Certification Statement Signature and Contact Person Requirements - Revised
MLN Matters® Number: MM9776 Revised
Related Change Request (CR) #: CR 9776
Related CR Release Date: December 9, 2016
Effective Date: January 9, 2017
Related CR Transmittal #: R689PI
Implementation Date: January 9, 2017
This article was revised on December 22, 2016, to clarify certain information in the bullet points on pages 3 and 4. All other information remains the same.
Provider Types Affected
This MLN Matters® Article is intended for physicians, non-physician practitioners, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 9776 clarifies the certification statement signature requirements for the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) and paper Medicare enrollment applications, and addresses contact person requirements.
CR9776 does not involve any legislative or regulatory policies. Make sure that you are familiar with these requirements.
CR9776 informs the MACs that the Centers for Medicare & Medicaid Services (CMS) is updating Chapter 15 of the "Medicare Program Integrity Manual" in order to clarify the certification statement signature requirements for online and paper Medicare enrollment submissions, and to address contact person requirements. The main points of the updates are summarized below; and you can find the details in the manual's updated Chapter 15 (Medicare Enrollment), which is an attachment to CR9776.
Certification Signature Requirements
A. Paper Submissions
A signed certification statement shall accompany all paper CMS-855 applications, which your MAC will only accept if the signature date is within 120 days of the receipt date of the application. If the provider submits an invalid certification statement or fails to submit a certification statement, your MAC will still proceed with processing the application, however, a valid certification statement will be solicited as part of the development process. This includes certification statements that are: (a) unsigned; (b) undated; (c) contains a copied or stamped signature; (d) was signed (as reflected by the date of signature) more than 120 days prior to the date on which the MAC received the application); (e) for paper Form CMS-855I and Form CMS-855O submissions, someone other than the physician or non-physician practitioner signed the form, except as noted in Section 18.104.22.168; or (f) missing certification statements. The MAC will send one development request to include a list of all of the missing required data/documentation, including the certification statement. The MAC may reject the provider's application if the provider fails to furnish the missing information on the enrollment application - including all necessary documentation - within 30 calendar days from the date the MAC requested the missing information or documentation. The certification statement may be returned via scanned email, fax or mail to the MAC (as long as an original certification statement signature exist on file).
B. Internet-based PECOS Submissions
A signed certification statement shall accompany all web submitted CMS-855 applications. You may choose to electronically sign the application or submit the paper certification statement to your MAC. Paper certification statements may be submitted by email, fax, or mail (as long as an original certification statement signature exists on file).
You should note that your MAC will not compare the signature on the application with the same provider, authorized or delegated official's signature on file to ensure that it is the same person; nor will they request the submission of a driver's license or passport to verify a signature.
Specific form signature requirements follow:
- The enrolling or enrolled physician or non-physician practitioner is the only person who can sign the Form CMS-855I or the Form CMS-855O. (This applies to initial enrollments, changes of information, reactivations, revalidations, voluntary withdrawals, etc.) This includes solely-owned entities listed in section 4A of the Form CMS-855I. A physician or non-physician practitioner may not delegate the authority to sign the Form CMS-855I or Form CMS-855O on his/her behalf to any other person. Note: Exceptions to the above policy may apply in the following scenarios: (1) in the case of death (an executor of the estate), may sign on behalf of the deceased provider, or (2) if an employer is terminating an employment arrangement with a physician assistant, the Authorized or Delegated Official of the organization may sign the application. These situations would only apply to change of information applications.
- Form CMS-855R (Medicare Enrollment Application - Reassignment of Medicare Benefit), submitted for initial applications, must be signed and dated by the physician or non-physician practitioner and the authorized or delegated official of the provider or supplier; while those submitted to change and/or update the provider or supplier's Medicare enrollment data (to include updates to the primary practice location) may be signed by either the physician or non-physician practitioner or the authorized or delegated official of the provider or supplier.
- Form CMS-855A (Medicare Enrollment Application - Institutional Providers), CMS-855B (Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers), and CMS-855S (Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers), submitted for initial applications, must be signed and dated by an authorized official of the provider or supplier; while those submitted to change, update and/or revalidate the provider or supplier's Medicare enrollment data may be signed and dated by the authorized or delegated official of the provider or supplier.
The certification statement for the CMS-855A, CMS-855B and CMS-855S Medicare enrollment applications must be signed by an individual who has the authority to bind the provider or supplier, both legally and financially, to the requirements set forth in 42 CFR 424.510. This person must also have an ownership or control interest in the provider or supplier, such as, the general partner, chairman of the board, chief financial officer, chief executive officer, president, or hold a position of similar status and authority within the provider or supplier organization. The signature attests that the information submitted is accurate; and that the provider or supplier is aware of, and abides by, all applicable statutes, regulations, and program instructions.
Your MAC will verify and validate all information collected on the enrollment application, provided that a data source is available. You should remember that:
- For paper CMS-855 submissions, if you submit an invalid certification statement or do not submit a certification statement, your MAC will treat this as missing information and will request that you submit a correct certification statement, preferably via e-mail or fax. The certification statement may be returned via scanned email, fax or mail to the contractor (as long as an original certification statement signature exist on file).
- For Internet-based PECOS submissions, if you choose to submit your certification statement via paper rather than through e-signature, you may do so by email, fax or mail (as long as an original certification statement signature exist on file). You must submit the paper certification statement within 20 calendar days of the date on which you submitted your Internet-based PECOS application, otherwise the MAC may reject your application.
- When submitting the certification statement, only the signature page is required, you do not have to include the additional page containing the certification terms.
- MACs will not request a driver's license or passport to verify the signature.
- Your MAC will send approval letters to the contact person listed on the application via email (if there is no contact person on file, they will send the approval letter to the provider or supplier at their correspondence address).
Contact Person Requirement Clarifications
MACs will accept end dates to contact persons via phone, scanned email, fax or mail from the individual provider, the Authorized or Delegated Official or a current contact person. This is an interim process until the Form CMS-855s can be updated to delete contact persons.
If any contact person listed on a provider or supplier's enrollment record requests a copy of their Medicare approval letter or revalidation notice, MACs will send it to the contact person via email, fax or mail.
While the above provides the key points of CR9776, providers may wish to review the entire revision to Chapter 15, which is attached to CR9776. CR9776 is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R689PI.pdf.
42 CFR 424.5120 is available at http://www.ecfr.gov/cgi-bin/text-idx?SID=7abb0c441a8cabde6594ca609fd194c5&mc=true&node=se42.3.424_1510&rgn=div8.
Last Updated Oct 04, 2018