| Personal Information |
Description: Personal information is required
- Full Legal Name as indicated on the social security card
- HINT: NPPES Registry name must match
- Birth Place (don’t forget to select “Apply”)
|
| Organizational Information |
Description: Organizational Information is required
- Full Legal Business Name as indicated on the IRS document
-
- HINT: NPPES Registry name must match
|
| Individual Control (Individual Enrollment) |
Description: Individual control is required
- Click on link “Individual control”
- Answer “NO” in that section
|
| Individual Control (Organization Enrollment) |
Description: Individual control is required
Sole Owner Only Having Individual Control
- Click on link “Individual control”
- Select “Add Information” (if individual not listed) or “Edit” (if corrections needed)
- Enter or verify the individual’s information
- SSN
- Birth Place (don't forget to select “Apply”)
- Select the roles and state effective date “must have at least 5% ownership and managing control, either W-2 or contracted”
- Final Legal Adverse: yes or no
- Question: Is this the Authorized and/or Delegated Official – answer “AO” enter telephone number and effective date
Authorized Official (AO)
-
- Click link “Individual control”
- Select “Add Information” (if individual not listed) or “Edit” (if corrections needed)
- Enter or verify the individual’s information
- SSN
- Birth Place (don’t forget to select “Apply”)
- Select the role(s) and state effective date ‒ must indicate at least one: 5% ownership, partner or director/officer
- Select if applicable, managing control, either W-2 or contracted
- Final Legal Adverse: yes or no
- Question: Is this the Authorized and/or Delegated Official – answer “AO” enter telephone number and effective date
Delegated Official (DO)
- Click link “Individual control”
- Select “Add Information” (if individual not listed) or “Edit” (if corrections needed)
- Enter or verify the individual’s information
- SSN
- Birth Place (don’t forget to select “Apply”)
- Select the role(s) and state effective date - must indicate at least one role
- Final Legal Adverse: yes or no
- Question: Is this the Authorized and/or Delegated Official – answer “DO” enter telephone number and effective date, state if W-2 employee
Individual control other than AO or DO
- Click link “Individual control”
- Select “Add Information” (if individual not listed) or “Edit” (if corrections needed)
- Enter or verify the individual’s information
- SSN
- Birth Place (don’t forget to select “Apply”)
- Select the role(s) and state effective date
- Final Legal Adverse: yes or no
- Question: Is this the Authorized and/or Delegated Official – answer “NEITHER AO or DO”
|
Reassignment (Error) (Individual Enrollment)
Reassignment (Warning) (Individual Enrollment) (primary/secondary location not required) |
Description: Reassignment/Primary Practice Location is required
- Click on link “Reassignment”
- Select a primary practice location
- Select Save
|
| Physical Location (Individual or Organization Enrollment) |
Description: Read Error Description
Practice location or Reassignment is needed
- Sole proprietor using SSN or EIN, add all practice locations
- Reassigning benefits add reassignment connection information
Only one IRS 575 allowed
- Practice location should only select one primary NPI as the IRS 575 for the enrollment
Practice location is needed (but a location is indicated)
- “Add information” for the practice location again
Note: If practice location has moved. First select “DELETE” under the old address location and enter end date, then select “Add Information” to identify the new location information and start date. |
| Geographic Location |
Description: Geographic Location is required
- Mobile/Portable Facility enter service area(s)
Note: If not a mobile/portable facility, return to “Physical Location and Special Payment Address” topic view and change selection to “practice location only” for each location listed. |
| EFT (Individual or Organization Enrollment) |
Description: EFT Information is required
- Go to the “Topic View” tab
- Find “Electronic Funds Transfer” topic
- Do you have EFT to report? Answer Yes and select Add Information
- Enter all EFT information
**Upload (PDF or TIFF) Supporting Documentation ‒ a copy of a voided check or bank confirmation letter
Reminder: Verify EFT information is present on individual sole proprietor or group enrollments. |
| Required and/or Supporting Documentation (Upload a voided check, license, diploma, CMS-460, etc.) |
Description: Do you wish to upload supporting documentation?
- Click on the error link “Required and/or Supporting Documentation”
- Select yes or no
- IF YES ‒ follow instruction to upload an attachment (must scan and save document as a PDF or TIFF), verify attached document
- IF NO ‒ select NO
Participating Agreement, if applicable
Only for initial application(s) or during Open Enrollment period, upload the signed and dated CMS-460 form
Do not upload the Certification Statement or EFT CMS-588 form under this topic
-
- Enter EFT information under EFT topic, if applicable
-
- All paper Certification Statements, including EFT should only be uploaded (PDF or TIFF) in the Manage Signature section
|
