Provider Enrollment

Top Reasons for Enrollment Delays

  • Section 2B 1of the 855A must reflect the Legal Business Name as it appears on the IRS document.
  • Section 4A of the 855A should reflect the last four digits of the zip code for the provider.
  • If a hospital has more than one practice location listed in section 4A of the 855A, the provider should indicate the type for the other locations listed.
  • At least one individual must be marked as a managing employee in section 6 of the 855A.
  • The adverse legal history box must be checked in section 6 of the 855A for each individual listed.
  • We strongly recommend the provider read all directions related to sections 5 & 6 of the 855A as many providers have very extensive managing control and organizational structures. All appropriate entities, individuals, and documents must be provided.
  • Federally Qualified Health Centers (FQHCs) are allowed only one location in section 4a of the 855A. This location must be indicated on the HRSA agreement, which is a required attachment to the 855A for FQHCs.
     

Last Updated Mon, 20 Aug 2018 08:43:36 +0000