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.

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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
  • Receive demographics for past six months showing age of patient population in order to verify that 50% of hospital's inpatients are under age of 18
  • 42 CFR 412.23(d): Servicing intermediary verifies compliance that more than 50%of its inpatients are individuals under age of 18

 

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
  • A diagram/flowchart identifying organizational structures of all its owners, including those that aren't required to be listed in Section 5 or 6 of CMS-855A application

 

Last Updated Oct 03, 2018