CMS Pub. 100-08, ch. 10, § 10.6.21

This section 10.6.21 addresses additional provider enrollment policies. Except as otherwise

stated, the instructions in this section supersede any other instructions to the contrary in this

chapter. It is anticipated that the provisions in this section 10.6.21 will eventually be moved to

those sections of this chapter most applicable to their respective subject matter. For

organizational reasons, section 10.6.21 is merely a placeholder section of chapter 10.

A. Special Form CMS-855S Instructions

1. Addresses

If an address (e.g., correspondence address, practice location) on the Form CMS-855S lacks a

city, state, or zip + four, the contractor can verify the missing data in any manner it chooses. In

addition, the contractor can obtain the zip + four from either the U.S. Postal Service or the

Delivery Point Validation in PECOS.

2. Insurance

With respect to the comprehensive liability insurance supplier standard in 42 CFR §

424.57(a)(10), the contractor shall: (1) verify with the insurance agent that the insurance policy is

active and current; and (2) ensure that the contractor (i.e., the NPE contractor) is listed as the

policy holder on the certificate. The contractor may contact the insurance agent via any manner

it chooses; however, verification shall be documented consistent with section 10.6.19 of this

chapter (e.g., documenting telephonic communications).

B. Transitioned Certified Providers and Suppliers – E-Mails to PEOG for Final

Application Review and/or Approval

As described in this chapter, the contractor must refer various matters involving transitioned

certified provider/supplier enrollment applications to PEOG for final application review and

approval (e.g., system updates, assignment of CCN, etc.) When making such referrals---and

notwithstanding any other instruction to the contrary in this chapter---the e-mail subject line shall

include the following: SUBJECT LINE: S&C: Facility Type; Application Type; Facility Name;

National Provider Identifier; CCN; Application Receipt Date (MMDDYY*) (*Date the

Contractor Received the Application from the Provider/Supplier). (Note, however, that this data

need not be duplicated in the e-mail’s body.) This instruction, to reiterate, only applies to e-mails to PEOG involving: (1) transitioned certified providers/suppliers; and (2) instances where

the contractor is explicitly required per this chapter to send the matter PEOG for final review,

approval, and/or denial of an application (e.g., initial application, CHOW, certain COIs) and to

wait for PEOG’s determination. (See, for example, section 10.6.1.2(A)(3)(a) of this chapter.)

C. Contacting State or SOG Location for Updates

1. “Transitioned” Certified Providers/Suppliers - In situations where the contractor recommends

approval to the state (initial applications, CHOWs, certain changes of information, etc.), the

contractor---if it has not received the state’s recommendation within 120 days after the contractor

sent its recommendation---may contact the state to ascertain whether said recommendation is

forthcoming. The contractor may contact the state every 30 days thereafter to determine the

recommendation’s status.

2. “Non-Transitioned” Certified Providers/Suppliers – If, as described in subsection (H)(1)

above, the contractor recommends approval to the state, the contractor may contact the state for

an update on the recommendation’s status beginning 120 days after the recommendation was

sent and every 30 days thereafter. If the state informs the contractor (via any means) that the

application has been forwarded to the SOG Location, the contractor may contact the SOG

Location for a status update every 30 days beginning on the date the contractor received this

notice from the state.

D. Survey and Certification Documents – All Certified Providers and Certified Suppliers

1. Documents from the State/AO

As applicable to the provider/supplier type in question, the state or accrediting organization (AO)

must provide the signed CMS-1561 (or other/similar contract) and copy of the HHS-690 to the

contractor with its approval recommendation. (Note that the contractor can accept a CMS-1561

or HHS-690 from either the state or AO.)

If the state/AO neither furnished said documents nor otherwise indicated that they were

uploaded into the Automated Survey Process Environment (ASPEN)/Internet Quality

Improvement and Evaluation System (IQIES), the contractor shall contact the state/AO via any

means for the applicable document(s). If the state/AO responds within 10 days of the

contractor’s request by either (a) sending the document(s) to the contractor or (b) stating that it

has uploaded the document(s) into ASPEN/IQIES, the contractor can continue processing the

application consistent with applicable instructions. (If the state/AO indicated (b) above, the

contractor shall note this in its referral to PEOG.) If the state/AO does neither (a) nor (b) within

this 10-day period, the contractor shall: (1) proceed with sending the referral to PEOG consistent

with existing instructions; and (2) include evidence of the state/AO’s lack of responsiveness

(e.g., e-mail evidence of the contractor’s request).

2. AO Documents to PEOG

As applicable to the situation and provider/supplier type, the contractor shall include the AO

deeming letter in referrals to PEOG that are required under this chapter (e.g., initial approvals).