CMS Pub. 100-08, ch. 10, § 10.3.1.1.10

A. Certification Statement – General Policies

(Unless otherwise specified, the instructions in this section 10.3.1.1.10(A) apply to: (1)

signatures on the paper Form CMS-855A; and (2) electronic signatures for web applications.)

For paper applications, handwritten (wet) signatures in ink and digital/electronic signatures

(digital or electronic signatures such as those created by digital signature options created in

software, such as Adobe) are acceptable. For web applications, electronic signatures are

required; the contractor may contact its PEOG BFL for questions regarding electronic signatures.

B. Paper Submissions

A signed certification statement shall accompany the paper Form CMS-855A application. If the

provider submits an invalid certification statement or no certification statement at all, the

contractor shall still process the application. The contractor shall solicit an appropriate

certification statement as part of the development process – preferably via the PCV, e-mail or

fax. This includes certification statements that are: (a) unsigned; (b) undated; (c) signed (as

reflected by the date of signature) more than 120 days prior to the date on which the contractor

received the application); (d) missing; or (e) stamped. The contractor shall send one

development request to include a list of all of the missing required data/documentation, including

the certification statement. The contractor may reject the provider’s application if the provider

fails to furnish the missing information on the enrollment application - including all necessary

documentation - within 30 calendar days from the date the contractor requested the missing

information or documentation.

Unless stated otherwise in this chapter or in another CMS directive:

(i) The contractor shall begin processing the application upon receipt and shall develop for

missing certification statements and all other missing information (including an application fee)

upon review.

(ii) The contractor may return a certification statement via scanned email or fax.

(iii) Signature dates cannot be more than 120 days prior to the receipt date of the application.

(iv) For paper applications that require development, the dated signature of at least one of the

provider’s authorized or delegated officials must be on the certification statement that must be

sent in within 30 days. Obtaining the signatures of the other authorized and delegated officials is

not required.

(v) For paper changes of information (as the term “changes of information” is defined in section

10.4.4 of this chapter), if the certification statement is signed by an individual not on file with the

contractor as an authorized or delegated official of the provider, the contractor may accept the

certification statement. However, it shall develop for information on the person consistent with

the procedures in this chapter.

(vi) The contractor need not compare the signature on the Form CMS-855A with the same

authorized or delegated official’s signature on file to ensure that it is the same person.

(vii) The contractor shall not request the submission of a driver’s license or passport to verify a

person’s signature or identity.

C. PECOS Submissions

Unless stated otherwise in this chapter or in another CMS directive:

(i) The contractor shall (a) begin processing the application upon receipt via PECOS; (b) perform

all required manual validations; and (c) develop for any needed clarifying or missing information

or documentation consistent with section 10.3 above and all other applicable instructions in this

chapter.

(ii) If the provider submits an invalid certification statement, the contractor shall treat this as

missing information and develop for a correct certification statement – preferably via the PCV,

e-mail, or fax. (This includes certification statements that are signed by a person unauthorized to

do so under 42 CFR Part 424, subpart P.) The contractor shall send one development request to

include a list of all of the data/documentation to be furnished or clarified, including, as

applicable, the certification statement. The contractor may reject the provider’s application if the

provider fails to furnish said data/documentation within 30 calendar days from the date of the

contractor’s request.

(iii) For PECOS applications that require development, at least one of the provider’s authorized

or delegated officials must sign any certification statement that must accompany the provider’s

response. Obtaining the signatures of the other authorized and delegated officials is not required.

(iv) For PECOS changes of information, if the certification statement is signed by an individual

who is not on file with the contractor as an authorized or delegated official of the provider, the

contractor may accept the certification statement. However, it shall develop for information on

the person in question consistent with the procedures in this chapter.

(v) The contractor need not compare the signature thereon with the same authorized or

delegated official’s signature on file to ensure that it is the same person.

(vi) The contractor shall not request the submission of a driver’s license or passport to verify a

person’s signature or identity.

D. Certification Statement Development

If, as already mentioned, the provider submits an invalid certification statement (as described in

subsections (B) and (C) above), the contractor shall develop for a correct certification statement

and send a development letter to the provider. The provider must submit the requested

certification statement as follows:

(i) Paper applications -- Via scanned email, fax, or mail. Only the actual signature page is

required; the provider need not submit the additional page containing the certification terms.

(This also applies to the provider’s initial submission of a certification statement. Such instances

require the submission of only the signature page and not the certification terms.)

(ii) Web applications – Via electronic signature.

(iii)