Helpful Tips

CMS-20134 Completion Tips for Medicare Diabetes Prevention Program Suppliers

Review the standards on page 2 and follow the instructions printed on the CMS-20134 application

Section General Guidelines
Section 1: Basic Information 1A – Select Reason for Application and follow instructions in Required Sections
  • Specify the supplier effective date, NPI and PTAN, when applicable
Section 2: Identifying Information 2A – Specify the type of supplier by selecting “In-Person MDPP Supplier” 

2B1 – Complete all fields that apply
  • The legal business name reported must match the NPPES Registry and the IRS document exactly, including any suffix, i.e., PC, PA, LLC, etc.
  • Specify the EIN/TIN
2B2 – Specify recognition status information
  • Preliminary as defined at 42 CFR 424.205 or Full as determined by CDC (DPRP)
2B3 – Enter the clinic/group’s correspondence address and telephone number
  • Must be where the entity in 2B1 can be reached directly
  • May not report a billing agency’s address/phone number
Section 3: Adverse Legal Action/Convictions Section must be answered and only a “yes” or “no” response is acceptable
  • If there are no final adverse legal actions, convictions, exclusions, revocations, or suspensions, be sure to check the box labeled ‘No’
  • If there are any actions whether under the current or a former name or business identity, check the box labeled ‘Yes’ and list details and attach final adverse legal action documentation and/or resolutions
Section 4: MDPP Location Information Copy appropriate page in each section as many times as necessary

Note: A separate provider enrollment record will be required for the Entity Tax Identification Number per state and each record will require an Administrative setting (even if Administrative location is in another state)

4A – Complete this section for each practice location and specify Administrative or Community setting; as well as for all Administrative settings: indicate office/clinic, hospital, SNF etc. or any other health facility where the supplier will be rendering services 4B – Enter special payment address (pay to address) information

4B – Enter special payment address (pay to address) information

4C – Enter medical records location(s) if different than 4A
Section 5: Ownership Interest and/or Managing Control Information (Organizations) Copy appropriate page as many times as necessary

5A–5B – Complete these sections for each organization that has ownership interest or managing control  or select Not Applicable
  • For each section 5A, complete a corresponding section 5B
Section 6: Ownership Interest and/or Managing Control Information (Individuals) Copy appropriate page in each section as many times as necessary

6A–6B – Complete these sections for every individual with ownership interest or managing control (i.e. manager, owner, board of trustees or other governing body, and authorized or delegated official)
  • AO – at least one authorized official must be designated and reported.
    • To report an authorized official, must select ‘Authorized Official’ and an additional box indicating ‘5 Percent or Greater Direct/Indirect Owner’, ‘Partner’ and/or a ‘Director/Officer’
  • May also select Managing Employee
  • Managing Employee – at least one Managing Employee or Contracted Managing Employee must be designated
  • Delegated Official – is optional
    • To report a delegated official, must select ‘Delegated Official’ and an additional box specifying an additional relationship
    • May not select Contracted Managing Employee
  • For each section 6A, complete a corresponding section 6B
Section 7: Coach Roster Copy appropriate page as many times as necessary

Identify eligible coach information with appropriate effective date of change add or delete

  • A MDPP enrollment must have an eligible coach on file at all times
  • The effective date should represent date the coach changed/furnished/stopped MDPP services
Section 8: Billing Agency Information Complete with billing agency information or select the box indicating that this does not apply
Section 13: Contact Information Copy appropriate page as many times as necessary
  • Complete with the contact person’s information
Section 15: Certification Statement 15B and 15C – Authorized Official signature and date, when applicable
Section 16: Delegated Official 16A and 16B – If Delegated Official is established on enrollment, DO can sign and date without a signature of an established Authorized Official on enrollment. If enrolling a new Delegated Official, then this section must be completed and cosigned by an Authorized Official
Section 17: Supporting Documentation Required documents needed when applicable:
  • Certificate or Determination Letter of MDPP Preliminary or Full CDC DPRP
  • Written confirmation from the IRS of your legal business name and EIN/TIN (e.g., IRS CP-575) (501(c) 3 non-profit status) including any suffix such as PC, PA, LLC, etc.
    • If an individual sole proprietor, the full legal name as reported to the Social Security Administration and must also match the NPPES Registry exactly including any initials, credentials, and suffixes.
  • If applicable, attestation for government entities and tribal organizations or IRS confirmation of Disregarded Entity
  • CMS-588 Electronic Funds Transfer (EFT) Authorization Agreement CMS-588 and a confirmation of account information on bank letterhead or a voided check
  • Final Adverse Legal Action of entity, ownership or managing control organization or individuals

Changes in ownership, coach roster, and adverse legal action history must be made within 30 days of the change. All other changes to the application must be made within 90 days of the indicated change.

Revised 12/27/2021