CMS 855A Attachment Questions
- What is an Internal Revenue Service (IRS) CP-575 Form?
- When a provider receives a request for Revalidation, what do they need to submit?
- What other documentation does a provider have to submit with the CMS form 588 Electronic Funds Transfer (EFT)?
Q1 - What is an Internal Revenue Service (IRS) CP-575 Form?
A1 - 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.
Q2 - When a provider receives a request for Revalidation, what do they need to submit?
A2 - 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).
Q3 - What other documentation does a provider have to submit with the CMS form 588 Electronic Funds Transfer (EFT)?
A3 - 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).
Page Last Updated: Tuesday, 15-Jul-2008 10:34:13 CDT
