CMS Pub. 100-08, ch. 10, § 10.3.1.1.14

The processing alternatives in this section 10.3.1.1.14 are in addition to, and not in lieu of, any

other processing alternatives described in this chapter or another CMS directive. These

processing alternatives also apply notwithstanding any instruction in this chapter to the contrary.

As stated in section 10.3, however, some of the application data elements and verification

procedures that have previously been subject to a processing exception/alternative may no longer

be so or are moot under PECOS 2.0. (See section 10.3 for a discussion of such data and

procedures.) In such situations, the contractor shall disregard the exception/alternative and

follow the instructions in sections 10.3 through 10.3.1.1.10.

A. General Principle

(Subject to the exceptions listed below as well as the instructions in section 10.3, the following

principle applies to all Form CMS-855A sections.)

If a data element on the provider’s Form CMS-855A application is missing but the information is

disclosed (1) elsewhere on the application or (2) in the supporting documentation submitted with

the application, the contractor need not obtain the missing data via an updated Form CMS-855A

page and a newly-signed certification statement; no further development – not even by telephone

– is required. The following information, however, must be furnished in the appropriate

section(s) of the Form CMS-855A, even if the data is identified elsewhere on the form or in the

supporting documentation:

(i) All organizational and individual ownership and managing control information on the Form

CMS-855A

(ii) Except as otherwise stated in section 10.6.6 of this chapter, any final adverse action data

requested in the Final Adverse Legal Actions/Convictions section and the final adverse legal

action history for any organization or individual listed in the Ownership Interest and/or

Managing Control Information sections of the Form CMS-855A

(iii) All legal business names (LBNs) (e.g., provider, chain home office) (NOTE: If an

application is submitted with a valid NPI and CCN combination but (1) the LBN field is blank,

(2) an incomplete or inaccurate LBN is submitted, or (3) the applicant includes a DBA name in

the Practice Location Information section of the Form CMS-855A and the contractor can

confirm the correct LBN based on the NPI-CCN combination provided, the contractor need not

develop.)

(iv) All tax identification numbers (TINs) (e.g., provider, owning organization)

(v) NPI-legacy number combinations in the Practice Location Information section of the Form

CMS-855A (NOTE: The contractor may use the shared systems, PECOS, or its provider files as

a resource to determine the PTAN or NPI before developing with the provider.)

(vi) Provider type

(vii) The following data in the Change of Ownership (CHOW), Acquisitions/Mergers or

Consolidations sections of the Form CMS-855A:

• DBA name

• Effective dates of sale/transfer/consolidation

• Checkbox in the Identifying Information (CHOW Information) section indicating whether

buyer will accept assets/liabilities

• Names of units with separate legacy numbers/NPIs

• All NPIs and legacy numbers (NOTE: The contractor may use the shared systems, PECOS,

or its provider files as a resource to determine the CCN or NPI before developing with the

provider).

B. Supporting Documentation Resubmission

If supporting documentation currently exists in the provider’s file, the provider need not submit

that documentation again during the enrollment process. The contractor shall utilize the existing

documentation for verification. In short, documentation submitted with a previously submitted

enrollment application (or documentation currently uploaded in PECOS) qualifies as a

processing alternative (unless stated otherwise in this chapter or any CMS directive).

C. City, State, and ZIP Code

If an address in any section of the Form CMS-855A (e.g., correspondence address, practice

location) lacks a city, state, or zip + four, the contractor can verify the missing data in any

manner it chooses. In addition, the contractor can obtain the “zip + four” from either the U.S.

Postal Service or the Delivery Point Validation in PECOS.

D. Licenses

In situations where the provider is required to submit a copy of a particular professional or

business license, certification, or registration but fails to do so, the contractor need not obtain

such documentation from the provider if the contractor can verify the information independently.

The contractor can do this by: (1) reviewing and printing confirmation pages from the applicable

state web site; (2) requesting and receiving from the appropriate state body written confirmation

of the provider’s status therewith; and (3) using any other third-party verification source. In

addition, if the provider submits a copy of the applicable license, certification, or registration but

fails to complete the appropriate section of the form, the section need not be completed if the

data in question can be verified on the license/certification itself or via any of the three

mechanisms above. The contractor shall, however, note the following:

(i) The above-referenced written confirmation from a state body of the provider’s status can be

in the form of a letter, fax, or e-mail, but it must be in writing. Documentation of a verbal

conversation between the contractor and the body in question does not qualify as appropriate

confirmation.

(ii) The aforementioned licensure exception only applies to those documents that traditionally

fall within the category of licenses, registrations, or certifications. It is inapplicable to materials

such as adverse action documentation, bills of sale, etc. Furthermore, the exception is moot in

cases where: (a) the state does not require a particular license/certification; or (b) the

license/certification has not been obtained because a state survey has not yet been performed.

E. Documentation of Missing Information Elsewhere

The contractor shall document in PECOS that the missing information covered under this section

10.3.1.1.14 was found elsewhere in the enrollment package. However, this excludes information

that must be verified at the current point in time (i.e., a license without a primary source

verification method).

F. Relationship to Opt-Out

The contractor shall not utilize information submitted with opt-out applications for enrollment

application processing or vice-versa.