CMS Pub. 100-08, ch. 10, § 10.3.1.2.2

A. License, Certification, and Accreditation Information

1. Background

Regarding licensure information in the Identifying Information Section of the Form CMS-855B,

the extent to which the applicant must furnish licensure, certification, or accreditation data

depends upon the supplier type involved. Requirements will vary by supplier type and by

location; for instance, some states may require a particular supplier to be “certified” but not

“licensed” (or vice versa).

The only licenses that the supplier must submit with the application are those that Medicare

and/or the state requires to function as the supplier type in question. Licenses and permits not of

a medical nature are not required. In some instances, licensure may not be required in a

particular state at all, though the contractor in this case shall still ensure that the supplier meets

all applicable state and Medicare requirements.

If the contractor knows that a particular state does not require licensure/certification and the “Not

Applicable” boxes are not checked in the Identifying Information Section of the Form CMS-

855B, no further development is needed.

2. Jurisdictions and Practice Locations

Except as otherwise stated in this chapter or in another CMS directive, the contractor shall verify

that the supplier is licensed and/or certified to furnish services in:

(i) The state where the supplier is enrolling; and

(ii) Any other state within the contractor’s jurisdiction in which the supplier (per the “Practice

Location Information” section of the Form CMS-855B) will maintain a practice location

3. Permissible Independent Verification

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

addition, if the supplier 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 supplier’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, paramedic intercept agreements, 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.

4. Additional Policies

a. License Reinstatement - If the applicant had a previously revoked or suspended license

reinstated (and unless CMS states otherwise in this chapter or elsewhere), the applicant must

submit a copy of the reinstatement notice with the application.

b. License expiration/revocation dates for non-certified suppliers - For expired licenses, the

contractor shall enter into PECOS the date after the expiration as the expiration date. For

revoked and suspended licenses, the contractor shall enter into PECOS the revocation date (not

the day after) as the expiration date.

B. Clinical Laboratory Improvement Act (CLIA) and Drug Enforcement Agency (DEA)

CLIA and DEA certificates are not required. If the applicable CLIA and DEA certificates are not

furnished or the applicable Form CMS-855B sections are blank, no further development is

needed.

See section 10.6.19 et seq. of this chapter for special instructions regarding periodic license

reviews.

C. Supplier Identification Information – Business Information

Unless otherwise stated in this chapter or in another CMS directive, the contractor may capture

all information in the Identifying Information Section (with the exception of the TIN and LBN)

by telephone, fax, e-mail, the PCV, or a review of the supplier’s web site.

D. Physical Therapy/Occupational Therapy Groups

A PT/OT group must complete the questionnaire in the Identifying Information Section for

PT/OT groups. In doing so:

(i) If the group indicates that it renders services in patients’ homes, the contractor shall verify

that the group has an established private practice where it can be contacted directly and where it

maintains patients' records.

(ii) If the group answers “yes” to question 2, 3, 4, or 5, the contractor shall request a copy of the

lease agreement giving the group exclusive use of the facilities for PT/OT services only if it has

reason to question the accuracy of the group’s response. If the contractor makes this request and

the supplier cannot furnish a copy of the lease, the contractor shall deny the application.

E. State Surveys

Documents that can only be obtained after state surveys or accreditation need not be included as

part of the application. (This typically occurs with ASCs and portable x-ray suppliers.) The

supplier must, however, furnish those documents that can be submitted prior to the

survey/accreditation.

The contractor shall include any licenses, certifications, and accreditations submitted by

suppliers in the enrollment package that is forwarded to the state.

Once the contractor receives the approval recommendation notice from the state, the contractor is

encouraged (but not required) to contact the state or the supplier for the applicable licensing

and/or certification data and to enter it into PECOS.

F. Notarization

If the applicant submits a license that is not notarized or "certified true," the contractor shall

verify the license with the appropriate state agency. (A notarized copy of an original document

has a stamp that says "official seal," along with the name of the notary public, the state, the

county, and the date the notary's commission expires. A certified "true copy" of an original

document has a raised seal that identifies the state and county in which it originated or is stored.)

G. Correspondence Address and Telephone Number

The correspondence address in the Correspondence Address and Telephone Number Section of

the Form CMS-855B must be one at which the contractor can directly contact the applicant to

resolve any issues once the supplier is enrolled in Medicare. It cannot be the address of a billing

agency, management services organization, chain home office, or the provider’s representative

(e.g., attorney, financial advisor). It can, however, be a P.O. Box. The contractor need not

verify the correspondence address.

The supplier may list any telephone number it wishes as the correspondence phone number. The

number need not link to the listed correspondence address. If the supplier fails to list a

correspondence telephone number and it is required for the application submission, the

contractor shall develop for this information – preferably via the PCV, e-mail, or fax. The

contractor shall accept a particular phone number if it has no reason to suspect that it does not

belong to or is not somehow associated with the supplier. The contractor is not required to verify

the telephone number.

H. E-mail Addresses

An e-mail address listed on the application can be a generic e-mail address. It need not be that of

a specific individual. The contractor may accept a particular e-mail address if it has no reason to

suspect that it does not belong to or is not somehow associated with the supplier.