Inquiries and Solutions - JE Part A

Q. How do we make changes/updates to our provider files?
A. Changes must be reported using CMS-855A Application for Health Care Providers or Pecos Web application that will bill Medicare Fiscal Intermediaries. Review section 1B of form 855A to determine which sections to complete or update the specific topics of Pecos Web that are changing.

Note: Providers making any change to their file that are not set up with Electronic Funds Transfer (EFT), will be required to submit the CMS 588 form (See number 3 for instruction).

Providers making any changes to their file that have not submitted a change since 2003, will be required to complete a full CMS 855A or Revalidate their Pecos Web enrollment information in order to update their existing Medicare information.

Q. How many CMS-855As must be submitted?
A. You must submit one CMS-855A per Medicare Part A Provider Transaction Access Number (PTAN) unless the PTANs in question are a hospital and its PPS excluded units or a Critical Access Hospital and its distinct part units. In all other cases, one 855A must be submitted per Medicare Part A PTAN or facility.

Q. Will changing my Legal Business Name affect billing?

A. There are two scenarios:

1. You have successfully reported your NPI(s) to Noridian Provider Enrollment on an 855A. Your NPI/PTAN match is golden. This means that Medicare has entered your NPI(s) into the Enrollment database. The name change will not affect billing.

Change your Organization Name (LBN) at NPPES and then mail your 855A to Noridian.

2. You have not successfully reported your NPI(s) to Noridian Provider Enrollment on an CMS- 855A. Your NPI is entering our system through a crosswalk between NPPES and Medicare. In order for that crosswalk to work, certain information such as the tax id and Legal Name must match between the two systems; therefore your name change will affect billing.

Mail the CMS-855A and wait for Provider Enrollment to request that you change your Organization Name (LBN) at NPPES. Our office will work with you to schedule a time to change the name at NPPES to minimize the impact on billing.

Q. What happens after the CMS-855A Initial Enrollment Application has been completed by Noridian Provider Enrollment?
A. When provider enrollment has completed the CMS-855A, send a copy of the application and recommendation letter to the State and CMS Regional Office. The State schedules and performs any necessary surveys then sends its findings to the CMS Regional Office who makes the final determination regarding approval (including your Provider Transaction Access Number (PTAN) and effective date) or Denial. CMS should send a copy of the approval/denial notification to the Provider, State, and Noridian.

Once the CMS-855A has been sent to the State and Regional Office, the provider will need to contact the State and Regional Office for status updates.

Q. We received the Approval Letter from CMS issuing my Provider Transaction Access Number (PTAN) and effective date; however, when we try to bill, we are told the NPI isn't found on the crosswalk. What happened?
A. Even though you have received your formal acceptance into the Medicare Part A Program, there is additional computer work our company must complete in order for you to bill. Fax your letter to our Enrollment department. Enrollment will complete the process of setting up your file with the new PTAN and effective date, after which Audit & Reimbursement will be notified to begin putting in your rates. You will receive a letter in the mail from Audit & Reimbursement. At this point you may contact EDI to set up for electronic billing.

Q. Who must be reported in section 6 of the CMS-855A?

A. Per CMS regulation, all of the following individuals must be reported in section 6.

• A 5 percent or greater direct or indirect ownership interest in the provider.
• A 5 percent or greater mortgage or security interest in the provider.
• Any general partnership interest in the provider, regardless of the percentage. This includes: (1) all interests in a non-limited partnership, and (2) all general partnership interests in a limited partnership.
• For limited partnerships, any limited partnership interest that is 10 percent or greater.
• Managing control of the provider. (For purposes of enrollment, such a person is considered to be a – managing employee. A managing employee is any individual, including a general manager, business manager, office manager or administrator, who exercises operational or managerial control over the provider's business, or who conducts the day-to-day operations of the business. A managing employee also includes any individual who is not an actual W-2 employee but who, either under contract or through some other arrangement, manages the day-to-day operations of the business.)
• Officers and directors, if the applicant is a corporation. (For-profit and non-profit corporations must list all of their officers and directors. If a non-profit corporation has – trustees instead of officers or directors, these trustees must be listed in section 6 of the Form CMS-855.) Note that only officers and directors of the provider must be reported. Board members of the provider‘s indirect owners need not be disclosed to the extent they are not otherwise required to be reported (e.g., as an owner or managing employee) in section 6.
• Chain Home Office Administrator (if applicable)

The individual's FULL Legal name on file with the SSA must be reported, along with their Date of Birth and SSN. Be sure to indicate (check off) each applicable relationship the individual has to the Organization enrolling/enrolled. Adverse Legal Action must be reported, or the question regarding this must be checked no. Section 3 of the 855A includes a list of reportable Adverse Legal Actions.

Government entities need only list their managing employees in section 6 of the Form CMS-855, as they do not have owners, partners, corporate officers, or corporate directors.

Q. What must be reported in section 5 of the CMS-855A?
A. This section is to be completed with information about any organization that has direct or indirect ownership of, a partnership interest in, and/or managing control of the provider identified in Section 2. If there is more than one organization, copy and complete this section for each. All Organizations that have any of the following must complete section 5, but is not limited to:

• A 5 percent or greater direct or indirect ownership interest in the provider.
• Mortgage or security interest
• Any general partnership interest in the provider, regardless of the percentage. This includes: (1) all interests in a non-limited partnership, and (2) all general partnership interests in a limited partnership.
• For limited partnerships, any limited partnership interest that is 10 percent or greater.
• Managing control of the provider or supplier
• Entities with an investment interest in the provider (e.g., investment firms)
• Banks and financial institutions (e.g., mortgage interests)
• Holding companies
• Trusts and trustees
• Governmental/Tribal Organizations:
• Charitable and Religious Organizations

In addition to furnishing the information in this section, the provider must submit:

• IRS generated documentation to verify the Legal Name, TIN and entity listed.
• An organizational diagram identifying all of the entities listed in this section and their relationships with the provider and with each other.

SNF Only: a diagram identifying the organizational structures of all of its owners, including owners that were not required to be listed in this section or in Section 6.