CMS Pub. 100-08, ch. 10, § 10.4.1.3.3

(Development)

(Rev. 13355; Issued: 08-13-25; Effective: 05-05-25; Implementation: 05-05-25)

This section 10.4.1.3.3 addresses the contractor’s solicitation of missing/clarifying

information/documentation and/or a valid certification statement. The policies herein apply

except as otherwise stated in this chapter (e.g., section 10.3) or another CMS directive.

A. Only One Request Needed

The contractor need only make one request. Of course, the contractor should respond to any of

the provider’s telephone calls, e-mails, etc., resulting from the request. Yet the contractor need

not – on its own volition – make an additional request unless the contractor uncovers missing

data (or data that must be clarified) that it failed to detect prior to sending the original

development letter.

To the extent possible, the contractor should avoid contacting the provider for missing/clarifying

data/documentation until it has attempted to validate all of the data on the application. This will

obviate the need to contact the provider each time the contractor discovers an issue.

B. Commencement of Timeframe

The provider has 30 calendar days to furnish the information or documentation the contractor

requested. This 30-day clock commences on the day on which the contractor sends the

development request (e.g., via the PCV).

C. Telephonic Requests

Unless otherwise stated in this chapter or in another CMS directive, telephonic requests for

missing/clarifying data/documentation are generally not permitted for paper or PECOS

applications; it is important that requests for information or clarification be formalized in writing.

However, in cases where CMS permits telephonic requests for such data, the contractor shall

adhere to the following:

1. A telephonic request is made when the contractor: (1) speaks with an appropriate

provider official, or (2) leaves a message either with an appropriate official’s staff (e.g.,

executive assistant) or with an appropriate official’s voice mail service. In situation (2),

the contractor shall leave the name and telephone number of an appropriate individual at

the contractor site who the official can contact; otherwise, the contact does not qualify as

a legitimate request for clarification.

2. When leaving a message, the contractor shall also state that the requested

data/clarification must be furnished within 30 days.

3. Telephone requests shall be made on weekdays between 9 am and 5 pm of the provider’s

time zone.

4. The 30-day clock begins on the day (1) of the telephone conversation with the

appropriate official, or (2) the message is left.

5. All telephone activity that falls within this subsection (C) shall be documented in PECOS

consistent with the instructions in section 10.6.19(H) of this chapter.

D. Inability to Contact Provider

If the contractor cannot, for the reasons listed in (i) through (iii) below, communicate with the

provider to request information/documentation, it shall attempt one alternative means of

communication:

(i) The mailed letter is returned because the provider is not at that address;

(ii) The contractor cannot e-mail (e.g., via the PCV) the letter to the provider because of issues

with the recipient’s e-mail system; or

(iii) The provider’s fax number is repeatedly busy

If an alternative communication, too, cannot be completed for one of the above reasons, the

contractor need not make another attempt to obtain the data and may reject the application once

the applicable 30-day period expires. However, it is strongly advised that the contractor make a

third attempt to contact the provider prior to taking this step, especially if it appears the provider

is acting in good faith. (The contractor shall document in PECOS each attempt to contact the

provider.)

(With respect to e-mail (including via the PCV), an alternative communication includes sending

an e-mail to another listed contact person, delegated official, or authorized official.)

E. Development Reasons and Elements of Letter

1. Paper Applications

a. Reasons to Develop

Development is necessary if the provider or supplier: (i) submits an application with at least one

missing required data element; (ii) fails to submit at least one required document; (iii) submits an

invalid certification statement; (iv) writes “N/A” (or a variation thereof) in response to a question

that requires a “yes” or “no” answer; or (v) submits the full application via fax or e-mail unless

the contractor has provided for an exception based on extenuating circumstances or the

submission via this means is otherwise authorized by CMS. (If the contractor instructs the

provider to submit the application via fax or e-mail, the contractor shall inform its PEOG BFL.)

Development is also required if the contractor determines that clarification is needed regarding

certain information (e.g., particular data cannot be verified or there are data inconsistencies).

b. Elements of a Development Letter

If any of the development reasons in section 10.4.1.3.3(E)(1)(a) above apply, the contractor shall

send a development letter to the provider – preferably via the PCV, e-mail or fax - that contains,

at a minimum, the applicable elements in (i) through (vi) below. (See section 10.7 et seq. of this

chapter for these model letters.)

i. A list of all of the missing required data/documentation, an explanation of the certification

statement’s deficiencies, and/or the issues/information to be clarified.

ii. A request that the provider submit the missing data/documentation, clarification, and/or

revised certification statement within 30 calendar days.

iii. Unless the only data that is missing is documentation, a request that the provider submit an

appropriately signed and dated certification statement. (This certification statement will cover

both the submission of any missing data as well as any deficiencies associated with the original

certification statement.) The provider may submit the certification statement via scanned e-mail,

fax or mail.

(A new certification statement is not required if the only missing material is documentation or if

the requested clarification does not require any changes to the provider’s Form CMS-855 or

CMS-20134 application.)

iv. If missing data is involved, the contractor shall direct the provider to the CMS Web site at

which the CMS-855 or CMS-20134 forms can be found.

v. A fax number and mailing address to which the missing/clarifying data/documentation/correct

certification statement can be sent to the contractor. An e-mail address may be included if

applicable.

vi. The name and phone number of a contact person at the contractor site. An e-mail address may

be included if applicable.

2. PECOS Applications

a. Reasons to Develop

Development is necessary if the provider or supplier: (i) submits an application with at least one

required data element that needs clarification; or (ii) fails to submit at least one required

document.

b. Elements of a Development Request

When developing for more information, the contractor shall send a request to the provider via the

PCV containing:

(i) A list of all missing documentation or information to be clarified;

(ii) A request that the provider submit the data/materials in question within 30 calendar days; and

(iii) The name and phone number (an e-mail address is optional) of a contact person at the

contractor site.

The contractor shall not attempt to contact the provider for the missing/clarified information or

documentation prior to sending the PCV request referenced above, though the contractor is free

to make a follow-up contact with the provider after sending the PCV request.