Iowa, Kansas, Missouri and Nebraska Providers
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To enroll in Medicare as a provider or make changes to your existing Medicare information, you must complete the CMS-855A application. Per the Program Integrity Manual, Chapter 10, Section 7.1.1, you must submit a complete CMS-855A if you have not completed and full 855A application in the past few years.
You can help us process your application by submitting complete, accurate information the first time. Please do the following when submitting your application:
Call our Provider Enrollment staff at 1-866-734-9444 and ask for Provider Enrollment Send your completed application, including original signatures, to:
Provider Enrollment A WPS Medicare Medicare Provider Enrollment PO Box 1604 Omaha, NE 68101
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An IRS CP 575 form provides the Legal Name and Tax Identification number (EIN) as reported to the Internal Revenue Service. The IRS sends this confirmation document when an entity initially obtains their Tax ID number with the reporting Legal Name. We will also accept a Quarterly Form 941 printed from the IRS or a Tax coupon.
When a contractor issues a letter requesting revalidation for specific provider(s), the provider(s) will need to submit all sections of the 855A application except sections 2G, 2F, & 2H. Please also include a separate section 5 & 6 for all Ownership/Managing control organizations and individuals. The provider(s) will also need to submit all supporting documentation including: IRS CP 575, NPI notification(s), CMS Form 588 EFT, voided check, company letterhead with the authorized signers & titles on the account, Licenses & Certifications, Articles of incorporation/organization, and home office chain listing (if applicable).
The provider must submit a letter on company letterhead listing the authorized signers & titles for the bank account as well as a voided check or account/routing number. An IRS CP 575 may be required if the contractor can't verify the legal name and Tax Identification number (EIN).
Yes. Anytime additional information accompanies the original submission of an 855A application, the contractor must have a new signed and dated section 15/16. The authorized signature verifies that all information submitted is complete and accurate.
According to Pub 100-08 PIM Chapter 10 Section 17.2, "Once the provider has submitted an enrollment application (as well as after it has been enrolled), the contractor may not release -either oraly or in writing - any information about the provider's enrollment status (unless specifically authorized in some other CMS instruction) to any person in the provider's organization other than an authorized or delegated official of the provider, or the provider's contact person listed in section 13 of the CMS-855A."
Yes. The provider must submit a 9-digit zip code for all locations listed on the CMS 855A form. If a section of the 855A form does not contain the full 9-digit zip code, the contractor will request the appropriate sections be revised and resubmitted.
Yes, as long as each authorized official meets the definition stated in Pub 100-08 PIM Chapter 10 section 1.1. The provider will also need to submit a section 6 for each authorized official on the CMS 855A form.
No, a provider will have to submit a CMS 855A application to change "Ownership Interest/Managing Control Information (Individuals)." A provider will need to submit a section 6 for each individual that no longer has ownership interest and managing control (check delete and effective date) and a section 6 for each individual that has taken over ownership interest or managing control (check add and effective date).
Even though we try to expedite all 855A applications as quickly as possible, it may take more time depending on volume and time spent on each application.
Please note: In order to help expedite the process, please ensure that all required fields and sections of the 855A application are completed and are 100% accurate. Please also include the necessary attachments with the 855A application. This will help to eliminate requests for additional information causing delays in processing the request.
There is a possibility that a Tie-in Notice will be issued within 6 to 9 months from the date the contractor forwards the necessary documentation to the State Agency and CMS Regional Office.
Yes. Per Pub. 100-08 PIM Chapter 10; section 5.1 contractors "shall ensure that the provider completed all required data elements on the CMS-855 - including all effective dates - and that all supporting documentation has been furnished." That is, every required data element on the CMS-855 application must be fully completed, regardless of: (1) the relative materiality of the data element in question; or (2) whether the missing data is available elsewhere on the provider's application.
The effective date should be the date the organization, location, or individual became a part of the organizational structure or left the organizational structure.
Page Last Updated: Thursday, 15-Dec-2011 13:46:58 CST
