Form CMS-10175 EFI Certification Statement

Certification Statement for Electronic File Interchange Organizations that Submit NPI Data to the National Plan and Provider Enumeration System (CMS-10175)

CMS-10175 - ELECTRONIC FILE INTERCHANGE ORGANIZATION (EFIO)

Certification Statement for Electronic File Interchange Organizations that Submit NPI Data to the National Plan and Provider Enumeration System

OMB: 0938-0984

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OMB Control No. 0938-0984/Expiration Date: XX/XX/XXXX

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

ELECTRONIC FILE INTERCHANGE ORGANIZATION (EFIO) CERTIFICATION STATEMENT

By his/her signature(s) below, the authorized official(s) of___________________________________________ (hereinafter referred to as the electronic file interchange organization, or EFIO) legally binds the EFIO to full adherence to all of the following conditions:

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  1. I certify that the EFIO has the written legal authority to act on behalf of any and all providers for whom the EFIO submits information to CMS or its agent (hereinafter collectively referred to as the Enumerator). This legal authority includes the submission of the provider’s application for a National Provider Identifier (NPI) and, if agreed to between the EFIO and the provider, updates and changes to the provider’s NPI data, deactivations, and other information.

  2. I certify that any and all data the EFIO submits to the Enumerator on behalf of a provider will be no more than 12 months old from the date the provider certifies to the accuracy of the data to be submitted on his/her/its behalf.

  3. For those providers on whose behalf the EFIO submits an initial application for an NPI, I certify that the EFIO will promptly notify via letter or e-mail each provider of the latter’s newly issued NPI or, if applicable, the rejection of the latter’s application. I further certify that the EFIO will only disseminate a provider’s NPI for purposes permitted under Federal or State law.

  4. In situations involving providers on whose behalf the EFIO submits a request to change the provider’s existing NPI information or to deactivate the provider’s NPI, the EFIO agrees to promptly inform the provider of the confirmation of the change.

  5. I certify that each provider on whose behalf the EFIO submits a NPI application has informed the EFIO in writing that the provider’s information that will be submitted to NPPES is accurate and complete. This applies to the provider’s initial application for a NPI and, if agreed to between the EFIO and the provider, updates and changes to the provider’s NPI data, and deactivations.

  6. I certify that the EFIO is duly licensed to conduct business in all States that require the EFIO to obtain such licensure prior to conducting business in that jurisdiction.

  7. I certify that the EFIO will maintain records of all correspondence and communications between itself and all providers on whose behalf the EFIO acts in the submission of NPI data to the Enumerator, and will maintain all electronic files and records submitted to and received from the Enumerator in the course of acting on a provider’s behalf. I certify that the EFIO will maintain such records and files referred to in this paragraph for a period of 7 years, unless CMS prescribes a shorter period.

I further certify that the EFIO will ensure that such records and files (including, but not limited to, the NPIs themselves) cannot be accessed by any person or entity not authorized under Federal or State law to review them.

  1. I certify that the EFIO will fully and promptly cooperate with the Enumerator upon the latter’s request in all matters relating to the verification of any information submitted by the EFIO on behalf of any provider. This includes promptly contacting the provider at the Enumerator’s request to obtain clarification of the provider’s data.

  2. I understand that the Enumerator, on an as-needed basis, reserves the right to require the EFIO to furnish to the Enumerator additional or clarifying information, such as written documentation, to confirm: (1) my authority or any EFIO representative’s authority to act on behalf of the EFIO, (2) the status of any agency relationship between the EFIO and a provider, and (3) the EFIO’s status as a legitimate business organization. I certify that the EFIO will furnish the Enumerator with the requested information in a prompt fashion.

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  1. I certify that the EFIO has adequate procedures and resources in place to promptly handle any and all issues, questions, and concerns raised by providers on whose behalf the EFIO is acting for purposes of submitting NPI data.

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Shape5 Form CMS-10175 (Rev. xx/xx Page 1

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