Enrollment Documentation Requirements by Provider Type - JF Part A

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.

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

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

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

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)

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

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

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

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

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

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

CMS-855A Medicare Enrollment Application and the ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES.

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 8 of CMS-855A application and the ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES.

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

Submit 3 organizational structure diagrams or flowcharts:

• A chart identifying all the entities listed in Section A of the Organizations section of the Attachment that shows their relationships with the SNF and each other. (This chart will thus include the SNF’s organizational ADPs.)
• A chart identifying the organizational structures of all its owners, including owners not listed in the SNF Attachment (e.g., less than 5% direct or indirect owners of corporations).
• A chart outlining the organizational structures of each ADP of the facility. This must include a written description of the relationship of each ADP to the facility and to all the SNF’s other ADPs.

At least one of these three charts must also identify the SNF’s ultimate parent company and the entities situated between the SNF and the parent in the organizational arrangement. Also, the charts must be three separate ones and should not be combined into one or two.