CMS Pub. 100-08, ch. 10, § 10.3.1.5.1

A. Basic Information (Section 1)

In this section, the ordering or certifying individual indicates the reason for the application

submittal. Unless otherwise stated in this chapter, in another CMS directive, or as permitted by

PECOS, the ordering or certifying individual may only check one reason for submittal.

With the exception of the voluntary termination checkbox---and except as stated in section

10.6.1.3 of this chapter---any blank data/checkboxes in the Basic Information section can be

verified via any means (e.g., e-mail, telephone, fax).

B. Identifying Information (Section 2)

1. License/Certification/Registration Information

The extent to which the ordering or certifying individual must complete the licensure,

certification, or accreditation information depends upon the individual’s supplier type.

Requirements will vary by supplier type and by location; for instance, some states may require a

particular supplier type to be “certified” but not “licensed,” or vice versa. In general, individuals

will have licensure information to submit. However, a “License Not Applicable” check box is

furnished for cases where a state does not require licensure or, for unlicensed residents, if the

application submission includes either:

(a) A residency contract signed and dated by both an official of the institution and the resident

physician; or

(b) A letter on institution letterhead signed and dated by an official of the institution that (i)

confirms the applicant’s status as a resident physician and (ii) contains, at a minimum, the

applicant’s name.

The only licenses that must be submitted with the application are those required by Medicare or

the state to function as the ordering or certifying supplier type in question. Licenses and permits

not of a medical nature are not required. In addition, cases might arise where the individual need

not be licensed in a particular state at all; however, the contractor shall still ensure that the

supplier meets all applicable state and Medicare requirements.

If the supplier is required to submit a copy of a particular professional or business license,

certification, registration, or degree but fails to do so, the contractor need not obtain such

documentation from the supplier if the contractor can verify the information independently. This

can be done by: (1) reviewing and printing confirming pages from the applicable state,

professional, or school web site; (2) requesting and receiving from the appropriate state,

professional, or educational body written confirmation of the supplier’s status therewith; or (3)

utilizing another third-party verification source. Likewise, if the supplier submits a copy of the

applicable license, certification, registration, or degree but fails to complete the applicable

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.

2. Correspondence Address and Telephone Number

The correspondence address 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 supplier’s

representative (e.g., attorney, financial advisor). It can, however, be a P.O. Box or, in the case of

an individual practitioner, the person’s home address. The contractor need not verify the

correspondence address.

The applicant may list any telephone number 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 the latter 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 it does not belong to or is not somehow

associated with the supplier. The contractor need not verify the telephone number.

3. E-mail Addresses

An e-mail address listed on the application can be a generic one. 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 it

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

4. Drug Enforcement Agency (DEA)

DEA certificates need not be submitted if the applicable DEA information was furnished on the

Form CMS-855. Likewise, if the aforementioned certificates are furnished but the applicable

Form CMS-855 sections are blank, no further development is needed.

C. Final Adverse Legal Actions/Convictions (Section 3)

See section 10.6.6 of this chapter for information regarding final adverse actions. Except as

otherwise stated, the PECOS policies in section 10.3 supersede those in section 10.6.6 (e.g.,

communicating with the provider via the PCV).

D. Medical Specialty Information (Section 4)

The contractor shall validate that any supplier identifying a primary specialty on the Form CMS-

855O has the appropriate medical license. The contractor shall validate the license using the

state’s medical license website. If an active license is not found, the contractor shall develop via

telephone, fax, the PCV, e-mail, or mail to confirm the supplier’s intent and to obtain a copy of

the license, if applicable.

E. Important Address Information (Section 5)

The address information furnished in the Important Address Information section of the Form

CMS-855O helps the contractor contact the supplier directly, if necessary.

F. Contact Person Information (Section 6)

(See section 10.6.9 of this chapter for more information on contact persons. Except as otherwise

stated, the PECOS policies in section 10.3 above supersede those in section 10.6.9.)

If Section 6 is completely blank, the contractor need not develop for this information and can

simply contact the physician or practitioner.

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

contractor shall therefore accept end-dates of a contact person via phone, the PCV, e-mail, fax,

or mail from the individual or a current contact person on file. The contractor shall document in

PECOS who requested the termination, how it was requested (email, phone or fax), and when it

was requested. The addition of contact persons must still be reported via the Form CMS-855O.

G. Penalties for Falsifying Information (Section 7)

See the Penalties for Falsifying Information section of the Form CMS-855O for the penalties that

apply to suppliers for deliberately furnishing false information on this application to gain or

maintain Medicare enrollment.