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Add Change in Control Agreement countersignature

welcome to enrollment on demand in this video we'll learn how to fill out a CMS 855 a for any specialty completing a buyer change of ownership or Chow by following these step-by-step instructions it will help to avoid delays in application processing the information given in this training is correct at the time of this recording the most current information regarding Medicare requirements can be found in various CMS instructions and on the nuridium Medicare website at the address listed on the slides now we will begin to fill out the CMS 855 a application before we do we want to ensure that the most current version of the application is being filled out please go to the forms page on the nuridium Medicare website an application must be completed for each Medicare ID and subunit page numbers on this presentation are according to the numbers at the bottom of the CMS form determine what type of Chow you were doing in this video we'll go over a regular change of ownership most will be a change of ownership with the transfer of the old seller PTM sections needed by type of Chow for regular Chows you will need to complete sections 1a Chow page 6 all sections except to G and 2h on page 6 select the box labeled there has been a change of ownership of a Medicare enrolled provider check the buyer / new owner box and list the tax ID on page 10 section 2a identifying information check the appropriate boxes for the type of non hospital provider only for hospitals and critical access hospitals check all subgroups and answer questions 3 & 4 each subgroup with its own PT on undergoing the Chow will need its own application on page 11 identifying information enter the legal business name as reported to the IRS do not abbreviate check the appropriate organizational structure in most cases government entities will choose other and specify the structure if the organization has a DBA name list that name in the other name field and identify the type of name check how the business is registered with the IRS next fill in the requested year-end costate an answer if this supplier is an Indian Health facility it is important to note that if you are either a non-profit or government entity you will need to supply either the 501c3 for nonprofit or an attestation letter if you are a government agency if this organization does not have a license and our certification check the box state license not applicable on page 12 for license and certification information check the applicable boxes and fill in the license or certification number state were issued effective date and expiration date note that a current copy of the license and certification will need to be submitted if your licensure certification is pending or numel supply a copy of the renewal application on page 12 section to see correspondence ad enter the correspondence address of the organization the address listed here must be one where the organization can be directly reached it cannot be the address of a billing agency management services organization chain home office or the providers legal representative enter the correspondence phone number fax and email address in Section 2d accreditation check the appropriate box if checked yes enter the date of the accreditation expiration date the name of accrediting body type of accreditation and any comments if needed provide a copy of the accreditation on page 13 change of ownership Chow seller information enter the legal business name as it appears on the IRS document doing business as name if applicable enter the old owners type 2 NPI effective date of transfer and the name for fee service contractor check the appropriate box for the question will the new owner be accepting assignment of the current provider agreement note if you answered no to this question this is an initial application and will no longer be a buyer chow you will need to follow the initial 855 a enrollment instructions on page 17 section 3 final adverse legal action convictions answer if the provider has any legal history if yes fill out the columns below and attach a copy of the final adverse legal action documentation and resolution C attached is not acceptable on page 20 section 4c check add and enter the change of ownership date enter the legal business name or the doing business as name listed in Section 2 B 1 next to enter the practice location street address city state and zip code as it appears on usps.com this should match the sellers practice location information enter the phone number and if applicable fax or e-mail address fill in the type 2 NPI associated with this prac dislocation enter the clea or FDA certification number for this practice location if applicable provide a copy of the document situational for hospitals and critical access hospitals complete additional section for a for each practice location the first location listed in this section will be the primary location on page 21 section 4b special payments address check the ad box and enter the chain of ownership date this should also match section 2f and 4a if the special payments location is the same as the practice location check the first box indicating address is the same as the practice location if the new special payments address is different than the practice location or there are multiple practice locations mark this box and fought the street address city state zip code ensure the informations matches what is on USPS situational this section does not need to be completed if the patient's medical records storage location is the same as a practice location on the bottom of page 21 section 4 see medical records check the add box and enter the effective date enter the city state and zip code as it appears on the USPS com if there is more than one facility fill out the additional address on page 22 situational complete this section if you provide mobile services in Section 4d base of operations check the add box and list the effective date if this address is the same as the practice location in section 4a check the box otherwise fill in the street address city state zip code as it reads on USPS calm then enter the telephone number and if applicable a fax or e-mail address situational on page 23 section for a vehicle information vehicle information is needed on any vehicle where mobile health services are performed such as an ambulance or trailer complete as many of these sections as needed check the add box and enter the effective date type a vehicle vehicle ID number or VIN for each vehicle supply a copy of the registration with the vehicle ID number as well as any licenses or certification for this vehicle situational on page 23 section 4f geographic location formal providers if practicing in the entire state check the box and list the state it is not necessary to report each city or town if practicing in selected cities list the city state and zip code only the zip code if not providing services in the entire city or town if there are organizations with ownership on page 29 section 5 ownership interests or organizations check the ad box and list the effective date fill in the legal business name as reported to the IRS and the doing business as name if there is one enter the street address city state and zip code as it appears on USPS comm enter the tax ID Medicare ID and type 2 NPI are not required under type of organization check each box that applies to this organization make sure to specify if selecting other on the next three pages check the box for each applicable role enter the effective date and the exact percentage of ownership make sure all effective dates are the same on page 32 lists if there are any final adverse legal action specifically for the organization listed in section 5a if yes fill out the columns below and attach a copy of the final adverse legal action documentation there must be information listed in East column C attached is not acceptable feel free to include a letter to explain changes occurring submit as many section 5s as needed include an organizational chart sniffs include an ownership chart with ownership percentages if there's an individual with ownership on page 34 section 6 ownership interests for individuals check the ad box and enter the effective date please note that if the organization is a government agency at least one individual needs to be listed in this section enter the first and last name social security number and date of birth type 1 NPI Medicare place and country of birth are all optional on page 34 through 37 check the box for each appropriate role enter the effective date an exact percentage and title on page 38 section 6 B final adverse legal action history list if there is any adverse legal action specifically for the individual listed in Section 6a if yes fill out the columns below and attach a copy of the final adverse legal action documentation there must be information listed in every column C attached is not acceptable submit as many section sixes as needed include a flowchart situational on page 39 section 7 chain Home Office if this section does not apply check the does not apply box and move to the next section otherwise check the add check box and enter an effective date check the first box for provider in chain is enrolling in Medicare for the first time and add the effective date listed above on page 40 section 7 C fill in the legal business name as it appears on the IRS document street address and phone number enter fax an email if there is one next enter the tax ID and cost report date enter the Medicare contractor and home office chain number if there is one this entity must also be listed in section 5 check the appropriate boxes below for business structure and how the chain home office is affiliated with the provider on page 41 billing agency information if this section does not apply check the does not apply box and move to the next section otherwise check the add box and list an effective date if the billing agency is an individual list the legal name date of birth and social security number this must match what is on file at the Social Security Administration if the billing agency is an organization list the legal business name tax ID number the name must also match what is reported to the IRS do not abbreviate please include a copy of the billing agency's IRS doc enter the street address city state zip code and the telephone number of the billing agency on page 44 contact person section 13 lists the contacts information the email and phone number will be used to verify information on this application if the only contact is the authorized or delegated official listed on the application check the appropriate boxes nuridium can only communicate with the people listed in this section and the authorized or delegated officials so fill out as many sections 13s as needed if multiple contacts are provided and you wish to have a primary contact right primary at the top of the page on page 49 section 15 certification statement for authorized officials check the add check box fill in the first and last name telephone number title sign and date this section with blue or black ink include as many section 15s as needed for all authorized officials any individuals listed in this section will also need to fill out section 6 to prove they have authority to sign the application on pages 50 and 51 section 16 certification statement for delegated officials check the add check box next fill in the first and last name a telephone number title and sign and date this section was blue our black ink this must be signed and dated with the authorized official listed in section 15 include as many section 16s as needed for the delegated officials any individual listed in this section needs to fill in section 6 to prove they have authority to sign the application a bill of sale or final sales agreement is required on all Chows even if one is not provided with the sellers Chau IRS documentation for any entity listed in to be one is required include a flow chart for sections 5 and 6 as well as a list of board members any state license certification national accreditation CLIA at da certificate an EFT and a bank letter or voided check must accompany your application these next two slides are specialty dependent and will help you submit any additional documentation needed FQHCs a full copy of the hersa grant award for FQHCs is required if the practice location is not listed on the hersa then you are also required to submit the form 5 Part B service cites document an exhibit 1 7 7 in full with legal business name and physical practice location signed and dated by an authorized or delegated official for California FQHCs only a copy of State License intermittent clinics operating for less than 30 hours a week do not need their own license but need to be listed on the parent license if the practice location is not currently listed on the state license confirm you have applied to be added to the parent license in either case we have to have a copy of the state license in order to forward for approval if you state you have applied to be listed on the parent license and the state does not have your information your application will be delayed CMHC's submit a document verifying that 40% of the clients receiving services are not medicare eligible this document must be provided by an independent entities such as an accountant technician the document must certify that the entity has reviewed the CMHC's client care data and to the CMHC meets the applicable 40 percent requirement complete a letter of participation and medicare that includes describing services provided and the number of full-time equivalent employees exhibit 282 attachment B RHC submit a para bihter based at test station statement if you want to be provider-based to a hospital sniff submit a diagram slash flowchart identifying all of the applicants owners including those that were not required to be listed on the organizational control and individual control topics Children's Hospital submit a demographics covering the past six months showing that the age of the participation population in order to verify that 50% of the hospitals in patients are under the age of 18 things to remember don't forget to sign the application signatures must be dated within 120 days prior to the date of the receipt signatures without dates are not valid ensure the final sales agreement is signed dated and has the date in which the sale becomes final make sure that things are not abbreviated the names must match what is listed with the SSA or the IRS thank you for attending today's training