enrollment, Chain and Ownership System (PECOS) is currently used to verify physician information submitted on the Section 1011 enrollment application, verify physician Medicare enrollment, and collect the physician SSN, if available. We also use the Unique Physician/Practitioner Identification Number (UPIN) registry in some instances for verification purposes but UPINs are no longer being issued and the registry was discontinued in May 2008.

In querying PECOS we cannot always identify physician information. For example, if there are 20 John Smiths in PECOS and none of them match the address or the information submitted to Section 1011, we have no way of verifying the physician’s Medicare participation except to require and request the Medicare Federal Health Care Provider/Supplier Enrollment Application (either an 855I or 855B) to verify provider eligibility and process the Section 1011 application.

If we have the SSN, we can use it to do the search in PECOS and eliminate the need for requesting an 855. The SSN is also the only way to search Qualifier NET to check for sanctions on providers.

Requiring a SSN on the Section 1011 enrollment application will give us the ability to perform a more accurate verification process and eliminate additional data requests from the provider that will both slow down the enrollment process and make it more administratively burdensome for the provider.

2. What will happen if you cannot use the SSN as a data element?

We will need to request either an 855I or 855B (OMB Control Number 0938-0685), from the applicant if we are unable to confirm physician Medicare participation through PECOS. The 855 is estimated to take 3-5 hours to complete and will require additional processing time by the CMS and may delay provider enrollment in the Section 1011 program.

3. Explain alternative data elements considered and why you do not consider them suitable replacements for the SSN.

We can search PECOS using the provider's name as a search element. Sometimes this is successful if we have a provider with a unique name. Otherwise, we must attempt to verify using the provider's address as a search element. If we have a different address than what is recorded in PECOS, we are unable to verify Medicare participation and must request the 855 as discussed above.

4. What are the costs associated with alternatives?

If the SSN is not included on the form, in most cases we have to handle the enrollment application two times. The approximate cost for handling an application with no SSN (i.e. we are not able to verify Medicare participation and have to request additional information/documentation) is $25.39 per application. If we have the SSN, the cost to process the application is approximately $12.70 per application.