Please
check one. Directions for completing this form begin on page 3.
New
Application
Change
Request
Voluntary
Termination
DEPARTMENT
OF HEALTH AND HUMAN SERVICES CENTERS
FOR MEDICARE & MEDICAID SERVICES
Form
Approved
OMB
No. 0938-0929
SECTION
1011 PROVIDER ENROLLMENT APPLICATION
1.
Applicant’s Legal Business Name as Reported to the IRS and
Individual Physician Name when applicant is Physician in Box 9
2.
Doing Business AS (DBA) Name (if applicable)
3.
Physical Address
4.
Name, telephone number, and address of person to be contacted on
matters involving the application.
5.
County
6.
E-mail address of person to be contacted on matters involving the
application.
7.
State of Service (Note: A separate application must be submitted for
each State of Service)
8.
Current Medicare Fiscal Intermediary or Carrier
9.
Type of Applicant (Check one)
Hospital
Physician
Physician
Group (must complete attachments 1 and 2)
Ambulance
10.
Applicant’s Medicare Identification Number, NPI and SSN
Hospital
(Medicare
#/CCN and NPI)
Physician
(NPI
and UPIN or PTAN)
Physician
(SSN
(voluntary))
Physician
Group
(NPI
and UPIN or PTAN)
Ambulance
(NPI
and UPIN or PTAN)
11.
Hospital Election (Hospital only)
Payment
for hospital and physician services
(Note:
Hospitals electing to receive payment for both hospital and
physician services must complete Attachment 1.)
Payment
for hospital and a portion of on-call payments made by the hospital
for physician services.
(Note:
If a hospital elects this option, physicians will separately bill
for section 1011 services.)
12.
Physician Privileges (Note: If a physician has privileges at
multiple hospitals, the physician must complete Attachment 2)
Hospital
Name:
Medicare
Number:
NPI
Number:
Physician
Group Privileges (Note: If enrolling a group, the group must
complete Attachments 1 and 2)
13.
Applicant’s Federal Tax Identification Number
14.
Applicant’s Routing Transit Number, Deposit Account Number
Routing
Transit #
Checking
Account
#
Savings
Form
CMS-10115 (04/12)
1
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ALL
PROVIDERS In
order to receive payment under section 1011 of the Medicare
Modernization Act of 2003, the provider submitting this enrollment
application agrees to collection requirements approved under the
Paperwork Reduction Act. This agreement,
upon submission by the provider of services and acceptance by the
Secretary of Health and Human Services,
shall be binding on the provider of services and the
Secretary.
The
hospital, physician, ambulance provider, or any other person or
entity receiving section 1011 payments (hereinafter
“payee”) acknowledges that those payments may be
retroactively adjusted at the end of each fiscal year in
accordance with subsection (c)(2) of section 1011. If CMS determines
that payments must be retroactively adjusted, the payee agrees that
it will promptly remit the full amount of the reduction to CMS in
accordance with instructions provided
with the notice of retroactive adjustment. Payee acknowledges that
there will be no appeal or review of
the
determination of retroactive adjustment. Any payment owed to CMS
must be remitted promptly, but in no event later
than 30 days after notice.
HOSPITALS
ONLY I
agree to provide patient eligibility information to physicians and
ambulance providers within 120 days of the date of service. I agree
to notify the physicians within my hospital about my payment
election (see item 10 above.) I further agree to reimburse
physicians in a prompt manner after receiving section 1011
reimbursement and agree not to
charge an administrative or other fee with respect to transferring
reimbursement to a physician.
ATTENTION:
READ THE FOLLOWING PROVISION OF FEDERAL LAW CAREFULLY BEFORE
SIGNING. Whoever,
in any matter within the jurisdiction of any department or agency of
the United States knowingly and willfully
falsifies, conceals or covers up by any trick, scheme or device a
material fact, or makes any false, fictitious or fraudulent
statement or representation, or makes or uses any false writing or
document knowing the same to contain any false, fictitious or
fraudulent statement or entry, shall be fined not more than $10,000,
imprisoned not more than 5
years, or both (18 U.S.C. section 1001).
To
the best of my knowledge and belief, all data in this application
are true and correct, and the governing body of the
applicant has duly authorized the document.
Form
CMS-10115 (04/12)
2
15.
Write Name and Title of Authorized Official
16.
Telephone Number (including area code)
17.
Signature of Authorized Official
18.
Date
APPLICATION
DEFINITIONS AND INSTRUCTIONS
The
purpose of collecting the information on the section 1011 Enrollment
Application is to determine or verify the eligibility of
individuals or organizations enrolling in the section 1011 program
as providers. This information will also be used to ensure that
payments are made to eligible providers as described in section
1011(e)(4) of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003. All information on this form is required
for new applications to be processed. Applications not properly
or fully completed are denied and returned as incomplete.
APPLICATION
DEFINITIONS
CMS
Form 10115 This
application allows eligible providers to apply for payment of some
or all of their unreimbursed costs of providing services required
by Section 1867 of the Social Security Act and related hospital
inpatient, outpatient, and ambulance services furnished to
undocumented aliens, aliens paroled into the United States at a U.S.
port of entry for the purpose of receiving such services, and
Mexican citizens permitted temporary entry to the U.S. with a laser
visa.
Application
Submission
To
enroll in this program, a provider must MAIL
an original APPLICATION
with an original signature to the following address. An original or
copy of
the Medicare 855i or your Medicare confirmation letter must be
included. Applicable attachments must be included with the
application as well
as an Electric Funds Transfer (EFT) Agreement, (FORM CMS-588) and an
Electronic Remittance Advice (ERA) Request Application. Applications
missing
any information, attachments or EFT Agreement and ERA application
will be denied and returned to the provider.
Novitas
Solutions, Inc. Attn:
Section 1011
P.O.
Box 3121
Mechanicsburg,
PA 17055-1831
Change
Requests Once
a section 1011 Provider Identification Number (PIN) has been issued,
changes may be made to the information on file. The information
that is changing should be completed on the Application as well as
boxes 1, 2, 10, 13, 15, 17 and 18. An original signature
of the Authorized Official is required. The change request will be
denied if the required information is not completed.
Voluntary
Termination Should
a provider choose to no longer participate in the section 1011
program, they may terminate their PIN. Sections 1, 2 10,
13, 15, 17 and 18 must be completed on the application. An original
signature of the Authorized Official is required. The termination
will not be processed if the required information is not completed.
APPLICATION
INSTRUCTIONS
Box
1
List
the legal business name that is reported to the Internal Revenue
Service (IRS) for tax reporting purposes and also list the
physician’s
name when applicant is a physician as checked in Box 9.
Box
2
Indicate
the Doing Business Name if different than Box
1.
Box
3
Record
the physical address of the facility, ambulance company or physician
office.
Box
4
Provide
the name and address of the enrollment contact person.
Box
5
Submit
the county of the physical address in Box
3.
Box
6
Note
an e-mail address of the contact person listed in Box
4.
Box
7
Provide
the state where services will be performed. A separate application
is required for each State of Service.
Box
8
List
your current Medicare Intermediary or Carrier (if applicable).
Form
CMS-10115 (04/12)
3
Section
1011 Provider Enrollment Application—Form CMS-10115
APPLICATION
DEFINITIONS AND INSTRUCTIONS
Box
9 Check
the correct box indicating the type of provider you are according to
the below defined terms. Hospital:
This term is defined at section 1861(e) of the Social Security Act
(42 U.S.C. I395x(e) ). Physician:
This term is defined at section 1861(r) of the Social Security Act
(42 U.S.C. I395x(r)).
Box
10 Medicare
Identification Number is a generic term for any number that uniquely
identifies the provider. Hospitals must provide their
Medicare Number or CMS Certification Number (CCN) and NPI number;
physicians must provide either their UPIN or Provider Transaction
Access Number (PTAN), NPI number and SSN; ambulance providers must
provide their UPIN or PTAN and their NPI number.
Box
11
HOSPITALS
ONLY:
Hospitals
must select to receive payment for both hospital and physician
services or just for hospital services and
a portion of on-call payments. Should a hospital elect to receive
payment for physician services, Attachment 1 must be completed
and the hospital agrees to bill section 1011 for for all physicians
employed by or contracted with that hospital and not
solely for employed physicians. A hospital electing this option must
bill for any and all physician services performed in that hospital,
without regard to the legal arrangement with the physician.
Hospitals may not submit payment requests for certain physicians
while allowing others to bill separately.
Box
12 PHYSICIANS
ONLY:
Physicians should elect to enroll separately or with a group.
Physicians enrolling separately should indicate the hospital name,
and NPI for which that physician has privileges. If the physician
has privileges at multiple hospitals then Attachment 2 must be
completed. Groups
enrolling their physicians must complete Attachments 1 and 2 and
obtain individual signatures of the physicians in which they are
enrolling.
Box
13 List
the Tax Identification Number which is the number issued by the
Internal Revenue Service (IRS) that is used by the provider to
report
tax information to the IRS.
Box
14 Furnish
the applicable routing and account numbers for banking information
and specify whether it is a checking or savings account.
Information recorded in this box should also match banking
information in the EFT Agreement. The information concerning
your financial institution should be available through your
organization’s treasurer or financial institution. A contact
person
and telephone number are important for verification purposes. Your
financial institution can assist you in providing the correct
banking information, including the bank’s routing number.
Boxes
15–17: Provide
the name and title of the Authorized Official with an original
signature and a phone number. An Authorized Official is an appointed
official
to whom the provider has granted legal authority to enroll it in
section 1011, to make changes and/or updates to the provider’s
financial information,
and to commit the provider to fully abide by the laws and program
instructions of section 1011. The authorized official must be the
provider’s
general partner, chairman of the board, chief financial officer,
chief executive officer, chief operating officer, president, direct
owner of
five percent of more of the provider or must hold a position of
similar status and authority within the provider’s
organization such as Director, Administrator, County Commissioner,
Chancellor, Chief, Vice President or AVP. The
physician’s signature is required on the physician application
as the authorized official for individual physician.
According
to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this
information collection is 0938-0929. The time required to complete this
information collection is estimated to average 30 minutes per
response, including the time to review instructions, search existing
data resources,
gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to
CMS: Attn: PRA Reports Clearance Officer, 7500 Security Boulevard,
Baltimore,
Maryland 21244-1850.
Form
CMS-10115 (04/12)
4
Section
1011 Provider Enrollment Application—Form CMS-10115
(Continued)
SECTION
1011 PROVIDER ENROLLMENT APPLICATION
ATTACHMENT
1
This
attachment is required for hospitals electing to receive section
1011 payment for hospital and physician services and
physician groups electing to receive payment for group members
(physicians) and must list the names and provider numbers
of physicians with hospital privileges. All information is
required and a physician signature is required for group
applications
only.
Form
CMS-10115 (04/12)
5 (GROUP
ENROLLMENT ONLY)
NPI
NUMBER
UPIN
OR PTAN
SSN
PHYSICIAN
SIGNATURE
SECTION
1011 PROVIDER ENROLLMENT APPLICATION
ATTACHMENT
2
This
attachment is required for physicians with privileges at more
than one hospital or Physician Group applications.
Physicians
with hospital privileges at more than one hospital must list the
names, Medicare numbers (CCN) and NPI numbers
of the hospitals where they have privileges.
Physician
Groups must list the names, Medicare numbers and NPI numbers
(CCN) of the hospitals where the group physicians
have privileges.
Form
CMS-10115 (04/12)
6
MEDICARE
NUMBER (CCN)
NPI
NUMBER
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File Modified | 0000-00-00 |
File Created | 2021-01-29 |