CMS Pub. 100-08, ch. 10, § 10.3.1.5.3

The contractor shall follow all applicable instructions in section 10.3 when processing Form

CMS-855O initial applications and change requests.

A. Processing Initial Form CMS-855O Submissions

1. Returns

Section 10.4.1.4.2 of this chapter (which reflects 42 CFR § 424.526) outlines the reasons for

which the contractor may immediately return a Form CMS-855O. If the contractor determines

that one or more of these reasons applies, it may return the form in accordance with the

instructions outlined in that section.

2. Verification

Unless stated otherwise in this chapter or in another CMS directive, the contractor shall ensure

that all information on the Form CMS-855O is verified. This includes, but is not limited to:

a. Verification of the individual’s name, date of birth, social security number, and NPI.

b. Verification that the individual meets the supplier type’s requirements.

c. Verification that the individual is of a supplier type that can legally order or certify.

d. Reviewing the Medicare Exclusion Database (MED) and System for Award Management

(SAM) to ensure that the individual is not excluded or debarred. (See section 10.6.6 of this

chapter for additional adverse action verifications that may be required.)

If, at any time during the verification process, the contractor needs additional or clarifying

information from the physician/eligible professional, it shall follow existing CMS instructions

for obtaining said data (e.g., sending a development letter). The information must be furnished to

the contractor within 30 calendar days of the contractor’s request.

3. Disposition

Upon completion of its review of the form, the contractor shall approve, deny, or reject it.

a. Denial

Grounds for denial are as follows:

i. The supplier is not of a type that is eligible to use the Form CMS-855O.

ii. The supplier is not of a type that is eligible to order or certify items or services for Medicare

beneficiaries.

iii. The supplier does not meet the supplier type’s licensure, certification, or educational

requirements.

iv. The supplier is excluded per the MED and/or debarred per the SAM.

If the contractor believes that another ground for denial exists for a particular submission, it

should contact its PEOG BFL for guidance.

b. Rejection

The Form CMS-855O may be rejected if the supplier fails to furnish all required information on

the form within 30 calendar days of the contractor’s request to do so. (This includes situations in

which information was submitted but could not be verified.) The basis for rejection shall be 42

CFR § 424.525(a). (See section 4.1.4.3(A)(1) for more information on rejection bases.)

c. Denial or Rejection – PECOS and Letters

When denying or rejecting an initial Form CMS-855O, the contractor shall: (1) switch the

PECOS record to a “denied” or “rejected” status (as applicable); and (2) send a letter to the

supplier notifying the latter of the denial or rejection and the reason(s) for it. The letter shall

follow the applicable letter formats described in section 10.7, et seq. Denial letters shall be sent

via certified mail. Rejection letters shall be sent by mail, the PCV, or e-mail. (NOTE: A denial

triggers appeal rights. A rejection does not.)

d. Approval

If the Form CMS-855O is approved, the contractor shall: (1) switch the PECOS record to an

“approved” status, and (2) send a letter (via mail, the PCV, or e-mail) to the supplier notifying

the latter of the approval. The letter shall follow the applicable format outlined in section 10.7.3

of this chapter.

4. Miscellaneous Policies

The contractor shall observe the following:

a. The supplier shall be treated as a non-participating supplier (or “non-par”).

b. If the supplier is employed by the DVA, the DOD, or the IHS, the individual – for purposes of

the Form CMS-855O - need only be licensed or certified in one state. Said state need not be the

one in which the DVA or DOD office is located.

c. Nothing in this section 10.3.1.5.3(A) affects any existing CMS instructions regarding the

processing of opt-out affidavits.

d. Suppliers cannot submit an abbreviated version of the Form CMS-855I in lieu of the Form

CMS-855O.

e. Per 42 CFR § 424.522(b), the effective date of a Form CMS-855O enrollment shall be the

date on which the contractor received the application if all other requirements are met.

f. If the supplier’s Form CMS-855O has been approved and the individual later wants to obtain

Medicare billing privileges, the individual must voluntarily withdraw the Form CMS-855O

enrollment prior to receiving Medicare billing privileges. (The supplier must complete the Form

CMS-855I in order to receive Medicare billing privileges.)

B. Processing Form CMS-855O Change of Information Requests

1. Receipt

Section 10.4.1.4.2 of this chapter outlines the reasons for which the contractor may immediately

return a Form CMS-855O. If the contractor determines that one or more of these reasons

applies, it may return the change request via the instructions outlined in that section.

Suppliers who are enrolled in Medicare via the Form CMS-855I may not report changes to their

enrollment information via the Form CMS-855O. They must use the Form CMS-855I.

Likewise, suppliers whose Form CMS-855O submissions have been approved must use the Form

CMS-855O to report information changes; they cannot use the Form CMS-855I for this purpose.

2. Verification

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

the new information that the supplier furnished on the Form CMS-855O. (This includes

checking the supplier against the MED and the SAM.) If, at any time during the verification

process, the contractor needs additional or clarifying information, it shall follow existing CMS

instructions for obtaining said data (e.g., sending a developmental letter). The information must

be furnished to the contractor within 30 calendar days of the contractor’s request.

C. Disposition

Upon completion of its review of the change request, the contractor shall approve, deny, or reject

the submission. The principal ground for denial will be that the new information was furnished

but could not be verified. If the contractor believes this is the case or if another ground for denial

exists with respect to a particular submission, it should contact its PEOG BFL for guidance.

The change request may be rejected if the supplier failed to furnish all required information on

the form within 30 calendar days of the contractor’s request to do so. The basis for rejection

shall be 42 CFR § 424.525(a). (See section 4.1.4.3(A)(1) for more information on rejection

bases.)

When denying or rejecting the change request, the contractor shall: (1) switch the PECOS record

to a “denied” or “rejected” status (as applicable); and (2) send a letter (via mail, the PCV, or e-mail) to the supplier notifying the latter of the denial or rejection and the reason(s) for it.

If the change request is approved, the contractor shall (1) switch the PECOS record to an

“approved” status and (2) send a letter (via mail, the PCV, or e-mail) to the supplier notifying the

latter of the approval.

D. Relocation

Since the Form CMS-855O is a national enrollment, suppliers who relocate to another state need

not disenroll in the current state and reenroll in the new state. The contractor that maintains the

Form CMS-855O enrollment in PECOS is responsible for processing the change request, even if

the supplier is relocating to a state outside of the individual’s jurisdiction. If any new licenses

and/or certifications are obtained as a result of the supplier’s relocation, the contractor shall

ensure that the updated information is captured in the supplier’s enrollment record.

This policy applies to any physician, non-physician practitioner, or resident who is enrolled via

the Form CMS-855O.