| EFT Information |
Fully complete and send the form CMS-588 (01/17) EFT Authorization Agreement. Be sure to:
- Specify the legal name on the EFT agreement and that name must match exactly (including middle initial, suffix, credentials) the name on file with the IRS or SSA and on the voided check or bank letter.
- Check either SSN or EIN box.
- Check either checking account or savings account box.
- Include a voided check. If the legal business name on the voided check is not an exact match to what is reported to the IRS or SSA, it is recommended that you obtain and include a bank letter specifying your name to match.
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If EFT information is already present, verify the information is accurate.
If EFT information is missing or requires updates, enter the information into the EFT topic. Ensure the legal name on the EFT agreement matches exactly (including middle initial, suffix, credentials) the name on file with the IRS or SSA and on the voided check. Upload (PDF or TIFF) a copy of the voided check. If the legal business name on the voided check is not an exact match to what is reported to the IRS or SSA, it is recommended that you obtain and upload (PDF or TIFF) a bank letter specifying your name to match.
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NPPES Registry Name Mismatches
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Check the NPPES Registry
to verify your NPI and name. An individual’s name and an organization’s legal business name on file with NPPES must match what is reported to Medicare and the IRS or SSA records exactly.
If an NPPES correction is necessary, complete the correction prior to submitting your revalidation application.
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Check the NPPES Registry
to verify your NPI and name. An individual’s name and an organization’s legal business name on file with NPPES must match what is reported to Medicare and the IRS or SSA records exactly.
If an NPPES correction is necessary, complete the correction prior to submitting your revalidation application.
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Missing or Expired State Required Licenses/Certifications
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Ensure all state required licenses/certifications are current. Complete necessary updates prior to submitting your revalidation application. Include a copy of the license/certification with your application.
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Ensure all state required licenses/certifications are current. Complete necessary updates prior to submitting your revalidation application. Upload (PDF or TIFF) a copy of the license/certification to PECOS.
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Incorrect Owner/Managing Employee Social Security Number or Date of Birth
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Specify the correct social security number and date of birth in Section 6A of the form CMS-855A.
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Verify all names, SSNs, and DOBs are correct.
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Missing Practice Location Information in Section 4 of the CMS-855A
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Specify all practice locations in Section 4 of the form CMS-855A. When adding a new practice location, specify the date you saw your first Medicare patient at that location.
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Verify all locations are present.
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Missing signatures for New AO or DO when Adding New AO or DO
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The form CMS-855A Section 15 must be signed by one authorized official to revalidate.
If also adding a new AO, then the new AO must also complete Section 6A and 6B and sign Section 15.
If also adding a new DO, then the new DO must also complete Section 6A and 6B and sign Section 16.
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Obtain all necessary signature(s).
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Missing Information for Individuals with Ownership and/or Managing Control in Section 6 of the CMS-855A
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Copy and complete Section 6 of the form CMS-855A for all owners, officers/directors, managing employees. For each person listed in Section 6A, there must be a corresponding Section 6B.
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Verify all individuals that are required to be included are present in the enrollment record.
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Documentation from the IRS
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Written IRS documentation confirming legal business name and Tax ID number must be submitted. If the entity's status is non-profit, the IRS 501c3 form must be submitted to verify non-profit status.
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Written IRS documentation confirming legal business name and Tax ID number must be submitted. If the entity's status is non-profit, the IRS 501c3 form must be submitted to verify non-profit status.
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Medicare Application Fee
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The Medicare application fee applies to all part A revalidation applications.
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The Medicare application fee applies to all part A revalidation applications.
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