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CMS-855B Completion Tips for Ownership Interest and/or Managing Control Information

Table of Contents

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Section 5 – Ownership interest and/or managing control information

This section is to be completed with information about any organization that has direct or indirect ownership of, a partnership interest in, and/or managing control of the provider identified in Section 2 (applicant). The applicant itself should not be listed in Section 5.

All entities that must be listed include but not limited to any organizations that have:

  • Five percent or greater direct or indirect ownership
  • Owning/managing control organizations
    • Corporations (profit or nonprofit)
    • Partnerships and limited partnerships (general or limited)
    • Limited liability companies
    • Charitable and/or religious organizations
    • Governmental and/or tribal organizations
    • Managing control (conducts day-to-day operations)

Ownership/managing control of organizations need to follow state regulations and guidelines.

In additional to furnishing the information in this section, the provider must submit:

  • An organizational diagram identifying all of the entities listed in this section and their relationships with the provider and with each other.
  • Each nonprofit organization should submit a copy of a 501(c) (3) document verifying its nonprofit status.
  • Governmental/tribal organizations must submit a letter on the letterhead of the responsible organization that attests that the government or tribal organization will be legally and financially responsible of any outstanding debt owed to CMS.

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Instructions for Completing Section 5

Section 5A - Ownership/Managing Control Organization

  • Complete section per organizational relationship.
  • Indicate if action is a change, add, or delete and state effective date if applicable or Mark -Not Applicable and go to section 6.
  • Indicate the type of organizational relationship. Check all that apply.
  • Complete with the identifying information of the organization.
  • Provide effective date for either acquired ownership and/or acquired managing control. Furnish both dates if applicable.

Each organization listed in Section 5A must have a Section 5B. Report any final adverse legal action imposed against organization identified in Section 5A.

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Section 5B - Final Adverse Legal Action History

  • Question 1 must be answered by selecting Yes or No.
  • If yes, report details in Questions 2 and submit a copy of the adverse legal action documentations and resolutions.

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Section 6 – Ownership interest and/or managing control information (individuals)

This section is to be completed with information about any individual that has direct or indirect ownership of, a partnership interest in, and/or managing control of the provider identified in Section 2 (applicant). Note that the applicant must have at least one owner and/or managing employee.

All individuals that must be listed include but not limited to any individual that have:

  • Five percent or greater direct or indirect ownership interest
  • Partnership interest (general and limited)
  • Officers and directors, trustees or board of directors
  • W-2 or contracted managing employee
  • Authorized officials
  • Must have another relationship indicated: owner, partner, or director/officer
  • Delegated officials
  • Must have another relationship indicated: owner, partner, director/officer, or managing employee

Note: Governmental or tribal organization only need to report managing control employees as well as indicating the authorized official and if any delegated officials.

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Instructions for Completing Section 6

Section 6A - Ownership/Managing Control Organization

  • Complete section per individual with ownership and/or managing control.
  • Indicate if action is a change, add, or delete and state effective date if applicable.
  • Complete with the identifying information of individual.
  • Indicate the type of ownership and/or managing control of individual. Check all that apply.
  • Provide effective date for either acquired ownership and/or acquired managing control. Furnish both dates if applicable.

Each individual listed in Section 6A must have a Section 6B. Report any final adverse legal action imposed against individual identified in Section 6A.

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Section 6B - Final Adverse Legal Action History

  • Question 1 must be answered by selecting Yes or No.
  • If yes, report details in Questions 2 and submit a copy of the adverse legal action documentations and resolutions.