CMS 855O - Revisons Spreadsheet - 01042012

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Overview

Sheet1
Sheet2

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Sheet 1: Sheet1

#	Form	Change	Location	Reason
1	O	Delete all references to "enrollment" including "enrolled," "enrolling," and any other variations of the word "enrollment" and replace with "register" including "registered," "registering," "registration," and any other necessary variations of the word "register", including revision of prior or preceding modifier (e.g., "enrolling in" revised to "registering with")	All sections of application, including title page	Ordering and Referring (O & R) physicians and non-physician practitioners are not enrolling in Medicare, which is defined in 42 CFR § 424.502, as "…the process that Medicare uses to establish eligibility to submit claims for Medicare covered services and supplies." Rather, O & R physicians and non-physician practitioners are registering to be identified by Medicare to order and refer beneficiaries to enrolled providers and suppliers. O & R physicians and non-physician practitioners submit the CMS 855O for inclusion on CMS' Ordering and Referring Registry for verification of the O & R NPI.
2	O	Add the letter "s" to "http" and italicize the letter "l" at the end of the web address so it reads, "https://www.cms.gov/MedicareProviderSupEnroll."	p. 1 - Who Should Complete This Application	error correction
3	O	In the 2nd paragraph, 3rd line, delete the word "permit" and replace with the word "requires" between the words "CMS" and "certain"	p. 1 - Who Should Complete This Application	error correction
4	O	In the 2nd paragraph, last sentence, delete the words "wish to" between the words "may" and "register"	p. 1 - Who Should Complete This Application	clarification of instructions
5	O	In the 3rd bullet, after the 2nd paragraph add a "/" between the words "DOD" and "Tricare"	p. 1 - Who Should Complete This Application	editorial revision
6	O	Delete 4th bullet after the 2nd paragraph and replace with, "Employed by the Indian Health Service (IHS) or a Tribal Organization"	p. 1 - Who Should Complete This Application	clarification of instructions
7	O	Delete paragraph "CMS is not requiring these physicians an non-physician practitioners to send the CMS 460, "Medicare Participating Physician or Supplier Agreement," or the CMS 588, "Electronic Funds Transfer (EFT) Authorization Agreement."	p. 1 - Who Should Complete This Application	O & R physicians and non-physician practitioners are not enrolling in Medicare as defined in 42 CFR § 424.502, and therefore do not need the CMS 460, "Medicare Participating Physician or Supplier Agreement," or the CMS 588, "Electronic Funds Transfer (EFT) Authorization Agreement."
8	O	Delete header "Billing Number Information" and replace with "National Provider Identifier"	p. 1 - National Provider Identifier (new)	O & R physicians and non-physician practitioners are not enrolling in Medicare as defined in 42 CFR § 424.502, and therefore do not need billing number information.
9	O	Add "National Provider Identifier" before "NPI" and put parenthesis around "NPI" in line 1 of instruction.	p. 1 - National Provider Identifier (new)	editorial revision
10	O	Add "./NPPES/Welcome.do." into 1st web address so it reads, "https://nppes.cms.hhs.gov/NPPES/Welcome.do."	p. 1 - National Provider Identifier (new)	error correction
11	O	Add "https://" to the front of the 2nd web address so it reads, "https://www.cms.gov/NationalProvIdentStand."	p. 1 - National Provider Identifier (new)	error correction
12	O	Delete paragraph "The Medicare Identification Number, often referred to as a Provider Transaction Access Number (PTAN) or Medicare legacy number, is a generic term for an identifier that Medicare assigns to its enrolled providers and suppliers."	p. 1 - National Provider Identifier (new)	O & R physicians and non-physician practitioners are not enrolling in Medicare as defined in 42 CFR § 424.502, and therefore do not need PTAN or legacy number information.
13	O	In the 3rd bullet, delete "fee-for-service" between the words "Medicare" and "contractor."	p. 1 - Instructions for Completing and Submitting This Application	error correction
14	O	Change footer date so all pages read, "CMS-855O (04/12)"	p. 1 - Footer	update
15	O	Delete header "Avoid Delays In Your Enrollment" and replace with "Avoid Delays In Your Registration"	p. 2 - Avoid Delays In Your Registration (new)	O & R physicians and non-physician practitioners are not enrolling in Medicare as defined in 42 CFR § 424.502.
16	O	Delete "fee-for-service contractor." and replace with "Medicare contractor." in 5th bullet.	p. 2 - Avoid Delays In Your Registration (new)	error correction
17	O	Add "https://" into web address so it reads, "https://www.cms.gov/MedicareProviderSupEnroll."	p. 2 - Additional Information	error correction
18	O	Delete 1st sentence and replace with, "The Medicare contractor, also referred to as a carrier or a Medicare Administrative Contractor (MAC), that services your state is responsible for processing your registration application."	p. 2 - Mail Your Application	error correction
19	O	Delete "fee-for-service contractor" and replace with "Medicare contractor" in the 3rd line.	p. 2 - Mail Your Application	error correction
20	O	Add "https://" into web address so it reads, "https://www.cms.gov/MedicareProviderSupEnroll."	p. 2 - Mail Your Application	error correction
21	O	Add new header "Acronyms Commonly Used In This Application"	p. 2 - Acronyms Commonly Used In This Application (new)	clarification of instructions
22	O	Under new header (above), list the following acronyms and their unabbreviated forms as follows: "AMA - American Medical Association, DEA - Drug Enforcement Agency, MAC - Medicare Administrative Contractor, NPI - National Provider Identifier, NPPES - National Plan and Provider Enumeration System, PECOS - Provider Enrollment Chain and Ownership System, SSN - Social Security Number, U.S.C. - United States Code" (formatting note - acronyms should be in the form of a list under the new header)	p. 2 - Acronyms Commonly Used In This Application (new)	clarification of instructions
23	O	Move the OMB PRA Statement from the bottom of current page 11 to the bottom of page 2	p. 2 - bottom of page	formatting to condense form
24	O	2nd checkbox, 3rd box - delete the word "all" and replace it with bolded word "applicable"	p. 3 - Basic Information	clarification of instructions
25	O	Add 3rd checkbox: You are voluntarily withdrawing your Medicare registration to solely order and refer/Enter your NPI/Complete section 2.A.1 (Name), section 2.A.4 (Social Security Number) and section 6 (Certification Statement). (formatting note - format in accordance with previous 2 checkbox lines)	p. 3 - Basic Information	error correction - erroneously omitted from previous version of the CMS 855O
26	O	In section 2.A.2., add the word "Other" in front of the words "Last Name" in the "Last Name" data field	p. 3 - Identifying Information	clarification of instructions
27	O	Add "3." in front of "Date of Birth" data field	p. 3 - Identifying Information	formatting for consistency within section
28	O	Delete "Country of Birth" data field and replace with "Gender Male Female" (formatting note - place checkboxes in front of the words "Male" and "Female" and delete the current "3." in front of the word "Gender"	p. 3 - Identifying Information	information no longer required/formatting for consistency within section
29	O	Move data field 2.A.4. (SSN) to the left margin and add "DEA Number (if applicable)" data field next to the SSN data field on the same line	p. 3 - Identifying Information	formatting for consistency within section
30	O	Add "5." in front of the "Medical or other Professional School..." data field and extend data field line length	p. 3 - Identifying Information	formatting for consistency within section
31	O	Delete "DEA Number (if applicable)" data field from "5. Medical or other Professional School…" data field line	p. 3 - Identifying Information	formatting for consistency within section
32	O	Delete the line under the words "License Information"	p.3 - License Information	formatting for consistency of CMS 855 applications
33	O	Add "6." in front of "License Number" data field (not header)	p.3 - License Information	formatting for consistency within section
34	O	On "License Number" and "State Where Issued" data field line, add "Effective Date (mm/dd/yyyy)" data field to end of line	p.3 - License Information	formatting for consistency of CMS 855 applications
35	O	Delete current line 2 under "License Information" ("Effective Date (mm/dd/yyyy)" and "Expiration/Renewal Date (mm/dd/yyyy)")	p.3 - License Information	information no longer required
36	O	After "License Number," "State Where Issued," and "Effective Date" data field line, insert: "Certification Information" (bolded, larger font, formatted the same as "License Information" header above	p. 4 - Certification Information (new)	error correction - erroneously omitted from previous version of the CMS 855O
37	O	Under new "Certification Information" header, add line with checkbox "Certification Not Applicable" (formatting note - same style as "License Not Applicable" above	p. 4 - Certification Information (new)	error correction - erroneously omitted from previous version of the CMS 855O
38	O	Add line with data fields for "7. Certification Number" "State Where Issued" and "Effective Date (mm/dd/yyyy)" data fields (formatting note - same style as "License Information" above)	p. 4 - Certification Information (new)	error correction - erroneously omitted from previous version of the CMS 855O
39	O	Delete 3rd and 4th sentences, "This address cannot be a billing agency's address. This address cannot be a billing address or P.O. Box."	p. 4 - Correspondence Address	error correction
40	O	In "Mailing Address Line 1…" data field, add "or P. O. Box)" so it reads, "Mailing Address Line 1 (Street Name and Number or P.O. Box)"	p. 4 - Correspondence Address	clarification of instructions
41	O	In section 2C, 3rd checkbox, revise "DoD" to read "DOD"	p. 4 - Factor Requiring You To Register Solely To Order Or Refer	error correction
42	O	In section 2C, 4th checkbox, add the word "the" between the words "by" and "IHS"	p. 4 - Factor Requiring You To Register Solely To Order Or Refer	error correction
43	O	In 2nd sentence of instruction, delete the words, "Federal and" between the words "all" and "State"	p. 5 - Physician Specialty	error correction
44	O	Delete "Chiropractic" checkbox in 1st column	p. 5 - Physician Specialty	error correction
45	O	Add "and Palliative Care" after the word "Hospice" in 1st column	p. 5 - Physician Specialty	error correction
46	O	Delete "Palliative Care" checkbox in 2nd column	p. 5 - Physician Specialty	error correction
47	O	In the 2nd sentence, add "certification,(comma)" between the words "licensing," and "educational," and delete "," (comma) after the word "educational"	p. 5 - Non-Physician Specialty	clarification of instructions
48	O	In the 3rd sentence, delete "fee-for-service" between the words "Medicare" and "contractor."	p. 5 - Non-Physician Specialty	error correction
49	O	In 2nd column of checkboxes, delete "Psychologist billing independently" checkbox	p. 5 - Non-Physician Specialty	error correction
50	O	Delete "/Convictions" from section title header	p. 6 - Final Adverse Legal Actions	error correction
51	O	In 1st paragraph, 2nd line, delete the "," (comma) after the word "revocations"	p. 6 - Convictions	editorial revision
52	O	Reword and reformat #1 to read: Reword and reformat #1 to read: "1. The physician or non-physician practitioner was, within the last 10 years preceding registration, convicted of a Federal or State felony offense. Reportable offences include, but are not limited to: • Felony crimes against persons and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pre-trial diversions; • Financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pre-trial diversions; • Any felony that placed the Medicare program or its beneficiaries at immediate risk (such as a malpractice suit that results in a conviction of criminal neglect or misconduct); and • Any felonies that would result in a mandatory exclusion under Section 1128(a) of the Social Security Act."	p. 6 - Convictions	clarification of instructions
53	O	In #3, delete the "," (comma) between the words "duty" and "or"	p. 6 - Convictions	editorial revision
54	O	In #5, delete the "," (comma) between the words "prescription" and "or"	p. 6 - Convictions	editorial revision
55	O	In "Exclusions, Revocations, or Suspensions" header, delete the "," (comma) between the words "Revocations" and "or"	p. 6 - Exclusions, Revocations or Suspensions	editorial revision
56	O	Delete "/Convictions" from section title header	p. 7 - Final Adverse Legal Actions (Continued) (new)	error correction
57	O	Under "FINAL ADVERSE LEGAL HISTORY" Add, "If reporting a new or a change to an existing final adverse legal action, check the appropriate box below, provide the effective date of the new or changed information and complete the appropriate fields in this section." New Change Effective Date (mm/dd/yyyy):__________________ (Formatting note - add checkboxes in front the words "New" and "Change")	p. 7 - Final Adverse Legal History	formatting for consistency of CMS 855 applications
58	O	In section 3, # 2, last sentence, add the words "You must" to the beginning of the sentence so it reads, "You must attach a copy of the final adverse legal action documentation and resolution."	p. 7 - Final Adverse Legal History	clarification of instructions
59	O	Delete 1st sentence of instruction and replace with, "Complete this section with information regarding a person you would like us to contact regarding this application if you are not available."	p. 7 - Contact Person	clarification of instructions
60	O	Revise suffix data field to read, "Jr., Sr., M.D., D.O., etc."	p. 7 - Contact Person	formatting for consistency of CMS 855 applications
61	O	In "Address Line 1…" data field, add "or P. O. Box)" so it reads, "Address Line 1 (Street Name and Number or P.O. Box)"	p. 7 - Contact Person	clarification of instructions
62	O	Move penalties # 7 and # 8 from current page 9 to bottom of current page 8	p. 8 - Penalties For Falsifying Information	formatting to condense form
63	O	In the 3rd paragraph, delete the words "entry to" between the words "denied" and "or"	p. 9 - Certification Statement	clarification of instructions
64	O	Under "Certification Statement" subheader, 1st line, capitalize and bold the words "sign and date"	p. 9 - Certification Statement	clarification of instructions
65	O	In #1 under the "Certification Statement" subheader, delete current language and replace with,"1. I understand that if I wish to be reimbursed by Medicare for services I have performed, I must first voluntarily withdraw my registration as an ordering and referring physician or non-physician practitioner, then subsequently enroll in Medicare as an individual supplier."	p. 9 - Certification Statement	clarification of instructions
66	O	In #2 under the "Certification Statement" subheader, 1st sentence, delete "," (comma) between the words "application" and "and"	p. 9 - Certification Statement	editorial revision
67	O	In #2 under the "Certification Statement" subheader, 1st sentence, delete "," (comma) between the words "correct" and "and"	p. 9 - Certification Statement	editorial revision
68	O	In #2 under the "Certification Statement" subheader, 2nd sentence, between the words "correct" and "complete" delete ", (comma) or" and replace with the word "and"	p. 9 - Certification Statement	editorial revision
69	O	In #2 under the "Certification Statement" subheader, last line, delete the words "fee-for-service" between the words "Medicare" and "contractor"	p. 9 - Certification Statement	error correction
70	O	In #2 under the "Certification Statement" subheader, last line, delete the words "of this fact" between the words "contractor" and "immediately."	p. 9 - Certification Statement	error correction
71	O	In #3 under the "Certification Statement" subheader, 1st line, un-bold the word "verify"	p. 9 - Certification Statement	error correction
72	O	In #3 under the "Certification Statement" subheader, delete the 2nd sentence and the first 2 words and subsequent comma (,) of the 3rd sentence	p. 9 - Certification Statement	editorial revision
73	O	In #3 under the "Certification Statement" subheader, in the new 2nd sentence, delete the word "other" between the words "any" and "changes"	p. 9 - Certification Statement	editorial revision
74	O	In #4 under the "Certification Statement" subheader, 2nd line, delete "," (comma) between the words "misrepresentation" and "or"	p. 9 - Certification Statement	editorial revision
75	O	In #4 under the "Certification Statement" subheader, 4th line, delete "," (comma) between the words "civil" and "or" and revise "or" so it reads, "and/or"	p. 9 - Certification Statement	editorial revision
76	O	In #4 under the "Certification Statement" subheader, 5th line, delete "," (comma) between the words "damages" and "and"	p. 9 - Certification Statement	editorial revision
77	O	In #5 under the "Certification Statement" subheader, delete the 1st sentence and replace with, "I agree to abide by all Medicare regulations, program instructions and Title XVIII of the Social Security Act."	p. 9 - Certification Statement	clarification of instructions
78	O	In #5 under the "Certification Statement" subheader, in the 2nd sentence, delete the comma (,) after the word "regulations"	p. 9 - Certification Statement	editorial revision
79	O	In #5 under the "Certification Statement" subheader, in the last sentence, delete the words "the supplier's" between the words "on" and "compliance" and replace it with the word "my"	p. 9 - Certification Statement	clarification of instructions
80	O	In #6 delete current language and replace with "I will not knowingly order and/or refer an item and/or service that allows a false or fraudulent claim to be presented for payment by Medicare."	p. 9 - Certification Statement	clarification of instructions
81	O	In #7 under the "Certification Statement" subheader, delete the period (.) after the 1st sentence, and replace it with "(comma), and I have signed and dated this application."	p. 9 - Certification Statement	clarification of instructions
82	O	Revise suffix data field to read, "Jr., Sr., M.D., D.O., etc."	p. 9 - Certification Statement	formatting for consistency of CMS 855 applications
83	O	In the 1st sentence of the note under the data field for "Practitioner Signature" add the word "blue" between the words "in" and "ink"	p. 9 - Certification Statement	error correction
84	O	In the 1st sentence of the note under the data field for "Practitioner Signature" delete the parenthesis and words "(blue ink preferred)"	p. 9 - Certification Statement	error correction
85	O	In the 2nd sentence of the note under the data field for "Practitioner Signature" add the words "or not dated" between the words "original" and "will"	p. 9 - Certification Statement	clarification of instructions
86	O	In the OMB statement's 3rd sentence, delete "4 hours" and replace with "be 30 minutes" between the words "to" and "per"	p. 9 - Certification Statement	error correction
87	O	Move signature data fields and applicable instructions from current page 11 to current page 10	p. 9 - Certification Statement	formatting to condense form
88	O	In the header, delete the words "Supplier Enrollment Application" and replace with "Registration"	p. 10 - Medicare Registration Privacy Act Statement (new)	O & R physicians and non-physician practitioners are not enrolling in Medicare as defined in 42 CFR § 424.502.
89	O	In the 2nd line, delete reference "1842(r)" and replace with reference "1866(j)(1)(C)"	p. 10 - Medicare Registration Privacy Act Statement (new)	error correction
90	O	In the 3rd line, delete ",(comma) and section 31001(1) of the Debt Collection Improvement Act [31 U.S.C. § 7701(c)]"	p. 10 - Medicare Registration Privacy Act Statement (new)	error correction
91	O	Delete the 1st paragraph under the references and replace with "The purpose of collecting this information is to determine or verify the eligibility of individuals to register in the Medicare program to order or refer items and services to Medicare beneficiaries and to assist in the administration of the Medicare program. This information will also be used to ensure that registered physician and non-physician practitioners are not excluded from participation in the Medicare program. All information on this form is required. Without this information, the ability to order or refer will be delayed or denied."	p. 10 - Medicare Registration Privacy Act Statement (new)	error correction

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Sheet 2: Sheet2

JSM 10353 issued last week needs additional clarification.  A change request is forth coming. 

As you know most physicians only enroll in the Medicare program to furnish covered services to Medicare beneficiaries. .  However, with the implementation of Section 6405 of the Affordable Care Act, CMS has become aware of certain physicians or  practitioners and other practitioners who have  unique enrollment issues and will need to enroll in the Medicare program for the sole purpose of certifying or ordering items or services for Medicare beneficiaries. These physicians and practitioner do not and will not send claims to a Medicare contractor for the services they furnish. 

CMS has abbreviated the enrollment process for physicians and practitioners who need to enroll for the sole purpose of certifying or ordering services for Medicare beneficiaries.  These unique providers must use the paper enrollment application process and do the following:

·        Complete the following sections of the paper CMS-855I, “Medicare Enrollment Application for Physicians and Non-Physician Practitioners;”

Section 1 – Basic Information (they would be a new enrollee)

Section 2 – Identifying Information (section 2A, 2B, 2D and if appropriate 2H and 2K)

Section 3 – Final Adverse Actions/Convictions

Section 13 – Contact Person

Section 15 - Certification Statement (must be signed and dated—blue ink recommended)

·        Include a cover letter with the application form stating the physician or practitioner is enrolling for the sole purpose of ordering and referring items or services for a Medicare beneficiary and cannot be reimbursed for services performed, and

·        Mail the completed form to the designated Medicare enrollment contractor 

These physician and other practitioners will be entered into PECOS as individuals only.  To enter the abbreviated application into PECOS,  we are providing the following using the action required field from the PECOS Enrollment Exception Report.  The following should be provided by the provider on the 855I:

1.      NPI

2.      License Information

3.      Place of Birth

4.      Practitioner Graduation Date

5.      Practitioner Medical School

6.      Primary Specialty

7.      Correspondence address

8.      Final Adverse Action

9.      Signature

A cover letter with the application form stating the physician is enrolling for the sole purpose of ordering and referring.

CMS is not requiring a CMS 460 or 588 to be sent in.

Contractors shall complete PECOS using the following:

1.      Medicare ID: Medicare contractor assigns

2.      All effective dates will be the date of receipt

3.      Certification Information: Contractor selects NA

4.      PAR Status:  Contractor selects “no” for non-par.

5.      Practice and Special Payment Address:  Contractor enters the correspondence address provided for both

6.      Reassignment Information:  Contractors selects ‘None’

7.      Any additional information that may be needed; the contractor can select the equivalent to ‘no’, n/a, ‘none’.

Until further notice please hold all physician assistant application using the abbreviated application. 

If you have any questions please contact you DPSE liaison or BFL.