Chapter 3
Provider Enrollment

3.1 Overview

This section provides information on how to apply for identification numbers (e.g., provider identification number, group identification number, independent physiological laboratory, clinical social worker, psychologist, certified registered nurse, ambulance, physical therapist, audiologist, etc.), changing or updating information, and applying for a unique physician identification number.

a. Provider Enrollment Services

The Provider Enrollment Services department is responsible for validating the licensure qualifications for doctors of medicine, osteopathy, dentistry, podiatric, optometry, and chiropractic. Licensure validation is also conducted for physical therapists, psychologists, certified registered nurses, midwives, clinical social workers, and pharmacies.

In addition, Provider Enrollment Services handles all changes to specialty, address, IRS tax identification numbers, one-man corporation status, participating status, resignations, and the complete review of your provider data file(s).

3.2 Applying for a Medicare Provider Identification Number (PIN)

A physician/healthcare practitioner must have an individual provider number to submit services to Medicare Part B. A physician means doctor of medicine, doctor of osteopathy, doctor of dental surgery or dental medicine, doctor of chiropractic, a doctor of podiatric medicine, or a doctor of optometry who is licensed to practice by the State in which he or she performs services. A healthcare practitioner includes, but is not limited to, physician assistant, certified nurse-midwife, qualified psychologist, nurse practitioner, clinical social worker, physical therapist, occupational therapist, respiratory therapist, certified registered nurse anesthestist, or any other practitioner as may be specified by the Secretary as defined in 1842 (b) (4) (I) of the Social Security Act.

a. Medicare Provider/Supplier Enrollment

a.1 Privacy Act Statement

The Health Care Financing Administration (HCFA) is authorized to collect the information requested on this form to ensure that correct payments are made to providers and suppliers under the Medicare program established by Title XVIII of the Social Security Act. See, sections 1814 and 1815 of the Social Security Act for payment under Part A of Title XVIII [42 U.S.C. §§ 1395f(a)(1) and 1395g(a)], section 1833(e) [42 U.S.C. § 1395l(e)] for payment under Part B. In addition, HCFA is required to ensure that no payments are made to providers or suppliers who are excluded from participation in the Medicare program under section 1128 of Title XVIII [42 U.S.C. § 1320a-70] or who are prohibited from providing services to the federal government under section 2455 of the Federal Acquisition Streamlining Act of 1994, (P.L. 103-355) [31 U.S.C. § 6101 note]. This information must, minimally, clearly identify the provider and its' place of business as required by the Budget Reconciliation Act of 1985 (P.L. 99-272) [42 U.S.C. § 9202(g)] and provide all necessary documentation to show they are qualified to perform the services for which they are billing.

The Debt Collection Improvement Act (DCIA) of 1996 (P.L. 104-134) [31 U.S.C. §§ 3720B-3720D] requires agencies to collect the Taxpayer Identification Number (either the Social Security Number or the Employer Identification Number) from all persons or business entities doing business with the federal government. Under section 31001(I)(1) of the DCIA [31

U.S.C. § 7701(c)(1)], the taxpayer identification number will be used to collect (including collection through use of offset) and report any delinquent amounts arising out of the business relationship with the Government. Therefore, collection of this data element is mandatory.

The purpose of collecting this information is to determine or verify the eligibility of individuals and organizations to enroll in the Medicare program as providers/suppliers of goods and services to Medicare beneficiaries and to assist in administration of the Medicare program and other Federal and State health care programs. All information on this form is required, with the exception of those sections marked as optional on the form. Without this information, the ability to make payments will be delayed or denied.

The information collected will be entered into either system number 09-70-0525 titled Unique Physician/Practitioner Identification Number (UPIN) System (published in the Federal Register in Vol. 61, no. 89, May 7, 1996), or the National Provider Identifier (NPI) System (OMB) approval 0938-0684 (R-187). The information in this application will be disclosed according to the routine uses described below.

Information from these systems may be disclosed under specific circumstances, to:

  1. Contractors working for HCFA to carry out Medicare functions, collating or analyzing data, or to detect fraud or abuse;
  2. A congressional office from the record of an individual health care provider in response to an inquiry from the congressional office at the written request of that individual health care practitioner;
  3. The Railroad Retirement Board for purposes of administering provisions of the Railroad Retirement or Social Security Acts;
  4. Peer Review Organizations in connection with the review of claims, or in connection with studies or other review activities, conducted pursuant to Part B of Title XVIII of the Social Security Act;
  5. To the Department of Justice or an adjudicative body when the agency, an agency employee, or the United States Government is a party to litigation and the use of the information is compatible with the purpose for which the agency collected the information.
  6. To the Department of Justice for investigation and prosecuting violations of the Social Security Act to which criminal penalties attach;
  7. To the American Medical Association (AMA), for the purpose of attempting to identify medical doctors when the Unique Physician Identification Number Registry is unable to establish identity after matching contractor submitted data to the data extract provided by the AMA;
  8. An individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, or to the restoration or maintenance of health;
  9. Other Federal agencies who administer a Federal health care benefits program to enumerate/enroll providers of medical services or to detect fraud or abuse;
  10. State Licensing Boards for review of unethical practices or nonprofessional conduct;
  11. States for the purpose of administration of health care programs; and/or
  12. Insurance companies, self insurers, health maintenance organizations, multiple employer trusts, and other health care groups providing health care claims processing, when a link to Medicare or Medicaid claims is established, and data are used solely to process provider's/supplier's health care claims.

The applicant should be aware that the Computer Matching and Privacy Protection Act of 1988, (P.L. 100-503) amended the Privacy Act, 5 U.S.C. § 552a, to permit the government to verify information through computer matching.

a.2 Protection of Proprietary Information

Privileged or confidential commercial or financial information collected on this form are protected from public disclosure by Federal law 5 U.S.C. 552(b)(4) and Executive Order 12600.

a.3 Protection of Confidential Commercial and/or Sensitive Personal Information

If any information within this application (or attachments thereto) constitutes a trade secret or privileged or confidential information (as such terms are interpreted under the Freedom of Information Act and applicable case law), or is of a highly sensitive personal nature such that disclosure would constitute a clearly unwarranted invasion of the personal privacy of one or more persons, then such information will be protected from release by HCFA under 5 U.S.C. § 552(b)(4) and/or (b)(6), respectively.

b. Medicare Health Care Provider/Supplier Enrollment Application Instructions

General Application - HCFA 855
 

General

This application must be completed by all providers and suppliers of medical and other health services for enrollment in the Medicare or any other federal health care program.

Some applicants may also need to be surveyed and/or certified by the appropriate State Agency or Regional Medicare Office when required to meet Medicare conditions of enrollment. In this case, those applicants must initially contact the State Agency or Regional Medicare Office prior to completion and submission of this application.

If you need assistance or have any questions concerning the completion of this application, contact your local Medicare or other federal health care contractor.

A separate application must be submitted for each classification of provider/supplier type (e.g., physician in private practice, physician in group practice) even if the different types of services are furnished within the same organization or entity (e.g., hospitals and all affiliated units).

Each entity of an organization must submit a separate application (e.g., hospital based skilled nursing facility, hospices, outpatient clinics, etc.). Each entity of a chain organization must submit a separate application.

Providers and/or suppliers enrolling in the Medicare or any other federal health care program as a group member, partner, or individual contractor who reassigns their Medicare or other federal health care program benefits to the enrolling applicant must also complete HCFA Form 855R (Individual Reassignment of Benefits Application).

Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies must enroll in the Medicare or any other federal health care program using HCFA Form 855S (DMEPOS Supplier Enrollment Application) instead of this application.

Upon completion and approval of this application, the applicant will be issued a provider/supplier billing number. This number will be automatically deactivated if it is inactive for 12 consecutive months. A new HCFA Form 855 must be completed and approved to
re-activate the billing number.

For your convenience, the application form of this package has been perforated for easy removal of individual pages. It is not necessary to return the instructions or unused attachments when returning this completed application.

Note: Any changes in the information reported in this application must be reported to the Medicare or other federal health care contractor within 30 calendar days of said change.

Definitions

Authorized Representative: The appointed official (e.g., officer, chief executive officer, general partner, etc.) who has the authority to enroll the entity in Medicare or other federal health care programs as well as to make changes and/or updates to the applicant's status, and to commit the corporation to Medicare or other federal health care program laws and regulations.

The Authorized Representative may be contacted to answer questions regarding the information furnished in this application.

Chain Organization: Multiple providers and/or suppliers (chains) are owned, leased or through any other devices, controlled by a single business entity. The chain organization must consist of two or more health care facilities. The controlling business entity is called the chain "Home Office." Each entity in the chain may have a different owner (generally chains are not owned by the "Home Office").

Typically, the chain "Home Office:"

Examples of provider types that would typically be chain organizations are: Certified Outpatient Rehabilitation Facilities (CORFs); Skilled Nursing Facilities (SNFs); and Home Health Agencies (HHAs).

Clinical Laboratory Improvement Amendments (CLIA) Number: This number is assigned to laboratories who are certified by the Health Care Financing Administration (HCFA) under the Clinical Laboratory Improvement Amendments.

Note: Any laboratory soliciting or accepting specimens for laboratory testing is required to hold a valid certificate issued by the Secretary of the United States Department of Health and Human Services or hold a license from a CLIA exempt State.

Consolidated Cost Report: A cost report compiled for multiple facilities joined together and filed under the parent facility's Medicare Identification Number.

Contractor: Any individual, entity, facility, organization, business, group practice, etc., receiving an Internal Revenue Service (IRS) Form 1099 for services provided to this applicant (e.g., independent contractor, subcontractor).

Distinct Part Unit [of a facility]: A separate psychiatric, rehabilitation, or skilled nursing unit that is attached to a hospital paid under the Prospective Payment System (PPS) but which is paid on a cost reimbursement or other non-PPS basis. It must be a clearly identifiable unit, such as an entire ward, wing, floor, or building, including all the beds and related services in the unit, that meets all the requirements for a type of facility other than the one in which it is located, and houses all the beneficiaries and recipients for whom payment is made under Medicare for services in the other type of facility.

Food and Drug Administration Number (FDA): This is the certification number assigned by the FDA for equipment used in mammography screening and diagnostic services.

Group Member: A physician or non-physician practitioner who renders services in a group practice and who reassigns benefits to the group.

Independent Diagnostic Testing Facility (IDTF) (formerly Independent Physiological Laboratories (IPL's)): An entity independent of a hospital or physician's office in which diagnostic tests are performed by licensed, certified non-physician personnel under appropriate physician supervision (e.g., free standing cardiac catherization facility, imaging center, etc.).

Legal Business Name: The legal name of the individual or entity applying for enrollment. This name should be the same name the applicant uses in reporting to the Internal Revenue Service.

Medicaid Number: This number uniquely identifies the applicant as a Medicaid provider and/or supplier in a given State.

Medicare Identification Number: his number uniquely identifies the applicant as a Medicare provider and/or supplier and is the number used on claim forms. The Medicare Identification Number is also known as Medicare Provider Number and Provider Identification Number (PIN). Examples of Medicare Identification Numbers are the UPINs, OSCAR numbers, and NSC numbers.

Note: If the applicant is enrolling in the Medicare or other federal health care programs for the first time, the applicant will receive a Medicare or other federal health care program identification number upon enrollment.

National Provider Identifier (NPI): This number is assigned using the National Provider System to identify health care providers and/or suppliers. In the future, it will replace the Medicare Identification Number.

National Supplier Clearinghouse Number (NSC): This number uniquely identifies the applicant as a supplier of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). It is the number used by DMEPOS suppliers on claim forms.

On-Line Survey Certification and Reporting System (OSCAR): National database used for maintaining and retrieving survey and certification data for certified providers and/or suppliers that are approved to participate in the Medicare, Medicaid and CLIA programs. OSCAR numbers are assigned by the Regional Medicare office.

Other Affiliated Units: Entities that are either a Provider Based Facility, a Distinct Part Unit, or file a consolidated cost report.

Provider Based Facility: Entities operating under the control of a parent organization (e.g., hospital based End Stage Renal Disease Unit, Skilled Nursing Facility, etc.).

Reassignee: An individual or organization that allows another organization to bill Medicare or other federal health care programs on their behalf for services rendered.

Unique Physician Identification Number (UPIN): This number is assigned to physicians, non-physician practitioners and groups to identify the referring or ordering physician on Medicare claims.

APPLICATION COMPLETION INSTRUCTIONS

Furnish all requested information in its entirety. If a field is not applicable, write N/A in the field. If entire section is not applicable, check the box at the beginning of the section indicating the entire section is not applicable. Any section of the application that does not have a check box at the beginning of the section indicating the entire section is not applicable must be completed by applicant.

Check Type of Business: (For administrative purposes only)

Check appropriate box indicating how applicant's business is structured. The answer to this item will not affect the amount of reimbursement or enrollment status.

Note: If applicant's business structure is a partnership, applicant must provide a copy of its partnership agreement signed by all parties and identifying the general partner (if any) and attest that the partnership meets all State requirements. Partnerships see group instruction.

Check "Applicant Enrolling As" Type: (For administrative purposes only) The answer to this item will not affect the amount of reimbursement or enrollment status.

See the instructions below that identify which sections the applicant is responsible for completing.

Individual: An individual person enrolling as a physician, supplier or non-physician practitioner (e.g., physician, nurse, midwife, etc.).

Note: An individual who is registered as a business is considered a sole proprietor for the purpose of completing this application and should not check this box.

Individuals complete sections 1a, 1d, 2, 3, 4, 5, 6, 7, 9, 14, 15, 17, and 18.

Sole Proprietor: An individual person registered as a business and issued a tax identification number from the IRS and rendering services under the business name.

Sole Proprietors complete sections 1a, 1b, 1d, 2, 3, 4, 5, 6, 7, 9, 14, 15, 17 and 18.

Organization: A company, not-for-profit entity, governmental agency (Federal, State, or Local) or a qualified health care delivery system which renders medical care (e.g., pharmacy, equipment manufacturer, hospital, Public Health Clinic, laboratory, skilled nursing facility, Ambulance Service Supplier, Independent Diagnostic Testing Facility, etc.).

Organizations complete sections 1b, 1d, 2, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 17, and 18.

Ambulance Service Suppliers must also complete Attachment 1.

Independent Diagnostic Testing Facilities must also complete Attachment 2.

Home Health Agencies must also complete Attachment 3.

Group: Two or more physicians, non-physician practitioners or other health care providers/suppliers who form a practice together (as authorized by State law) and bill Medicare or other federal health care programs as a single unit. A group has individual practitioners. The individual members must be enumerated and enrolled in the Medicare or other federal health care program as individuals in order to enroll as members of the group.

Only those health care practitioners who are authorized to bill Medicare or other federal health care programs directly in their individual capacities are allowed to form a group. A group can only be enrolled if it can meet the conditions for reassignment (see instructions for the Reassignment of Benefits section).

The above definition of a group is to be used for Medicare or other federal health care programs' enrollment purposes only. It is not the group definition described in section 1877(h) of the Social Security Act.

Groups/Partnerships complete sections 1c, 1d, 2, 5, 6, 7, 8, 9, 10, 11, 14, 15, 17 and 18.

All group member/partners must complete HCFA Form 855R.

Note: PARTNERSHIPS: For purposes of this application, partnerships should check that they are "enrolling as" a group.

Note: RURAL HEALTH CLINICS: Rural Health Clinics that meet the definition of a group, should also submit HCFA Form 855R (Individual Reassignment of Benefits Application) for each member of the group. This is not applicable to those Rural Health Clinics that are provider based.

Mass Immunization Biller Only: A health care provider/supplier who roster bills Medicare or other federal health care programs solely for mass immunizations.

Mass Immunization/Roster Billers complete sections 1a, 1b, 1d, 2, 5, 6, 7, 8, 9, 12, 14, 15, 17 and 18.

Note: Applicants enrolling in the Medicare or other federal health care program as mass immunization/roster billers cannot bill the Medicare or other federal health care program for any other services. The applicant agrees to accept assignment of the influenza/pneumococcus benefit as payment in full and cannot "balance bill" the beneficiary.

For those who are only applying to enroll in the Medicare or other federal health care program to roster bill for mass immunization, enter "Roster" under primary speciality in Section 1A if applicant is an individual, or enter "Roster" under type of facility in Section 1B if applicant is an organization.

Check appropriate federal health care program:

If applicant is enrolling in a federal health care program other than Medicare, check the appropriate box. Check only one box. For each federal health care program in which the applicant wishes to enroll, the applicant must complete a separate enrollment application and submit it to that federal health care program.

Check Application For:

Initial Enrollment: Applicant is enrolling in the Medicare or other federal health care programs for the first time, or re-activating a prior Medicare billing number.

Enrollment of Additional Location(s): Currently enrolled provider/supplier is applying to enroll a new practice location.

Recertification: Currently enrolled provider/supplier is completing application to comply with mandatory periodic re-survey and/or recertification through the State agency or Regional Medicare Office.

Change of Ownership (CHOW): This term applies to certain limited circumstances as defined in 42 CFR § 489.18 as described below.

A new or prospective new owner must complete this application to report new or prospective new ownership. In addition, the applicant must also submit an Individual Reassignment of Benefits Application (HCFA Form 855R) identifying all individuals who will reassign their benefits to the applicant.

A change of ownership is defined as:

Note: A currently enrolled provider/supplier who is reporting new information on the current owners (i.e., addition(s) or deletion(s) of owner(s)) which is not expected to result in a CHOW as defined above, must make the appropriate changes using the ownership information section of this application. This action is considered a change of information (see below).

Change of Information: Currently enrolled provider/supplier is completing applicable sections of the application to report a change in information other than a CHOW as defined above. Currently enrolled provider/suppliers can use HCFA Form 855C (Change of Information Form) to report changes in name, specialty, e-mail address, practice location address, billing agency address, pay to address, surety bond changes/renewals, mailing address, pricing locality, telephone number(s), fax number(s), deactivation of Medicare or other federal health care billing number(s), addition or deletion of authorized representatives, and potential termination of current ownership.

Changes not listed above must be reported using this application.

When using this application to notify the Medicare or other federal health care program that a practice location(s), owner(s), or various personnel are no longer associated with this entity, check the appropriate deletion box in the applicable section(s) and identify the practice location and/or personnel.

All changes must be reported in writing and have an original signature. For individuals, the applicant must sign and for organizations and group practices, an "Authorized Representative" must sign to confirm the requested change(s). Faxed or photocopied signatures will not be accepted.

Check Where Applicant Will Be Submitting Bills:

MEDICARE APPLICANTS ONLY

Fiscal Intermediary: Applicant will be enrolled to bill the fiscal intermediary only. The fiscal intermediary is generally known as the Part A Medicare Contractor. The applicant will generally be a hospital or other health care facility.

Carrier: Applicant will be enrolled to bill the carrier only. The carrier is generally known as the Part B Medicare Contractor. The applicant will generally be a physician or non-physician practitioner.

Both: Application will automatically be forwarded to bill both the fiscal intermediary and the carrier for enrollment consideration.

Regional Home Health Intermediary: Applicant will be enrolled to bill the regional home health intermediary.

If applicant checked that they will be billing a fiscal intermediary, indicate applicant's preferred choice of fiscal intermediary from the separate list included in this package.

Check other federal health care program(s) where applicant is currently enrolled:

If applicant is currently enrolled in any other federal health care program(s), check all appropriate boxes.

1. Applicant Identification

A. Individuals Only

Complete all items in this section if applicant plans to bill the Medicare or other federal health care program as an individual practitioner.

If an individual or sole proprietorship, complete applicant's full name (this is the name payment will be made in), date and place of birth (county and/or city). If applicant has previously practiced or operated a business under another name, including applicant's maiden name, supply that name under Other Name.

If applicable, check if applicant is a resident or intern at a hospital.

If applicant is enrolling as an individual or sole proprietor, furnish the applicant's primary speciality (e.g. general practitioner, urologist, nurse practitioner, etc.). Listing a secondary speciality is optional.

Gender and Race/Ethnicity information is optional. This data will only be used to assist HCFA in uniquely identifying the applicant.

If applicant is employed by an entity that will receive payments for the applicant's services, applicant must complete and sign the HCFA Form 855R (Individual Reassignment of Benefits Application).

B. Organizations Only

Complete this section if applicant is a sole proprietor of the business or if applicant is a publicly or privately held business entity.

Complete all items in this section. For Legal Business Name, supply the name that the business, organization or group practice reports to the IRS (this is the name payment will be made in). For Type of Facility give the classification that designates the entity (e.g., hospital, skilled nursing facility, home health agency, ambulance company, etc.), and check whether this facility is accredited or non-accredited.

Note: Clinical laboratories and independent diagnostic testing facilities should annotate this section "LABORATORY" (LAB).

All organizations must identify if they are considered a Provider Based Facility, a Distinct Part Unit, or file a consolidated cost report under another provider/supplier Medicare identification number. If an organization is a Distinct Part Unit, then the organization also falls under the broader category of Provider Based Facility.

If the organization is a:

then the organization must provide the name and Medicare identification number of their parent provider.

Note: The final determination as to whether an entity is truly a Provider Based Facility will be made by HCFA prior to completion of the enrollment process.

In addition to the parent provider relationship described above, the organization must identify how many Provider Based Facilities, Distinct Part Units, Branches, or Multi-campus sites the organization is responsible for. For each of those locations identified, the Practice Location(s) section of this application must be completed.

If applicant receives payment from Medicare or any other federal health care agency for any services rendered by a contractor, when permitted by Medicare or other federal health care program requirements, the contractor must complete and sign the HCFA Form 855R (Individual Reassignment of Benefits Application).

C. Physician and Non-Physician Practitioner Groups Only

Complete all items in this section. Furnish the group's legal business name. This should be the legal name used in reporting to the IRS. Furnish the group's primary specialty (the primary specialty of the majority of the group's members). Designation of a secondary specialty is optional. All group members who the group will be billing the Medicare or other federal health care program in their behalf, must be individually enrolled in the given Medicare or other federal health care program.

Note: The group's members must be enrolled within the same federal health care program as the group enrollment. Otherwise, the group member must enroll separately as an individual in the group's federal health care program prior to becoming a member of that group practice.

Each group member must complete and sign the HCFA Form 855R (Individual Reassignment of Benefits Application).

Note: PARTNERSHIPS: When completing this section, provide legal business name of partnership, date partnership was incorporated, and the State where the partnership is incorporated. Place "n/a" in the specialty block.

D. All Applicants

Provide applicant's mailing address. This is where the applicant can receive correspondence and bulletins from Medicare or other federal health care program contractors. This address may be the applicant's home address or a Post Office Box. Applicant must supply fax number and e-mail address if available. If applicable, provide applicant's previously assigned Medicare Identification Number(s) and the name(s) of the Carrier and/or Fiscal Intermediary to which applicant most recently submitted bills using this number. If applicable, provide applicant's most recent Medicaid number and the State in which it was issued. Applicant must provide his/her social security number and when applicable, his/her employer identification number(s).

Note: All applicants must provide either their social security number and/or, when applicable, their employer identification number (EIN). If applicant uses more than one EIN, list all, starting with the EIN(s) currently used or to be used for tax reporting purposes relating to this application. Attach a copy of IRS Form CP 575 to verify the applicant's EIN.

Applicant must answer all questions related to criminal activity. Answering "yes" to any of these questions will not automatically deny enrollment into Medicare or other federal health care programs. For purposes of these questions related to criminal activity, an "immediate family member" of the applicant is defined as:

For purposes of these questions related to criminal activity, "member of household" with respect to the applicant is defined as any individual sharing a common abode as part of a single family unit with the applicant, including domestic employees and others who live together as a family unit, but not including a roomer or boarder.

Indicate whether the applicant (under the name of the applicant shown on this application or any other name) has any outstanding overpayments with Medicare, Medicaid or any other federal program. If the applicant has an outstanding overpayment, furnish the name of the federal program where the overpayment exists. If this outstanding overpayment is in a name other than the name identified in the Applicant Identification section, furnish the other name in the space provided.

2. Professional and Business License, Certification, and Registration Information

All applicants are required to furnish information on all Federal, State and local (city/county) professional and business licenses, certifications and/or registrations required to practice as applicant's provider/supplier type in applicant's (e.g. State medical license for physician, State certification and/or registration for Nurses, Federal DEA number, Business Occupancy License, local business license, etc.). The local Medicare or other federal health care contractor will supply specific credentialing requirements for applicant's provider/supplier type upon request.

Notarized or "certified true" copies of the above information are optional, but will speed the processing of this application.

Notarized: A notarized copy of an original document that will have a stamp which states "Official Seal" along with the name and signature of the notary public, State, County, and the date the notary's commission expires.

Certified True: This is a copy of the original document obtained from where it originated or is stored, and it has a raised seal which identifies the State and County in which it originated or is stored.

In lieu of copies of the above requested documents, the applicant may submit a notarized or "certified true" Certificate of Good Standing from the applicant's State licensing/certification board or other medical association. This certificate cannot be more than 30 days old.

Non-physician practitioners who must meet Medicare or other federal health care program requirements for professional experience should submit evidence of practice and the dates of employment.

If applicant's enrollment requires a State survey and/or certification, the applicant is required to forward copies of State survey and/or certification documents to the Medicare or other federal health care contractor once they are received from the State agency or Regional Medicare Office.

Note: Temporary licenses are acceptable submissions with this application. However, once received, a copy of the applicant's permanent license must be forwarded to the Medicare or other federal health care program contractor within 30 days of receipt.

If applicant's State licensure is dependent upon State survey and/or certification, check applicable box and furnish information on all other required licensing information.

Note: A business license is required for each practice location.

If applicant had a previously revoked or suspended license, certification, or registration reinstated, attach a copy of the reinstatement notice(s) with this application, if applicable.

3. Professional School Information (Individuals Only)

If applicable, supply information about the educational institution from which applicant received medical, professional, or related degree or training as required by applicant's State. Enclose copies of diploma, degree or evidence of qualifying course work.

Non-physician practitioners who must meet HCFA or other federal health care program requirements for education must provide documentation of courses or degrees taken that satisfy Medicare or other federal health care program requirements. Contact the local Medicare or other federal health care program representative for requirements needed for applicant's provider/supplier type.

4. Board Certification

If applicant is Board Certified, furnish requested information for each Board Certification obtained by the applicant.

5. Exclusion/Sanction Information

Supply all requested information. If applicable, attach copy(s) of any official documentation related to the adverse legal action identified, including reinstatement notices. If applicant has not had any adverse legal actions, check the "none of these" box.

6. Practice Location(s)

Provide all information requested for each location where applicant will render services to Medicare or other federal health care program beneficiaries.

Individual practitioners should include all hospitals and/or other health care facilities where they render service or have privileges to treat patients. Individual practitioners who only render services in the patient's home (house calls) should supply his/her home address in this section. If individual practitioners render services in retirement or assisted living communities, complete this section using the names and addresses of these communities.

Hospitals must list all off-site clinics, distinct part units, and provider based facilities (e.g., skilled nursing facility, rural health clinic, etc.) and multi-campus sites.

Home health agencies and hospices must list all branches.

Note: Listing the facilities, clinics, units, and multi-campus sites controlled by a hospital or other entity does not automatically enroll them in the Medicare or other federal health program. The HCFA Form 855 (General Enrollment Application) must also be completed for each of these entities.

Post Office boxes and drop boxes are not acceptable as practice location addresses. The phone number must be a number where patients and/or customers can reach the applicant to ask questions or register complaints.

Furnish the "Pay To" address for payment of services rendered at this practice location. Payments will be made in the legal business name that the individual, organization, or group/partnership uses to report to the IRS, as reported in Section 1 of this application. In most circumstances, payment will be made in the name of the individual who furnished the service unless a valid Reassignment of Benefits Statement has been completed. The "Pay To" address may be a Post Office box.

Furnish the name and social security number of the primary managing/directing employee of this practice location.

If applicable, provide the CLIA number or FDA certification number associated with each piece of equipment at each practice location and submit a copy of the most current certification.

Indicate whether patient records are kept on the premises. If not, supply the name of the storage facility/location and the physical address where the records are maintained. Post Office boxes and drop boxes are not acceptable as the physical address where patient records are maintained.

7. Prior Practice Information

FOR MEDICARE ENROLLMENT ONLY

If applicant has previously billed Medicare or Medicaid, supply requested information about the prior practice. Indicate whether applicant was a participating or non-participating provider/supplier in the prior practice.

8. Ownership Information

Complete this section for all individuals and/or entities who have an ownership or control interest in the applicant's business/entity. If owner is an individual, complete owner name, social security number and employer identification number. If applicant is owned by another entity, complete legal business name and employer identification number of the owning entity as well as the name(s) and social security number of each owner of that entity. Entities with ownership interest must provide their legal business name(s).

A person or entity with an ownership or control interest is one that:

Supply all requested information about the owner's past and present billing relationships with Medicare. Furnish past history for the last 10 years. If data is not known or is incomplete, check the appropriate box.

Supply all requested adverse legal action information about the owner(s). If applicable, attach copy(s) of any official documentation related to the adverse legal action identified, including reinstatement notices. If none of the owner(s) has had any adverse legal actions, check the "none of these" box.

Attach a copy of the applicant's IRS Form CP 575 pertaining to this business. The IRS Form CP 575 will be used to verify the employer identification number (EIN).

In lieu of the IRS Form CP 575, the applicant may use any official correspondence, such as the quarterly tax payment coupon, from the IRS showing the name of the entity as shown on this application and the EIN.

9. Managing/Directing Employees

Complete this section for all managing and/or directing employees, employed by the applicant. This section should include, but is not limited to, general manager(s), business manager(s), administrator(s), director(s), or other individuals who exercise operational or managerial control over the provider/supplier, or who directly or indirectly conduct the applicant's day-to-day operations.

Note: This section is not to be completed with information about billing agency or management service organization employees. If applicant uses a billing agency or management service organization, complete the appropriate section of this application.

Note: Non-profit organizations should complete this section with information about the members on the Board of Directors and the managing and/or directing employees and submit a copy of the 501(C)(3) approval notification from the IRS.

Note: For large business organizations, furnish only the top 20 compensated managing and/or directing personnel. Social security numbers must be provided for all persons listed in this section.

Applicant must include all managing and/or directing employees for each practice location. Organizations must also complete this section for all corporate officers. Include the name(s) and address(es) of all practice location(s) where this employee manages and/or directs.

Supply all requested information about the managing and/or directing employee's past and present billing relationships with Medicare or other federal health care programs.

Supply all requested information about other entities this managing and/or directing employee managed or directed that previously billed or are presently billing the Medicare or other federal health care programs. Furnish past history for the last 10 years. If data is not known or is incomplete, check the box indicating this.

Supply all requested information about other entities this managing and/or directing employee had ownership interest in that previously billed or are presently billing the Medicare or other federal health care programs. Furnish past history for the last 10 years. If data is not known or is incomplete, check the appropriate box.

Supply all requested adverse legal information about the managing/directing employee(s). If applicable, attach copy(s) of any official documentation related to the adverse legal action identified, including reinstatement notices. If none of the managing/directing employee(s) has had any adverse legal actions, check the "none of these" box.

10. Parent/Joint Venture or Subsidiary Information

If applicant is a subsidiary (wholly or partially owned by another organization or business), or a joint venture (equally owned by another individual(s), organization(s) or business(s)), complete all information requested in this section about the parent company or joint venture. Attach a copy of the parent company's or other owner's IRS Form CP 575 pertaining to this business.

11. Chain Organization Information

When applicable, this section to be completed by Medicare Part A Institutional provider/suppliers ONLY. This includes all institutional chain provider/suppliers that bill fiscal intermediaries (e.g., Home Health Agencies and Skilled Nursing Facilities).

If applicant is in a chain organization, check appropriate action block for this chain, then supply all information requested about the chain home office.

12. Contractor Information (Business Organizations)

This section is to be completed with information about all business organizations that the applicant contracts with that:

Provide all requested information about the contractor's past and present billing relationships with Medicare or Medicaid.

Supply all requested adverse legal action information about the contractor(s). If applicable, attach copy(s) of any official documentation related to the adverse legal action identified, including reinstatement notices. If none of the contractor(s) has had any adverse legal actions, check the "none of these" box.

If a business or group contractor will be reassigning Medicare or other federal health care program benefits to the applicant, an authorized representative of the business or group contractor must complete and sign the Reassignment of Benefits section of this application. See instructions below for additional reassignment of benefits information.

Note: Individuals with whom the applicant contracts with to do business and who will reassign benefits to the applicant must complete the HCFA Form 855R (Individual Reassignment of Benefits Application).

If a currently enrolled provider/supplier is obtaining the services of a new contractor that will be reassigning its benefits, complete only the Application Identification section, the Contractor Information section and the Reassignment of Benefits Statement.

Note: All business contractors must disclose their EINs.

13. Reassignment of Benefits Statement

In general, Medicare and other federal health care programs make payment only to the beneficiary or the individual or entity that directly provides the service.

Reassigned benefits must be within the same federal health care program (e.g., Medicare to Medicare, CHAMPUS to CHAMPUS, etc.).

If the applicant receives payment on behalf of other business organizations for services provided, the other business organization must complete and sign the Reassignment of Benefits Statement. Failure to do so will cause a delay in processing the application and limit the Medicare or other federal health care program contractor's ability to make payment.

This section must be signed by an Authorized Representative of the entity reassigning its benefits to this applicant.

The reassignee is permitted by Federal law to reassign Medicare benefits to an employer, the facility where the service is rendered, a health care delivery system, or agent. For further information on Federal requirements on reassignment of benefits the applicant should contact the local Medicare or other federal health care program contractor before signing the application.

The Legal Business Name of the applicant must be the same as the Legal Business Name of the applicant identified in Section 1 of this application.

Individual practitioners, including individual contractors and group members, who reassign Medicare or other federal health care program benefits to this applicant must complete the HCFA Form 855R. Individual practitioners who are contracted by the applicant, but do not reassign their benefits to the applicant do not need to complete the HCFA Form 855R.

14. Billing Agency/Management Service Organization Address

A Billing Agency is a company contracted by the applicant to furnish all claims processing functions for the applicant's practice.

A Management Service Organization is a company contracted by the applicant to furnish some or all administrative, clerical and claims processing functions of the applicant's practice.

If the applicant currently uses or will be using a billing agency and/or management service organization to submit bills, complete all requested information and attach a current copy of the signed contract between the applicant and the billing agency or management service organization.

Note: If applicant uses a billing agency and/ or management service organization but no written contract exists between applicant and billing agency and/or management service organization, a contract must be written and furnished with this application.

Any change in the contract between the applicant and the billing agency and/or management service organization must be reported to the Medicare or other federal health care program contractor within 30 calendar days of said change.

Note: All billing agencies must disclose their EIN when completing this section of the application.

15. Electronic Claims Submission Information

If applicant plans to submit bills electronically, or would like information about electronic billing, supply a contact name and phone number. The Medicare or other federal health care program contractor will be in contact with further instructions about qualifying for electronic billing submissions.

Note: Electronic Funds Transfer can only be made into an account controlled exclusively by the applicant.

16. Surety Bond Information

Complete all requested information.

Annual surety bond renewals must be reported to the Medicare or other federal health care program contractor using HCFA Form 855C (Change of Information Form).

An original copy of the surety bond must be submitted with this application. Failure to submit a copy of the surety bond will prevent the processing of this application. In addition, the applicant must obtain and submit a certified copy of the agent's Power of Attorney with this application, if the bond is issued by an agent.

17. Contact Person

Provide the full name and telephone number of an individual who can be reached to answer questions regarding the information furnished in this application.

18. Certification Statement

This statement includes the minimum standards to which the applicant must adhere to be enrolled in Medicare or other federal health care programs. Read these statements carefully.

By signing the Certification Statement, the applicant agrees to adhere to all the conditions listed and is aware that the applicant may be denied entry to or revoked from the program if any conditions are violated. The Certification Statement must contain an original signature. Faxed or photocopied signatures will not be accepted.

Note: If applicant is applying as an individual or sole proprietor, applicant must sign and date the Certification Statement. If applicant is applying as an organization or as a group practice, an authorized representative of the organization/group practice must sign the Certification Statement. If applicant has more than one authorized representative, furnish the names and signatures of those authorized representatives who will be directly involved with the Medicare or other federal health care contractors.

b.1 Attachment 1 - Ambulance Service Suppliers

This attachment is to be completed by the applicant for each ambulance service company being enrolled in the Medicare or other federal health care program.

1. State License Information

If applicant is currently State licensed and certified to operate as an ambulance service supplier, complete this section and attach copy(s) of all State licenses and documents.

A copy of applicant's current license or certificate must be attached to this form. The effective date and expiration date must be stated on the license or certificate. Claims will be paid based on these dates. The applicant must provide this office with a copy of the renewal license in order to receive payment after the expiration date.

Effective October 1, 1999, ambulance providers were required to furnish Provider Enrollment Services with current license/certification information in order to maintain billing privileges. (Please reference the August 9, 1999 Medicare Special Notice for more information.) Providers with outdated licensure information on our file were also notified by letter to submit current license/certification information within 30 days.

Future updates to this information will be the responsibility of the ambulance provider. HGSAdministrators will not routinely develop for license/certification information. The absence of current license/certification information will result in claim denials. Providers should send updated license/certification information to:

Provider Enrollment Services
PO BOx 890157
Camp Hill, PA 17089-0157

2. Description of Vehicle(s)

Applicant must identify the type (e.g., automobile, aircraft, boat) of each vehicle, and furnish year, make, model, and vehicle identification number.

The applicant's vehicle(s) must be specially designed and equipped for transporting the sick or injured. It must have customary patient care equipment including, but not limited to, a stretcher, clean linens, first aid supplies and oxygen equipment, and it must have all other safety and lifesaving equipment as required by State and local authorities. If the ambulance will supply Advanced Life Support services, list all the necessary equipment and provide documentation of certification from the authorized licensing and regulation agency for applicant's area of operation.

Vehicles must be regularly inspected and recertified according to applicable State and local licensure laws. Evidence of recertification must be submitted to the Medicare or other federal health care program contractor on an ongoing basis, as required by State or local law.

Note: Air Ambulance

To qualify for air ambulance, the following is required:

3. Qualification of Crew

The ambulance crew must consist of at least two members. Those crew members charged with the care or handling of the patient must include one individual with adequate first aid training, (i.e., training at least equivalent to that provided by the basic and advanced Red Cross first aid courses). If the ambulance crew will provide ALS services, they must list their ALS training courses.

Training "equivalent" to the basic and advanced Red Cross first aid courses include ambulance service training and experience acquired in military service and/or successful completion by the individual of a comparable first aid course furnished by or under the sponsorship of State or local authorities, an educational institution, a fire department, a hospital, a professional organization, or other such qualified organization.

Applicant must enclose a certificate(s) showing that crew members have successfully completed the required first aid training, or give a description of the equivalent military training, where and when it was received. Crew must continue to pursue and complete continuing education requirements in accordance with State and local licensure laws. Evidence of recertification must be submitted to the Medicare or other federal health care program contractor on an ongoing basis, as required by State and local law.

4. Billing Method

FOR MEDICARE ENROLLMENT ONLY

Answer all applicable questions regarding billing methods. Supply the name of the Medical Director and the geographic area the applicant services.

Note: Paramedic Intercept Services:

Check the appropriate box indicating if applicant bills for nautical miles or statute miles.

If applicant is not enrolling in the Medicare program skip this section.

5. Exclusion/Sanction Information

Supply all requested adverse legal action information about the ambulance crew member(s). If applicable, attach copy(s) of any official documentation related to the adverse legal action identified, including reinstatement notices. If none of the ambulance crew members has had any adverse legal actions, check the "none of these" box.

b.2 Attachment 2 - Independent Diagnostic Testing Facilities (IDTFs)
Formerly known as Independent Physiological Laboratories.

This attachment is to be completed by the applicant for each Independent Diagnostic Testing Facility being enrolled in the Medicare or other federal health care program.

Definition:

Independent Diagnostic Testing Facility (IDTF): An entity independent of a hospital or physician's office in which diagnostic tests are performed by licensed, certified non-physician personnel under appropriate physician supervision (e.g., free standing cardiac catherization facility, imaging center).

Note: A cardiac catherization facility which is a physician's office is not an IDTF. The term "free standing" means that the cardiac catherization facility, whether office or IDTF, is independent of a hospital.

1. Identification of Practice Location

Indicate whether this practice location is operating as a mobile unit. If so, provide vehicle identification number and expiration date of vehicle license. If operating mobile units, the vehicles must be regularly inspected and recertified according to State and local licensure laws. Evidence of recertification must be submitted to the Medicare or other federal health care program contractor on an ongoing basis, as required by State and local law.

Identify practice location of IDTF for which this attachment is being completed. If this is a mobile unit, furnish the address where the vehicle is stored.

If applicable, complete all information concerning applicant's practice location.

2. Identification of Supervising/Directing Physician(s)

The information in this section is required only if applicant's State requires that a supervising physician be associated with all IDTFs. Supervising physicians must perform their duties as described by State requirements. Each supervising/directing physician is required to be enrolled as an individual practitioner in Medicare or other federal health care program for which the applicant is applying.

3. Service Performance

List all Current Procedural Terminology, Version 4 (CPT-4) and HCFA Common Procedure Coding System (HCPCS) codes this IDTF or its contractors intend to perform, supervise, interpret, or bill. Describe the setting where the service will be rendered, and identify each physician who will be performing, supervising, and/or interpreting the test results.

4. Referral Records

Explain how referral records, physician's written order and the name of the technician who rendered the service are maintained.

5. Supervising/Directing Physician Exclusion/Sanction Information

Supply all requested adverse legal action information about the supervising/directing physician(s). If applicable, attach copy(s) of any official documentation related to the adverse legal action identified, including reinstatement notices. If none of the supervising/directing physician(s) has had any adverse legal actions, check the appropriate box and skip this section.

6. Signature of Supervising/Directing Physician(s)

Each supervising/directing physician identified in Section 2 of this attachment must sign this attachment.

b.3 Attachment 3 - Home Health Agencies (HHAs)

This attachment is to be completed by all Home Health Agencies for enrollment in the Medicare or other federal health care program.

This attachment must be completed with information about other related business interests in which the HHA itself has a 5% or more ownership interest in or control of the other related business.

In addition, each owner listed in the Ownership Information section and each managing/directing employee listed in the Managing/Directing Employee section who has a 5% or more ownership interest in or controls the other related businesses (as defined below) must complete this attachment.

Copy and submit a separate Attachment 3 for the HHA, each owner and each managing/directing employee, as applicable.

Definitions:

Related to the Provider: Related to the provider (HHA) means that the provider (HHA), to a significant extent, is associated or affiliated with or has control of or is controlled by an organization furnishing services, facilities, or supplies to the provider.

Common Ownership: Common ownership exists if an individual or individuals possess significant ownership or equity in the provider (HHA) and the institution or organization serving the provider (HHA).

Control Interest: Control exists if an owner of the HHA has the power, directly or indirectly, to significantly influence or direct the actions or policies of an organization or institution furnishing services, facilities, or supplies to the provider (HHA).

1. Other Related Business Interests

The HHA itself and all owners and managing/directing employees of the enrolling Home Health Agency are required to furnish identifying information about all other related businesses in which they have a 5% or more ownership in and/or control interest.

In general, businesses than furnish services, facilities, and supplies to the provider (HHA) that are related to the provider (HHA) by common ownership or control interest are to be listed in this attachment.

Supply all requested information about the related businesses.

For purposes of this application, the definition of related businesses as found in 42 CFR § 413.17 which concerns ownership and control, and is limited to businesses who actually do business with the HHA being enrolled will be used. These rules apply regardless of that business' relationship to Medicare, Medicaid or any other health care program, industry, or business.

Examples of related businesses:

Identify the type of business in which the related business is engaged (e.g., durable medical equipment company, consulting firm).

Identify the relationship of the related business to the HHA (e.g., affiliate, joint venture, supplier).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0685. The time required to complete this information collection is estimated at 1 ½ - 3 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: HCFA, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.
 

c. MEDICARE HEALTH CARE PROVIDER/SUPPLIER FORM CHANGE OF INFORMATION INSTRUCTIONS

Change of Information Form-HCFA 855C

General

This form is for reporting changes in provider/supplier information for Medicare or any other federal health care programs. All changes must be requested in writing and have an original signature. Faxed or photocopied signatures will not be accepted. Changes on this form are those made most frequently and may also be reported using HCFA Form 855, 855R, or 855S, as appropriate. All changes not on this form must be reported using HCFA Forms 855, 855R, or 855S.

This form is not to be used to report a change of ownership (CHOW) as defined in 42 CFR § 489.18. A change of ownership requires the new owner to submit a completed HCFA Form 855 (General Enrollment Application). However, the current owner should complete the Potential Termination of Current Ownership section of this form to report that a potential change of ownership may occur.

Check Type of Change Being Reported

Check all changes that apply.

1. Provider/Supplier Identification

Complete provider/supplier's full name, social security number and employer identification number as it is currently on file at the Medicare or other federal health care contractor. The current Medicare or other federal health care program identification number must be provided (e.g. UPIN, NSC, OSCAR, PIN, NPI).

For legal business name, supply the name that the individual or entity uses in reporting to the Internal Revenue Service (IRS), as well as the individual's or entity's employer identification number (EIN) as it is currently on file at the Medicare or other federal health care contractor. If the EIN has changed, a new enrollment application (HCFA Form 855 or 855S) must be completed.

2. Name Change Information

If the provider/supplier is reporting a name change, complete applicable changes to the individual, organization or group name, and/or the "doing business as" name in the appropriate section. If an organization or group is requesting a name change, an IRS Form CP 575 or other official IRS correspondence must be submitted showing the new name and the tax identification number related to the new name.

3. Address/Telephone Number Change Information

Complete provider/supplier's new mailing address. This is where the provider/supplier receives notices from the Health Care Financing Administration or other federal health care programs.
 

Complete the "Pay To" address section if provider/supplier would like payments to go to an address other than the reported "Pay To" address currently on file. This address may be a Post Office box.

If the provider/supplier is reporting a billing agency or management service organization address change, complete identifying information for the current agency or organization and furnish the new address. If the provider/supplier is reporting a NEW billing agency or management service organization, do not use this form. Provider/supplier must complete the Provider/Supplier Identification and Billing Agency/Management Service Organization Address sections in the HCFA Form 855 (General Enrollment Application) and submit a copy of the new billing agreement or contract.

If provider/supplier is changing the location of the current practice, complete all information requested for the new location where provider/supplier will render services to Medicare or other federal health care program beneficiaries. If establishing a concurrent location (in addition to the current location), a new HCFA Form 855 (General Enrollment Application) must be completed for the new location. If deleting a current practice location, check the appropriate box.

A Post Office box or drop box is not acceptable as a practice location address. The phone number must be a number where patients and/or customers can reach the provider/supplier to ask questions or register complaints.

Indicate whether patient records are kept at the new practice location. If records are not kept at the new practice location, supply the physical address where the records are maintained. A Post Office or drop box address is not acceptable for records storage.

4. Provider/Supplier Specialty

Complete this section if provider/supplier's primary and/or secondary specialty is changing.

5. Medicare or Other Federal Health Care Program Billing Number Deactivation Information

If the provider/supplier wishes to deactivate his/her Medicare or other federal health care program billing number, identify the type of Medicare or other federal health care program billing number (e.g. UPIN, NSC, OSCAR, CHAMPUS) and provide the billing number, the effective date of deactivation for that billing number, and the reason for deactivation. Provider/suppliers may deactivate any and all Medicare or other federal health care program billing numbers as necessary by listing all applicable numbers, their types, and effective dates of deactivation as outlined above. However, applicant must notify each individual federal agency regarding the deactivation of the number(s) under that agency's control.

6. Addition/Deletion of Authorized Representative

Complete this section if provider/supplier wishes to delete a currently listed authorized representative, or the provider/supplier would like to report a new authorized representative.

An Authorized Representative is the appointed official (e.g., officer, chief executive officer, general partner, etc.) who has the authority to enroll the entity in Medicare or other federal health care programs as well as to make changes and/or updates to the applicant's status, and to commit the corporation to Medicare or other federal health care program laws and regulations.

The original signature of the new authorized representative is required to add a new authorized representative.

7. Surety Bond Information

This section to be completed by all providers/suppliers for which a surety bond is required.

Annual renewals must be reported to the Medicare or other federal health care program contractor using this Change of Information form - HCFA Form 855C.

An original copy of the surety bond must be submitted with this form. Failure to submit an original copy of the surety bond will prevent the processing of this form. In addition, the surety bond company must submit a certified copy of the agent's Power of Attorney with this form, if the bond is issued by an agent.

Note: It is the responsibility of the provider/supplier to obtain and submit with this form a certified copy of the surety bond agent's Power of Attorney from the surety bond company, if the bond is issued by an agent.

8. Potential Termination of Current Ownership

When a business or organization is planning a change of ownership which is in accordance with the provisions for Change of Ownership (CHOW) as defined in 42 CFR § 489.18, the current owner must furnish the name of the potential new owner and the projected effective date of the potential change of ownership as soon as the possibility of such an action is known to the current owner.

Note: This section is not to be completed when the existing business/organization is adding or deleting a new owner. Changes of individual owners should be reported using the appropriate sections of HCFA Form 855 (General Enrollment Application).

9. Effective Date of Change(s)

Report the date all listed changes are effective.

10. Attestation Statement

Sign and date this form attesting to the accuracy of the requested changes. If changes are being reported on an individual provider/supplier, then that individual provider/supplier must sign this form. If the changes are being reported for an organization or group practice, an authorized representative of the organization or group practice must sign this form to confirm the requested change(s).

d. MEDICARE HEALTH CARE PROVIDER/SUPPLIER ENROLLMENT APPLICATION
INSTRUCTIONS

Individual Reassignment of Benefits Application HCFA 855R

General

This application is to be completed for any individual who will reassign their benefits to an eligible entity.

THIS REASSIGNMENT OF BENEFITS APPLICATION MUST BE COMPLETED FOR THE FOLLOWING SITUATIONS:

Initial Enrollment: A newly enrolling entity will complete this application for each individual who will be reassigning Medicare or other federal health care program benefits to the enrolling entity.

Note: All entities and individuals must be currently enrolled or concurrently enrolling in the Medicare or other federal health care program in which they want to reassign their benefits.

Adding a Reassignment: An individual practitioner is currently enrolled in Medicare or another federal health care program(s) and will reassign benefits to an entity that is currently in the Medicare or the same other federal health care program(s).

Deleting a Reassignment: An individual that has been reassigning benefits to an entity is terminating that reassignment. No reassigned claims will be paid to the entity for dates of service after the effective date of deletion.

Changing Status of an Individual: An individual reporting a change in the type of income tax withholding or the practice location(s) with which he or she is associated.

Changes of Ownership (CHOW): This application is to be completed by all individual contractors, physicians, and other non-physician practitioners who will be reassigning their Medicare or other federal health care benefits to a new or a prospective new owner due to the occurrence or potential occurrence of a CHOW.

Definitions

Authorized Representative: The appointed official (e.g., officer, chief executive officer, general partner, etc.) who has the authority to enroll the entity in Medicare or other federal health care programs as well as to make changes and/or updates to the applicant's status, and to commit the corporation to Medicare or other federal health care program laws and regulations.

The Authorized Representative may be contacted to answer questions regarding the information furnished in this application.

Change of Ownership (CHOW): This term applies to certain limited circumstances as defined in 42 CFR § 489.18 as described below.

A new or prospective new owner must complete this application to report new or prospective new ownership. In addition, the applicant must also submit an Individual Reassignment of Benefits Application (HCFA Form 855R) identifying all individuals who will reassign their benefits to the applicant.

Entity: A business organization (e.g., group practice, hospital, clinic, health care delivery system) that is eligible to receive reassigned benefits as permitted under 42 CFR 424.80.

Individual: A physician or other individual practitioner who is eligible to receive Medicare or other federal health program benefits and is permitted to reassign his or her benefits to an eligible entity.

Medicare Identification Number: This number uniquely identifies individuals and entities as Medicare providers/suppliers and is the number used on claim forms. The Medicare identification number is also known as Medicare Provider Number and Provider Identification Number (PIN). Examples of Medicare Identification Numbers are the UPIN, OSCAR number and NSC number.

National Provider Identifier (NPI): This number is assigned using the National Provider System to identify health care provider/suppliers. In the future, it will replace the Medicare Identification Number.

Reassignee: An individual or organization that allows another organization to bill Medicare or other federal health care programs on their behalf for services rendered.

APPLICATION COMPLETION INSTRUCTIONS

Check the box indicating the reason this application is being completed.

1. Entity Identification

Complete information identifying the entity to whom Medicare or other federal health care program benefits are being reassigned.

The legal business name of the entity must be the same name the entity uses in reporting to the Internal Revenue Service.

Note: The entity must provide their EIN.

2. Individual Identification

Complete this section for each individual who is reassigning or terminating reassignment of his or her Medicare or other federal health care program benefits to the entity shown in the Entity Identification section. Indicate the type of action being reported.

Note: This form may be used to add or delete an individual who is reassigning or has previously reassigned his or her benefits to the entity.

3. Practice Location(s)

Complete all information requested for each location where the individual identified in the Individual Identification section (above) will render services to Medicare or other federal health care program beneficiaries on behalf of the entity identified in the Entity Identification section. The entity must have enrolled, or be in the process of enrolling, all of these practice locations using the HCFA Form 855 (General Enrollment Application).

4. Billing Agency/Management Service Organization Address

A Billing Agency is a company contracted by the applicant to furnish all claims processing functions for the applicant's practice.

A Management Service Organization is a company contracted by the applicant to furnish some or all administrative, clerical and claims processing functions of the applicant's practice.

Complete this section if the entity shown in the Entity Identification section currently uses a billing agency and/or management service organization to submit bills.

5. Reassignment of Benefits Statement

This Reassignment of Benefits Statement must be completed when an individual practitioner will be reassigning his or her benefits to an eligible entity (employer, facility, health care delivery system, or agent).

The Medicare law prohibits us from paying benefits due a physician or other supplier of health care items and services, to another person or organization, under a reassignment or power of attorney or under any other arrangement whereby that other person or organization receives those payments directly. Exceptions to this rule include:

- The agent receives the payment under an agency agreement with the physician or supplier;
- The agent’s compensation is not related in any way to the dollar amounts billed or collected;
- The agent’s compensation is not dependent upon the actual collection of payment;
- The agent acts under instructions which the physician or supplier may modify or revoke at any time; and
- The agent, in receiving the payment, acts only on the physician’s or supplier’s behalf.

A physician or supplier should notify us immediately if:

A physician or other eligible recipient of assigned payment who hereafter enters into or continues such a prohibited payment arrangement may have his/her right to receive assigned payment revoked.

In general, Medicare and other federal health care programs only make payments to the beneficiary or the individual or entity that directly provides the service. However, an individual may reassign benefits to an eligible entity as defined in 42 CFR 424.80.

The Legal Business Name of the entity must be the same as the Legal Business Name of the entity identified in Section 1 of this application.

The individual reassigning his or her benefits must sign this statement. Failure to complete and sign the Reassignment of Benefits Statement will cause a delay in processing the application and limit the Health Care Financing Administration's or other federal health care program's ability to make payment.

Note: For further information on Federal requirements on reassignment of benefits, the reassignee should contact his or her Medicare or other federal health care program contractor before signing this application.

6. Contact Person

Provide the full name and telephone number of an individual who can be reached to answer questions regarding the information furnished in this application.

7. Attestation Statement

The Authorized Representative of the entity that will receive payments must sign and date this application, attesting to the accuracy of the information provided and certifying that the entity applying to receive payments is eligible to receive reassigned benefits.

3.3 SUPPLEMENTAL Provider Enrollment Instructions

The following information is to guide you in completing certain sections of the HCFA 855 (1/98), 855C (1/98) and HCFA 855R (1/98-replaced the HCFA 855G) forms.

a. HCFA 855

The information listed below, in some cases, supersedes the "Application completion Instructions" on page III of the application. Because of budgetary constraints, we cannot change the application instructions at this time.

We are no longer requiring the following applicant types to complete the corresponding data fields:

Complete ALL sections (subsections) that are applicable to the type of provider you would like to enroll as and return all pages of this application. If a section is not applicable, please indicate by checking the appropriate box at the beginning of the section. If the section does not have a "not applicable" box, please indicate by writing "N/A" in the section.

a.1 What type of provider are you? What type of provider number are you applying for?

Complete sections: 1A, 1D, 2, 3, 4 (if applicable), 5, 6, 7, 9, 14, 15 (if applicable), 17, 18, and include copies of your State license and degree or certificate (diploma). For physician assistants, you must submit a HCFA 855R with your HCFA 855 to reassign benefits to your employer.

Complete sections: 1A, 1B, 1D, 2, 3, 4 (if applicable), 5, 6, 7, 9, 14, 15 (if applicable), 17, 18 and include IRS form CP575 and a copy of your State license.

Complete sections: 1B, 1D, 2 (if State requires license), 5, 6, 7, 8, 9, 10 (if applicable), 11 (if applicable), 12, 14, 15 (if applicable), 17, 18, and include IRS form CP575. If you are an ambulance supplier, ambulatory surgical center or a CLIA, please submit a copy of your State license. Ambulance suppliers must complete the 855 in conjunction with Attachment 1. IDTF’s must complete the 855 in conjunction with Attachment 2.

Note: Ambulatory Surgical Centers and Portable X-ray suppliers – you must submit your 855 Enrollment application to the Pennsylvania State Department of Health. The State will notify Medicare once they have performed a survey/certification process so that we can enumerate and assign a provider identification number for billing purposes.

Complete sections 1C, 1D, 6A, 6B, 6C, 14 (if applicable), 15 (optional), 17 and 18. Submit a copy of the letter issued by the Health Care Financing Administration’s Central Office issuing an indirect billing number. Include the contract number (H----) of the enrolling entity on the HCFA 855 form. Verify that all of your contracted physicians and eligible non-physician practitioners (e.g., nurse practitioners, physician assistants, physical/occupational therapists and Certified Registered Nurse Anesthetists (CRNA’s) have a PIN/UPIN in order to receive payment for any indirect payment procedures performed that are billable. Payment will not be made when a physician’s or eligible non-physician practitioner’s PIN/UPIN is not on the claim form. If the eligible physician or non-physician practitioners do not have a PIN/UPIN, they must complete and submit a HCFA 855 enrollment (See instructions for enrollment as an “individual”).

Complete sections:(for individuals): 1A, 1D, 2 (if required), 5, 6, 7, 8, 9, 14, 15 (if applicable), 17, 18 and include IRS CP575. (for organizations): 1B, 1D, 2 (if required), 5, 6, 7, 8, 9, 14, 15 (if applicable), 17, 18 and include IRS CP575.

Complete sections 1C, 1D, 2 (if State requires license), 5, 6, 7, 8, 9, 10 (if applicable), 11 (if applicable), 14, 15 (if applicable), 17, 18 and include IRS form CP575. If applying for a partnership, include a copy of your partnership agreement (see page III of the 855 instructions). For each group member, or partner, complete form HCFA 855R to reassign benefits to the group account/partnership.

b. HCFA 855R

Group Member: Use form HCFA 855R.

All sections of this application must be completed. The group member must sign section 5 and an authorized representative from the group account must sign section 7. We must receive original signatures. Signature stamps, faxed/xeroxed copies are not acceptable.

c. HCFA 855C

Change of Information: Use form HCFA 855C

To change your name (without a change in tax identification number), pay-to address, e-mail address, practice location address, telephone number(s), fax numbers, billing agency address, authorized representative, mailing address, specialty, etc., use form HCFA 855C. Also use this form for the deactivation of Medicare billing number, surety bond changes or renewal information and a potential termination of current ownership. Sections 1, 9 and 10, along with the appropriate section for the change must be completed.

d. Provider Enrollment Reminders

Your enrollment applications and requests to update data on our files are very important. To help us expedite the processing of this information and avoid returning the request to you, please be sure to:

  1. Sign your application/request. The signature must be an original. A stamped/copied/faxed signature is not acceptable.
  2. Submit a copy of your diploma and license if you are enrolling as an individual or sole proprietor.
  3. Submit 855R Individual Reassignment Applications if you are an entity who has physicians/practitioners reassigning benefits to you (i.e., assignment accounts/groups).

Use these forms to enroll or submit updates to your provider file.

HCFA 855 General Enrollment Application - This application should be used for new enrollments and re-enrollments into the Medicare program. It can also be used for any type of update to your provider file.

HCFA 855C Change of Information Application - This application can also be used for updates to your provider file. The only two exceptions are adding additional locations, or the addition of a new billing agency. These two exceptions must be reported on the HCFA 855 General Enrollment Application.

3.4 Helpful Hints for Completing the HCFA 855 & 855R

a. When changing your tax identification number:

1. When requesting a change from an Employer Identification Number (EIN) to a Social Security Number (SSN) a HCFA 855 is not required. You may submit this change of information on form HCFA 855C.

2. When requesting a change from a Social Security Number (SSN) to an Employer Identification Number (EIN), you must submit a HCFA 855 form along with a copy of IRS CP575.

3. When requesting a change from an Employer Identification Number (EIN) to another Employer Identification Number (EIN), and this change is accompanied by a name change and/or an ownership change, a HCFA 855 is required and a new Provider Identification Number (PIN) will be assigned.

4. When requesting a change from an Employer Identification Number (EIN) to another Employer Identification Number (EIN), and this change is not accompanied by a name or ownership change, a HCFA 855 is required. A new Provider Identification Number is possible, this is the provider’s option based on certain tax ramifications, e.g., needing separate 1099’s at the year’s end.

b. HCFA 855 General Enrollment Application

Mandatory Submission of Social Security Account Numbers (SSNs) and Employer Identification Numbers (EINs) effective September 3, 1999

Section 4313 of the Balanced Budget Act (BBA) of 1997 strengthened provider enrollment efforts by requiring both SSNs and and EINs on the form HCFA 855, the Medicare General Enrollment Application and its attachments, i.e., form HCFA 855C, 855R and 855S. Effective September 3, 1999, Medicare carriers will require the applicants and/or entities listed on the 855 forms to provide the SSN/EIN, as well as those for other persons and organizations associated with the applicant as defined in 42CFR, Part 420, Subpart C (Disclosure of Ownership and Control Information). Prior to September 3, 1999, carriers routinely requested SSN/EIN information but did not have the authority to mandate the submission of this data. Failure to provide this information will result in delays and possibly denial into the Medicare Program; existing providers may have their Medicare numbers revoked.

1. Please be sure that you print or type all information so it is legible.
2. Please check the appropriate box next to the following:

3. If applying for an individual provider number, and you intend to join a group account, please keep in mind that you should be completing the 855 with your personal information, not information for the group account. Also, when enrolling as an individual, remember to enclose a copy of each degree or certificate (diploma) as instructed in Section 3 on page 2 of the HCFA 855 application.

Section 1D – Don’t forget your Employer Identification Number (EIN) or your Social Security Number (SSN).

Section 2 – Individuals must include a notarized or "certified true" copy of their professional and business license. (Groups must provide a copy of the IRS CP575 letter from the IRS). For a CRNA or CNS, please send a copy of your certification along with your license.

Section 6 – The practice address must be a specific street address as recorded by the U.S. Postal Service. Do not indicate an intersection or P.O. Box. Also, give the telephone number for the practice location(s) where the patient can contact the provider, not the billing office telephone number. You may receive more than one (1) provider identification number depending on how many practice locations you have and what physician fee locality the locations are in.

Section 6C – the "pay to" address is where all reimbursements and correspondence will be sent.

Section 6D&E – Don’t forget to fill in the name of the managing/directing employee and their SSN, and the CLIA and FDA Mammography Certification Numbers. If these sections do not apply, simply indicate by writing "N/A."

Section 9 – If you are a non-profit organization, you should complete this section with information about the members of the Board of Directors and the managing and/or directing employees and submit a copy of the 501(c)(3) approval notification from the IRS.
Also, if you are a non-profit organization, the ownership and parent/joint venture sections would not be applicable.

Section 14 – Please remember to provide the Employer Identification Number (EIN) for the billing agency/management service organization. Also, remember to attach a signed copy of the billing agreement for review.

If you acquire a new billing agent, a HCFA 855 General Enrollment Application must be submitted, along with a copy of the billing agreement, to the carrier for review. If there is information that has been updated to an existing billing agent, you must submit a HCFA 855C Change of Enrollment Information Application outlining the change along with a copy of the updated billing agreement to the carrier for review.

Section 16 – Surety Bonds are applicable for Home Health Agencies.

Section 18 – This section must contain an ORIGINAL signature by an individual whose signature binds the supplier to Medicare rules and requirements:

An Authorized Representative must be an individual who can obligate the group/organization. He/she must be an officer or a senior or majority partner of the business organization that is applying for the Medicare billing number. This individual should be listed in the application under owners, managing/directing employee, etc.

If applicant has more than one authorized representative, all names and signatures of those authorized representatives who will be directly involved with the Medicare program must be provided.

c. HCFA 855R Individual Reassignment of Benefits Group Members Application

Section 5 - The group member must sign and date this section. The signature must be an original. Stamped/faxed/copied signatures are not acceptable.

Section 7 - The authorized representative of the entity that will receive payments must sign and date this section attesting to the accuracy of the information provided and certifying that the entity applying to receive payments is eligible to receive reassigned benefits. An authorizing representative must be an officer, chief executive officer, or senior or majority partner of the business organization that is applying for or currently has the Medicare billing number. The signature must be an original. Stamped/faxed/copied signatures are not acceptable.

3.5 Instructions for Non-Physician Enrollment

When submitting a HCFA 855 application for enrollment, you must complete sections 1A, 1D, 2, 3, 4, 5, 6, 7, 9, 14, 15, 17, 18 and include a copy of your State license. Also, for those specialties with an asterisk (*), please complete the appropriate questionnaire included with this package.

a. *CLINICAL PSYCHOLOGIST (CP)

To qualify as a CP, a practitioner must meet the following requirements:

For further information concerning your specialty, please refer to the Medicare Carriers Manual Section 2150.

b. *INDEPENDENTLY PRACTICING PSYCHOLOGIST

Psychologists are considered independently practicing when:

A psychologist practicing in an office located in an institution may be considered an independently-practicing psychologist when both of the following conditions exist:

For further information concerning your specialty, please refer to the Medicare Carriers Manual Section 2070.2.

c. *CLINICAL SOCIAL WORKER

Clinical Social Worker Defined - Section 1861(hh) of the Act defines a "clinical social worker" as an individual who:

For further information concerning your specialty, please refer to the Medicare Carriers Manual Section 2152.

d. PHYSICIAN ASSISTANT (PA)

Definition of PA.--In order to provide covered PA services, the PA must meet the applicable State requirements governing the qualifications for PAs and at least one of the following 3 conditions for State licensure:

1. Is currently certified by the National Commission on Certification of Physician Assistants to assist primary care physicians;
2. Has satisfactorily completed a program for preparing PAs that:

3. Has satisfactorily completed a formal educational program for preparing PAs that does not meet the requirements of subsection A.2 and was assisting primary care physicians for a total of 12 months during the 18-month period immediately preceding January 1, 1987.
Employment Relationship.--Payment for services of a PA may be made only to the actual employer of the PA. The employer may be a physician, medical group, professional corporation, hospital, SNF, or NF. There must be a valid employment arrangement, and the test to be used to determine its validity is the common law test of an employer-employee relationship. A group of PAs may not incorporate and bill for their services. An ambulatory surgical center is not an appropriate employer for these purposes.

In order to reassign benefits to the employer, a HCFA 855R (Individual Reassignment of Benefits) must be completed and submitted with the HCFA 855 General Enrollment Application.

Please supply the supervising physician's name in Section 6D and information regarding the supervising physician in Section 9 under the Managing/Directing Employees of the HCFA 855 General Enrollment Application.

For further information concerning your specialty, please refer to the Medicare Carriers Manual Section 2156.

e. CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA)

A CRNA is a registered nurse who is licensed by the State in which the nurse practices and who:

In conjunction with the State license, also include a copy of your certification/recertification issued by the Council on Certification/Recertification of Nurse Anesthetists.

For further information concerning your specialty, please refer to the Medicare Carriers Manual Section 16003.

f. NURSE PRACTITIONERS (NP)

For his or her services to be covered, an NP must:
1. Be a registered professional nurse who is currently licensed to practice in the State in which the services are furnished;

2. Satisfy the applicable requirements for qualification of NPs of the State in which the services are furnished; and

3. Meet at least one of the following requirements:

For further information concerning your specialty, please refer to the Medicare Carriers Manual Section 2158.

g. CLINICAL NURSE SPECIALIST (CNS)

For his or her services to be covered, a CNS must satisfy the applicable requirements for qualifications of a CNS in the State in which the services are performed.

For further information concerning your specialty, please refer to the Medicare Carriers Manual Section 2160.

h. CERTIFIED NURSE MIDWIFE

A certified nurse-midwife is a registered nurse who has successfully completed a program of study and clinical experience in nurse-midwifery, meeting guidelines prescribed by the Secretary, or who has been certified by an organization recognized by the Secretary. The Secretary has recognized certification by the American College of Nurse-Midwives and State qualifying requirements in those States that specify a program of education and clinical experience for nurse-midwives for these purposes. A nurse-midwife must:

1. Be legally authorized under State law or regulations to practice as a nurse-midwife and have completed a program of study and clinical experience for nurse-midwives, as specified by the State; or

2. If the State does not specify a program of study and clinical experience that nurse-midwives must complete to practice in that State, the nurse-midwife must:

For further information concerning your specialty, please refer to the Medicare Carriers Manual Section 2154.

3.6 Medicare Specialties

a. Physician Codes:

Addiction Medicine
Allergy/Immunology
Anesthesiology
Cardiac Surgery
Cardiology
Chiropractor (July 1973)
Colorectal Surgery
Critical Care (Intensivists)
Dermatology
Diagnostic Radiology
Emergency Medicine
Endocrinology
Family Practice
Gastroenterology
General Practice
General Surgery
Geriatric Medicine
Gynecological Oncology
Hand Surgery
Hematology
Hematology/Oncology
Infectious Disease
Internal Medicine
Interventional Radiology
Maxillofacial Surgery
Medical Oncology
Nephrology
Neurology
Neuropsychiatry
Neurosurgery
Nuclear Medicine
Obstetrics/Gynecology
Ophthalmology
Optometry
Oral Surgery (Dentists Only)
Orthopedic Surgery
Osteopathic Manipulative Therapy
Otolaryngology
Pathology
Pediatric Medicine
Pheripheral Vascular Disease
Physical Medicine Rehabilitation
Plastic and Reconstructive Surgery
Podiatry
Preventative Medicine
Psychiatry
Pulmonary Disease
Radiation Oncology
Rheumatology
Surgical Oncology
Thoracic Surgery
Unknown Physician Specialty
Urology
Vascular Surgery

b. Non-Physician Provider Codes

Anesthesia Assistants (1/1/89)
Audiologist (Billing Independently)
Certified Clinical Nurse Specialists
Certified Nurse Midwife (7/1/88)
Certified Registered Nurse Anesthetist
Clinical Psychologist (Billing Independently)
Clinical Psychologists
Licensed Clinical Social Worker
Nurse Practitioner
Occupational Therapists (Effective 7/1/87)
Optician
Physical Therapists (Independently Practicing)
Physician Assistant
Unknown Physician Specialty

c. Supplier Codes

All Other Supplier, e.g., Drug Stores
Ambulance Service Supplier, e.g, Private Ambulance Companies, Funeral Homes, Public Health or Welfare Agencies (Federal, State and Local)
Ambulatory Surgical Center
Department Store
Grocery Store
Home Health Agency
Hospital
Independent Diagnostic Physiological Laboratory
Independent Laboratory (Billing Independently)
Intermediate Care Nursing Facility
Mammography Screening Center
Medical Supply Company with Respiratory Therapist
Nursing Facility, Other
Pharmacy
Portable X-ray Supplier (Billing Independently)
Skilled Nursing Facility
Voluntary Health or Charitable Agencies(e.g., National Cancer Society, National Heart Association, Catholic Charities)

d. Group Practice Codes

Multi-Specialty Clinic or Group Practice

3.7 Applying for Other Provider Identification Numbers

a.Independent Diagnostic Testing Facilities (IDTFs)

A new entity referred to as an Independent Diagnostic Testing Facility (IDTF) has eliminated the provider category of Independent Physiological Laboratories (IPLs). Effective for diagnostic procedures performed on or after January 1, 1998, Medicare will pay for diagnostic procedures under the physician fee schedule only when performed by a physician, a group of physicians, an approved supplier of portable x-ray services, or an indenpendent diagnostic testing facility (IDTF). An IDTF may be a fixed location, a mobile entity, or an individual non-physician practitioner. It is independent of a physician's office or hospital; however, these rules apply when an IDTF furnishes diagnostic procedures in a physician's office.

Note: For additional information on IDTFs supervising requirements, refer to our website at: www.hgsa.com/professionals/idtf.shtml.


b.Clinical Social Worker (CSW)

A clinical social worker is defined as an individual who:

Clinical social workers will need to complete a questionnaire to provide the above information in addition to the Medicare Provider/Supplier Enrollment Application when applying for a provider identification number. If you have any questions concerning the application, you may use the telephone numbers referenced in Chapter 1. The customer service representatives will be happy to assist you with the completion of your application.

c.Psychologists

To qualify as a clinical psychologist, a practitioner must meet the following requirements:

Psychologists will need to complete a questionnaire to provide the above information in addition to the completion of a Medicare Provider/Supplier Enrollment Application when applying for a provideridentification number. If you have any questions concerning the application, you may use the telephone numbers referenced in Chapter 1. The customer service representatives will be happy to assist you with the completion of your application.

d. Nurse Practitioner

A nurse practitioner must meet the following eligibility requirements:

Meet at least one of the following requirements:

Be currently certified as a primary care nurse practitioner by the American Nurses' Association or by the National Board of Pediatric Nurse Practitioners and Associates; or

Have satisfactorily completed a formal one year educational program for preparing registered nurses to perform an expanded role in the delivery of primary care. The education includes supervised clinical practice and at least 4 months (in the aggregate) of classroom instruction, and awards a degree, diploma, or certification for successful completion of the program; or

Have successfully completed a formal educational program (that does not qualify under the immediately preceding requirement) for preparing registered nurses to perform an expanded role in the delivery of primary care. The performance of that expanded role must be for a total of 12 months during the 18-month period immediately preceding February 8, 1978, (the effective date for the provision of the service of nurse practitioner as reflected in conditions for the certification for rural health clinics).

Nurse Practitioners will need to complete a send their nurse practitioner license to provide the above information in addition to the Medicare Provider/Supplier Enrollment Application when applying for a provider identification number. If you have any questions concerning the application, you may use the telephone numbers referenced in Chapter 1. The customer service representatives will be happy to assist you with the completion of your application.

e.Certified Registered Nurse (CRN)

Certified registered nurses should provide the following information in addition to the completion of a Medicare Provider/Supplier Enrollment application when applying for a provider identification number:

If you have any questions concerning the application, you may use the telephone numbers referenced in Chapter 1. The customer service representatives will be happy to assist you with the completion of your application.

f. Physical Therapist

Effective January 1, 1999, Physical and Occupational Therapists are no longer required to have a state survey completed as part of the enrollment process. Applications should be completed and returned directly to Provider Enrollment Services.

g. Audiologist

An audiologist should complete the Medicare Provider/Supplier Enrollment Application when applying for a provider identification number. If you have any questions concerning the application, you may use the telephone numbers referenced in Chapter 1. The customer service representatives will be happy to assist you with the completion of the application.

h. Ambulance

Ambulance companies must meet certain state and local requirements to provide emergency medical services. The Health Care Financing Administration (HCFA) also mandates that certain criteria must be met by ambulance companies providing services to Medicare beneficiaries.

 

Ambulance companies should complete the Medicare Provider/Supplier Enrollment Application, as well as, attachment 1 when applying for a provider identification number. If you have any questions concerning the application, you may use the telephone numbers referenced in Chapter 1. The customer service representatives will be happy to assist you with the completion of the application and attachment 1.

3.8 Provider Identification Numbers (PIN) Deactiviated for Inactivity

Carriers are instructed by the Health Care Financing Administration to routinely search their files to identify providers that have not billed the Medicare Part B program in the prescribed time frame, and to deactivate the provider’s billing status. Per Section 1030 of the Medicare Carrier’s Manual, an inactive provider is one who has not billed the Medicare program for 12 consecutive months. Providers meeting the “inactivity” threshold will be notified in writing by the Provider Enrollment Services department that their billing status has been deactivated.

Providers that have been deactivated due to inactivity must complete a new HCFA 855 enrollment application in order to be considered for re-enrollment into the Medicare Part B program. Providers that have been deactivated and bill electronically will also need to re-enroll for electronic billing by completing the EDI Enrollment Form (8259). The Provider Enrollment Services department will then notify the provider by letter once the provider is eligible to bill, and EDI Services will notify the provider by letter once the provider is eligible to begin electronic billing again (if applicable). Failure to re-enroll in the program will result in claim denials.

3.9 Unique Provider Identification Number (UPIN)

a.Services Requiring a UPIN

All Medicare claims reporting referred or ordered services must include the name and unique provider identification number (UPIN) of the provider who referred or ordered the services to be rendered.

All Medicare claims reporting the following services must always report the name and UPIN of the referring or ordering provider. If this information is not reported, the claim will be rejected. Claims that are rejected must be resubmitted for payment with the appropriate UPIN information reported.

The following situations require the UPIN of the referring or ordering provider:

b. Receipt of a Unique Provider Identification Number

All physicians and health care practitioners who treat and/or refer Medicare patients should receive a Unique Provider Identification Number (UPIN) prior to billing Medicare for services rendered. (Please refer to chapter 9, block 17A for a surrogate UPIN which should be used when the ordering/referring physician has not yet been assigned a UPIN.) A UPIN will be issued to the individual physician and/or health care practitioner upon approval of the Medicare Provider/Supplier Enrollment Application.

c. Charge Areas/Payment Locality

The number of charge areas for state of Pennsylvania within HGSAdministrators jurisdiction are defined as follows for 1998 :

Pennsylvania - Two charge areas.
01 = Bucks, Chester, Delaware, Montgomery and Philadelphia counties
99 = Remainder of the state