Most Commonly Asked Questions
Which providers must complete the HCFA 855 application?
Any health care provider entering the Medicare program or any existing Medicare certified provider undergoing a Change of Ownership after July 1, 1997 must complete a HCFA 855 application.
When should I complete a HCFA 855C form?
Any Medicare certified provider which has completed a HCFA 855 form in the past, because either they are a new Medicare facility since July 1997 or the have undergone a Change of Ownership after July 1997, must complete a HCFA 855C form to report any changes of information, such as those listed on the top of the form. Any other health care provider which has not completed a HCFA 855 form may also complete a HCFA 855C form to report these changes, but they are not required to do so. For these providers, informing the State Agency and Fiscal Intermediary with a letter printed on their official letterhead will suffice.
May I photocopy the forms?
Photocopies of the official OMB HCFA 855 and HCFA 855C forms are permitted and sometimes are necessary due to multiple information being required in certain sections on the application.
May I automate the forms?
The Provider Enrollment instructions now allow facilities to automate the HCFA 855 form, until such time as the official automated form is made available by HCFA on the Internet. From that point forward, only this official automated version may be used. At no time, may the form be altered in any way to change the wording or required fields in any section.
Which sections must I complete?
You must complete all sections of the application which apply to your facility. Except for sole proprietors, section 1A, 1C, 3, and 4 will not apply to Part A applicants. Section 1B, 6, 17, 18 and the General Application Section must be completed by all Part A applicants. All other sections may be completed, depending on your particular organization.
Is my facility accredited?
Currently, HCFA recognizes the JCAHO accreditation organization. If you facility has been accredited by this organization, then please mark this field to indicate so.
Am I provider-based?
There are several requirements which must be met before a facility is considered to be provider-based, including sharing staff, a common governing board, and close proximity to the parent provider. If you believe that your facility is provider-based, please contact us for additional information.
What is a distinct part unit?
A distinct part unit is a psychiatric or rehabilitation unit of a hospital which has been excluded from the prospective payment system. For further clarification, please review HCFA Pub. 7, Section 3106.
Which licenses are required to be submitted?
Currently, for Part A organizations, all required business and professional licenses must be submitted. This includes, but is not limited to, a tax privilege license, a county business license, a certificate of incorporation from the Secretary of States office, and the health license granted by your State Agency.
When should I complete the Prior Practice Location (Section 7)?
If your facility previously billed Medicare or Medicaid, prior to beginning your current operations, then this section must be completed.
Who should be listed as owners of the organization?
All owners with a 5% or greater controlling interest must be listed. If your facility is owned by another corporation, then the information about that corporation must be completed in Section 8. If your facility is a non-profit foundation with no defined owners or if your facility is government-owned, state this fact in Section 8, and complete Section 8 for all board members.
What is an IRS Form CP 575?
The IRS Form CP 575 is the actual letter you receive from the IRS granting your Employer Identification Number. Please refer to the attached example.
Do I have to list all facilities that were ever managed or owned by any of the owners of our organization?
Yes. For the past 10 years, this information about each identified individual must be completed in its entirety.
Who is considered a managing/directing employee?
A managing/directing employee is generally defined as any employee who has day-to-day control over the organization, including hiring and firing capacity. Examples, would include, but are not limited to, administrator, director, chief financial officer, chief operating officer, chief executive officer, and Board of Directors. Examples of those which would probably not qualify are director of nursing (unless this individuals responsibility includes managing the staff), and medical director (unless this individual has the ability to hire and fire employees, as well). Ultimately, each applicant must decide which individuals meet this criteria. A good basic rule is to include any individual which you believe may qualify as a managing/directing employee.
Am I a part of a Chain Organization?
A Chain Organization consists of a group of two or more health care facilities or at least one health care facility and any other business or entity owned, leased, or through any other device, controlled by one organization. (See HCFA Pub. 15-I, Chapter 10 for definitions of common ownership and control.)
To whom do reassignment of benefits apply?
Generally, the reassignment of benefits only applies to individuals. For example, a physician may reassign his/her Medicare benefits to the organization where he/she works, in exchange for the organization providing certain services, including clerical support and billing services. Retaining the services of a billing agent/management company does not qualify as a reassignment of benefits. If you feel that this section applies to your organization, please contact your Fiscal Intermediary for further instructions.
Who should be listed as the contact person?
The contact person should be the person at your organization who is responsible for ensuring that your facility completes the Provider Enrollment process and who can answer any questions about information on the application. Please note that if the application must be returned for additional information, it will be returned to the individual listed in this section.
Who may sign the application?
Only an officer or owner of the organization may sign the application.
What additional information is needed with the HCFA 855 form?
Please be sure to include all applicable business and professional licenses, and IRS form CP 575, and any billing agent/management company contracts (if applicable).
What if there is so much information in a section that it would be too cumbersome to make photocopies of each section?
For larger organizations with many related Medicare providers, you may submit the supplemental information required in Sections 8 & 9 on a report generated from your own system, as long as the information from all of the required fields is present. This may eliminate your need to make numerous photocopies of these sections.
How in depth should I go when completing the information?
You should be as thorough as possible, including all information which you believe to be relevant. It is our responsibility to verify the accuracy of the information on the application, and we will ask you about any discrepancies we find.
How long until I receive my provider number?
Generally, you should expect to receive your Certification (Tie-In) letter form HCFA within four to six weeks from the Fiscal Intermediarys completion of your HCFA 855 application.