Enrollment Documentation Requirements by Provider Type - JE Part A
Enrollment Documentation Requirements by Provider Type
By selecting a specific Provider Type for the Medicare Part A Provider Enrollment, you will see a list of required documentation needed for your application form based on the specialty. Each Type has certain documentation that is needed in order to process an application request, along with special documentation based on that specialty type. Refer to these lists to ensure all required information is submitted prior to submitting the CMS-855A application, to avoid delays in the processing time.
- Community Mental Health Center (CMHC)
- Comprehensive Outpatient Rehabilitation Facility (CORF)
- Critical Access Hospital (CAH)
- End Stage Renal Disease Facilities (ESRD)
- Federally Qualified Health Centers (FQHC)
- Home Health Agency Sub-Unit (HHA Sub-Unit)
- Home Health Agency (HHA)
- Hospice
- Hospital
- Outpatient Physical Therapy (OPT)
- Rural Health Clinic (RHC)
- Skilled Nursing Facility (SNF)
Community Mental Health Center (CMHC)
Check Mark | Required Documentation |
---|---|
CMS-855A Medicare Enrollment Application | |
IRS-generated documentation verifying Legal Business Name (LBN) and Employer Identification Number (EIN) for enrollee in Section 2B1 of CMS-855A application | |
IRS Documents for all entities in Sections 5, 7 and 8 of CMS-855A application | |
Diagram all entities listed in Section 5 of CMS-855A application and their relationships with provider and each other | |
Electronic Funds Transfer (EFT) with copy of voided check/bank letter | |
Attestation letter, if a government entity | |
Copy of any state license, state certification, national accreditation, Clinical Laboratory Improvement Amendments (CLIA) and/or FDA, if not verifiable online | |
Exhibit 275 (Compliance Attestation Statement Form) | |
Exhibit 282 (Attachment B – CHMC site visit request form) | |
Written letter describing services provided and number of full time equivalent employees | |
Submit documentation verifying that 40% of clients receiving services are not Medicare eligible. Document must be provided by an independent entity (such as an accounting technician) and must certify that (1) entity has reviewed CMHC's client care data and (2) CMHC meets applicable 40% requirement | |
NOTE: Exhibits and letter only required for new enrollment – not necessary for revalidations/reactivations. |
Comprehensive Outpatient Rehabilitation Facility (CORF)
Check Mark | Required Documentation |
---|---|
CMS-855A Medicare Enrollment Application | |
IRS-generated documentation verifying Legal Business Name (LBN) and Employer Identification Number (EIN) for enrollee in Section 2B1 of CMS-855A application | |
IRS Documents for all entities in Sections 5, 7 and 8 of CMS-855A application | |
Diagram all entities listed in Section 5 of CMS-855A application and their relationships with provider and each other | |
Electronic Funds Transfer (EFT) with copy of voided check/bank letter | |
Attestation letter, if a government entity | |
Copy of any state license, state certification, national accreditation, Clinical Laboratory Improvement Amendments (CLIA) and/or FDA, if not verifiable online | |
501 C 3 IRS tax exempt letter, if non-profit |
Critical Access Hospital (CAH)
Check Mark | Required Documentation |
---|---|
CMS-855A Medicare Enrollment Application | |
IRS-generated documentation verifying Legal Business Name (LBN) and Employer Identification Number (EIN) for enrollee in Section 2B1 of CMS-855A application | |
IRS Documents for all entities in Sections 5, 7 and 8 of CMS-855A application | |
Diagram all entities listed in Section 5 of CMS-855A application and their relationships with provider and each other | |
Electronic Funds Transfer (EFT) with copy of voided check/bank letter | |
Attestation letter, if a government entity | |
Copy of any state license, state certification, national accreditation, Clinical Laboratory Improvement Amendments (CLIA) and/or FDA, if not verifiable online | |
501 C 3 IRS tax exempt letter, if non-profit |
End Stage Renal Disease Facilities (ESRD)
Check Mark | Required Documentation |
---|---|
CMS-855A Medicare Enrollment Application | |
IRS-generated documentation verifying Legal Business Name (LBN) and Employer Identification Number (EIN) for enrollee in Section 2B1 of CMS-855A application | |
IRS Documents for all entities in Sections 5, 7 and 8 of CMS-855A application | |
Diagram all entities listed in Section 5 of CMS-855A application and their relationships with provider and each other | |
Electronic Funds Transfer (EFT) with copy of voided check/bank letter | |
Attestation letter, if a government entity | |
Copy of any state license, state certification, national accreditation, Clinical Laboratory Improvement Amendments (CLIA) and/or FDA, if not verifiable online | |
501 C 3 IRS tax exempt letter, if non-profit |
Federally Qualified Health Centers (FQHC)
Check Mark | Required Documentation |
---|---|
CMS-855A Medicare Enrollment Application | |
IRS-generated documentation verifying Legal Business Name (LBN) and Employer Identification Number (EIN) for enrollee in Section 2B1 of CMS-855A application | |
IRS Documents for all entities in Sections 5, 7 and 8 of CMS-855A application | |
Diagram all entities listed in Section 5 of CMS-855A application and their relationships with provider and each other | |
Electronic Funds Transfer (EFT) with copy of voided check/bank letter | |
Attestation letter, if a government entity | |
Copy of any state license, state certification, national accreditation, Clinical Laboratory Improvement Amendments (CLIA) and/or FDA, if not verifiable online | |
501 C 3 IRS tax exempt letter, if non-profit | |
Copy of Health Resources and Services Administration (HRSA) Grant Award with site specifically listed (If address is not on Grant Award, must include HRSA and a copy of Form 5 Part B Services Site form with address on it) | |
If no HRSA, FQHC "Look-A-Like" letter from CMS | |
Exhibit 177 (Compliance/Funding form) |
Home Health Agency Sub-Unit (HHA Sub-Unit)
Check Mark | Required Documentation |
---|---|
CMS-855A Medicare Enrollment Application | |
IRS-generated documentation verifying Legal Business Name (LBN) and Employer Identification Number (EIN) for enrollee in Section 2B1 of CMS-855A application | |
IRS Documents for all entities in Sections 5, 7 and 8 of CMS-855A application | |
Diagram all entities listed in Section 5 of CMS-855A application and their relationships with provider and each other | |
Electronic Funds Transfer (EFT) with copy of voided check/bank letter | |
Attestation letter, if a government entity | |
Copy of any state license, state certification, national accreditation, Clinical Laboratory Improvement Amendments (CLIA) and/or FDA, if not verifiable online | |
501 C 3 IRS tax exempt letter, if non-profit | |
Documentation that demonstrates it meets capitalization (operating funds) requirements | |
Complete Sections 4D, 4F and 12 of CMS-855A application |
Home Health Agency (HHA)
Check Mark | Required Documentation |
---|---|
CMS-855A Medicare Enrollment Application | |
IRS-generated documentation verifying Legal Business Name (LBN) and Employer Identification Number (EIN) for enrollee in Section 2B1 of CMS-855A application | |
IRS Documents for all entities in Sections 5, 7 and 8 of CMS-855A application | |
Diagram all entities listed in Section 5 of CMS-855A application and their relationships with provider and each other | |
Electronic Funds Transfer (EFT) with copy of voided check/bank letter | |
Attestation letter, if a government entity | |
Copy of any state license, state certification, national accreditation, Clinical Laboratory Improvement Amendments (CLIA) and/or FDA, if not verifiable online | |
501 C 3 IRS tax exempt letter, if non-profit | |
Documentation that demonstrates it meets capitalization (operating funds) requirements | |
Complete Sections 4D, 4F and 12 of CMS-855A application |
Hospice
Check Mark | Required Documentation |
---|---|
CMS-855A Medicare Enrollment Application | |
IRS-generated documentation verifying Legal Business Name (LBN) and Employer Identification Number (EIN) for enrollee in Section 2B1 of CMS-855A application | |
IRS Documents for all entities in Section 5, 7 and 8 of CMS-855A application | |
Diagram all entities listed in Section 5 of CMS-855A application and their relationships with provider and each other | |
Electronic Funds Transfer (EFT) with copy of voided check/bank letter | |
Attestation letter, if a government entity | |
Copy of any state license, state certification, national accreditation, Clinical Laboratory Improvement Amendments (CLIA) and/or FDA, if not verifiable online | |
501 C 3 IRS tax exempt letter, if non-profit |
Hospital
Check Mark | Required Documentation |
---|---|
CMS-855A Medicare Enrollment Application | |
IRS-generated documentation verifying Legal Business Name (LBN) and Employer Identification Number (EIN) for enrollee in Section 2B1 of CMS-855A application | |
IRS Documents for all entities in Sections 5, 7 and 8 of CMS-855A application | |
Diagram all entities listed in Section 5 of CMS-855A application and their relationships with provider and each other | |
Electronic Funds Transfer (EFT) with copy of voided check/bank letter | |
Attestation letter, if a government entity | |
Copy of any state license, state certification, national accreditation, Clinical Laboratory Improvement Amendments (CLIA) and/or FDA, if not verifiable online | |
501 C 3 IRS tax exempt letter, if non-profit | |
Children's Hospital Only
|
Outpatient Physical Therapy (OPT)
Check Mark | Required Documentation |
---|---|
CMS-855A Medicare Enrollment Application | |
IRS-generated documentation verifying Legal Business Name (LBN) and Employer Identification Number (EIN) for enrollee in Section 2B1 of CMS-855A application | |
IRS Documents for all entities in Sections 5, 7 and 8 of CMS-855A application | |
Diagram all entities listed in Section 5 of CMS-855A application and their relationships with provider and each other | |
Electronic Funds Transfer (EFT) with copy of voided check/bank letter | |
Attestation letter, if a government entity | |
Copy of any state license, state certification, national accreditation, Clinical Laboratory Improvement Amendments (CLIA) and/or FDA, if not verifiable online | |
501 C 3 IRS tax exempt letter, if non-profit |
Rural Health Clinic (RHC)
Check Mark | Required Documentation |
---|---|
CMS-855A Medicare Enrollment Application | |
IRS-generated documentation verifying Legal Business Name (LBN) and Employer Identification Number (EIN) for enrollee in Section 2B1 of CMS-855A application | |
IRS Documents for all entities in Sections 5, 7 and 8 of CMS-855A application | |
Diagram all entities listed in Section 5 of CMS-855A application and their relationships with provider and each other | |
Electronic Funds Transfer (EFT) with copy of voided check/bank letter | |
Attestation letter, if a government entity | |
Copy of any state license, state certification, national accreditation, Clinical Laboratory Improvement Amendments (CLIA) and/or FDA, if not verifiable online | |
501 C 3 IRS tax exempt letter, if non-profit | |
Provider-Based Attestation Statement, if provider wants to be provider-based to a hospital |
Skilled Nursing Facility (SNF)
Check Mark | Required Documentation |
---|---|
CMS-855A Medicare Enrollment Application | |
IRS-generated documentation verifying Legal Business Name (LBN) and Employer Identification Number (EIN) for enrollee in Section 2B1 of CMS-855A application | |
IRS Documents for all entities in Sections 5, 7 and 8 of CMS-855A application | |
Diagram all entities listed in Section 5 of CMS-855A application and their relationships with provider and each other | |
Electronic Funds Transfer (EFT) with copy of voided check/bank letter | |
Attestation letter, if a government entity | |
Copy of any state license, state certification, national accreditation, Clinical Laboratory Improvement Amendments (CLIA) and/or FDA, if not verifiable online | |
501 C 3 IRS tax exempt letter, if non-profit | |
For Initial, Revalidations, and Reactivations
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