Riverbend

Common Errors on the CMS 855A

Most Common Errors on the CMS 855A

Section 1A

• Marking the wrong reason for submitting the application
• Missing the NPI and Medicare number on Change of Ownership and Change of Information applications.
• On CHOW applications, the NPI reported for new owner is the NPI of the old owner. New owner needs a NPI for the facility that matches the legal business name and tax id number for the new owner.

Section 1B

• Failure to complete all sections required for the type of application being submitted

Section 2A

• Marking the incorrect type of provider

Section 2B1

• Legal Business Name does not match IRS documentation.
• Missing IRS Documentation.
• Missing the Medicare Year-End cost report date.
• Missing the Incorporation Date and State where incorporated
• Missing incorporation documentation
• For sole proprietor, the tax identification number (TIN) is the individual’s SSN not the Employer Identification Number (EIN) for the provider.
• For sole proprietor, the name on the 1st line of the IRS CP575 is the legal business name. The name on the 2nd line is the Doing Business Name (DBA) name.

Section 2B2

• Failure to check not applicable box if not completing this section for licensure
• Failure to check not applicable box if not completing this section for certification
  

Section 2C

• The address for the facility is missing.
• Failure to provide the additional 4 digits of the zip code
  

Section 2D

• This section does not have “yes” or “no” marked.

Section 2F

• The legal business name does not match the one reported in Section 2B1 of the old owners CHOW 855A.
  

Section 3

• This section does not have “yes” or “no” marked.
  

Section 4A

• City/Town or State left blank.
• The zip code is missing the additional 4 digits
• Missing telephone and fax numbers
• NPI number missing and/or no NPI documentation attached.
• NPI documentation does not match name or address on 855A.
• The NPI reported is for a physician and not the facility
• For a CHOW, the NPI reported in 4A does not match the NPI reported in 1A.
• CLIA number is missing. Enter “N/A” if it does not apply or “Pending” if you have applied but not received the number.
• Medicare number reported is not a Part A or OSCAR number.
• For sole proprietor, the NPI reported on the 855 should be associated with the individuals SSN in NPPES.

Section 4B

• EFT (CMS Form 588) agreement and/or documentation is missing
• Did not answer special payments address, or did not include the plus 4 in the zip code.

Section 5A

• This section should have the box marked for Not applicable or be completed.
• Zip code is missing the additional 4 digits.
• Failure to complete this section for the home office in Section 7.
• Missing IRS documentation for tax id numbers for all entities reported.

Section 5B

• If 5A is completed then this section should be answered “yes or no”.
• If 5A is not completed then this section should be left blank.

Section 6A1

• Entire section is left blank. This section should be completed for each officer, owners, partners and/or managing employees of the facility.
• Failure to report at least one person as a managing employee.
• Failure to complete this section for the authorized and/or delegated official.
• Failure to complete this section for the Administrator or CEO of the home office in Section 7.
• Missing or incorrect Social Security numbers or dates of birth
• Reporting NPI and Medicare number that do not belong to the individual in this section.

Section 6A2

• Failure to mark fields all that apply.
• Failure to report at least one person as a managing employee.

Section 6B1

• If 6A is completed then this section should be answered “yes or no”.
• If 6A is not completed then this section should be left blank.
  

Section 7

• Failure to complete this section or mark that it is not applicable
• If section is completed, ensure the Home Office fee-for-service contractor and Home Office Chain number is listed.
• If section is completed, need to include additional 4 digits in the zip code.

Section 8

• Failure to complete this section or mark that it is not applicable
• If completed, ensure a copy of the billing agreement is attached and enter an effective date.
• If completed, need to include additional 4 digits in the zip code

Section 12

• Failure to mark the box that indicates that this section does not apply if the section is not completed.

Section 15

• Signature and dates in this section are not an original signature. Do not submit copies or stamped signature. Use blue ink to authenticate signature.
• This section should be signed and dated by an officer, owner or partner of the facility, not a managing employee.
• A section 6 must be completed on the individual signing this section of the application.
• The person signing is not officer, partner, or owner of the applicant/facility but is an officer or partner of an owning or parent company.

Section 16

• Application does not have an original signature and date
• Person signing this section must also have a section 6
• Person signing this section must be an officer, partner, or owner of the applicant but not of an owning or parent company.
• The person has indicated in Section 6 that they are a contracted managing employee. Delegated officials must be W-2 employees.

Missing Documentation

• IRS verification of the TIN reported in Sections 2B1, 5 or 7.
• EFT Agreement.
• Copy of adverse legal action documentation if applicable.
• Attestation from government entities that they are liable for any debts owed to CMS when applicable.
• Copy of the final bill of sale or sales agreement with all exhibits referenced in the agreement for a change of ownership
• The names/entities on the bill of sales or sales agreement do not match the names on the old and new owner CHOW 855As.