CMS Pub. 100-08, ch. 10, § 10.4.1.3.4

Development)

(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23)

(Note that references to missing information will generally only apply to paper applications.)

A. Requirement to Furnish All Missing/Clarifying Material

The provider must furnish all missing/clarifying data/documentation the contractor requested

within the 30-day timeframe. Whether the provider furnished all information is a decision

resting solely with the contractor. Should the provider furnish some (but not all) of the requested

data/clarification within the specified time period, the contractor need not contact the provider

again to request the remaining information. For instance, suppose the contractor requested

clarification regarding data the provider furnished in Sections 3, 4, and 5 of the Form CMS-

855A. The provider only clarified the Section 3 data. The contractor may reject the application

without attempting another contact.

B. Format of Furnishing Missing/Clarifying Data

1. Paper Applications

Unless stated otherwise in this chapter or in another CMS directive, the provider shall: (1)

provide the missing/clarification information (excluding documentation) on the applicable Form

CMS-855 or CMS-20134 page(s) and (2) submit the material via mail, fax, the PCV, or scanned

e-mail. A newly signed and dated certification statement must accompany the Form CMS-855 or

CMS-20134 page(s) containing any missing data – unless the only missing information is

supporting documentation, in which case no new certification statement is needed. The provider

may submit the certification statement via scanned e-mail, fax, the PCV, or mail (paper

submissions) along with any missing information.

2. PECOS Applications

Unless stated otherwise in this chapter or in another CMS directive, the provider must furnish the

clarifying data/documentation and/or missing/clarifying documentation via PECOS. (See section

10.3 for more information.)

C. Format of Clarifying Data

(For both paper and PECOS applications, the provider must submit any missing/clarifying data

or documentation and any required new certification statement within 30 days of the original

request for clarification (rather than 30 days from the date of any follow-up request to provide

the data.))

1. Paper Applications

In cases where clarifying (as opposed to missing) information is requested, the contractor may

accept the clarification by e-mail, fax, the PCV, or letter. If the provider furnishes the

clarification via telephone, the contractor shall – unless another CMS directive states otherwise -

request that the provider furnish said clarification in writing (preferably via e-mail).

If the furnished clarification requires the provider to change or alter data that must be reported on

the paper Form CMS-855 or CMS-20134, the contractor shall instruct the provider (via a follow-up e-mail or fax) to (1) submit the revised data on the applicable paper CMS-855 or CMS-20134

or PECOS application and (2) furnish a new certification statement. The provider must submit

the certification statement via scanned PCV, e-mail, fax, or mail.

2. PECOS Applications

The provider must furnish any clarifying information or missing documentation via the PCV if

no updates to its PECOS application are needed (e.g., no documentation need be uploaded, no

changes to its Section 4 enrollment data are required). If application updates and/or

documentation are required, the contractor shall instruct the provider (via the PCV) to (1) submit

the clarified information via PECOS and (2) furnish a new certification statement in PECOS.

(Paper certification statements are not permitted.)

Consider the following illustrations:

EXAMPLE 1: The contractor notifies the provider via an e-mailed letter on March 1 of a

discrepancy regarding its ownership information on the paper Form CMS-855A. The provider e-

mails the contractor on March 3 and explains the discrepancy. Based on this e-mail, the

contractor determines that the provider must correct its ownership data in Section 5 of its Form

CMS-855A. The contractor sends a follow-up e-mail to the provider on March 7 instructing the

provider to do so. The provider must submit the revised data on the Form CMS-855 or CMS-

20134 (with a new certification statement) by March 31 (not April 6, or 30 days from the date of

the follow-up e-mail).

EXAMPLE 2: The contractor notifies the provider via a PCV-transmitted letter on March 1 of a

discrepancy regarding certain ownership information on its PECOS Form CMS-855A. The

provider telephones the contractor on March 6 and explains the discrepancy to the contractor’s

satisfaction. Although the discrepancy does not require the provider to make any revisions to its

Form CMS-855A, the contractor shall request that the provider furnish its explanation in writing

via the PCV no later than 30 days from its March 1 e-mail (or March 31), not 30 days from the

date of its March 6 request for the written explanation.

EXAMPLE 3: The contractor notifies the provider via a PCV-transmitted letter on March 1 of a

discrepancy regarding certain ownership information on its PECOS Form CMS-855A.

Determining (based on the contractor’s notification) that the ownership information it provided

was incorrect, it submits a revised Section 5 of its Form CMS-855A to the contractor with a new

certification statement via PECOS but without any accompanying explanation of the change.

The contractor receives the revised Section 5 on March 12. If the contractor determines that the

discrepancy has been resolved via the revised submission, it need not contact the provider for a

written explanation. (This is because the clarification was furnished in writing via the Form

CMS-855 or CMS-20134 itself.) If, however, the contractor would like a written explanation or

otherwise needs clarification about the submission, it may request that the provider submit a

written explanation via the PCV no later than March 31.

D. Maintenance of Received Material

Paper Applications – The contractor shall maintain all missing/clarifying information or

documentation received (including new certification statements) in PECOS via the uploading

process described in section 10.3.

PECOS Applications – The contractor shall maintain in PECOS all clarifying

information/documentation and/or missing documentation.