CMS Pub. 100-08, ch. 10, § 10.3.1.1.9

Information) - Form CMS-855A

(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23)

A. Contact Person (Section 13)

(Regarding the Contact Person section of the Form CMS-855A, see section 10.6.9 of this

chapter. Except as otherwise stated, the PECOS policies in section 10.3 supersede those in

section 10.6.9.)

If this section is completely blank, the contractor need not develop for this information and can

simply contact an authorized or delegated official.

If neither box is checked but the contact person information is incomplete (e.g., no telephone

number listed), the contractor may either (1) develop for this information by telephone, e-mail,

the PCV, or fax, or (2) contact an authorized or delegated official.

There is no existing option on the Form CMS-855A to delete a contact person. The contractor

shall therefore accept a contact person’s end-date via telephone, e-mail, the PCV, fax, or mail

from the individual provider, an authorized/delegated official, or a current contact person on file.

The contractor shall document in PECOS who requested the termination, how the request

originated (e-mail, the PCV, phone, or fax), and when the request occurred. However, the

provider must still report all contact person additions via the Form CMS-855A.

B. Penalties for Falsifying Information (Section 14)

Please refer to the Penalties for Falsifying Information section of the Form CMS-855A for an

explanation of penalties for deliberately furnishing false information on this application to gain

or maintain Medicare enrollment.