Streamline Your Medical Receipt Format for Supervision with Ease

Medical receipt format for Supervision

Welcome to the training for completing the CMS form 855 B for certain organizations enrolling  in Medicare for the first time. This training will walk you through the process of completing the form   and help you to avoid delays in the application processing.   WPS GHA designed this program with the most current information available. All current rules and regulations will prevail.  There are some organizations that will need to complete  the CMS form 8 5 5 B, review the list provided on  this slide or on the application on page 1. If you need to, please pause this slide, make sure  your organization is listed before completing  the 855 B. If your organization is not listed, WPS GHA recommends contacting our call center for  additional help. This application is completed  for organizations that will be rendering Part B services. If the organization is part of a  facility, complete the 855 A. If your organization is a professional corporation, professional association, limited liability company, or another  company which has a sole owner as a doctor or other medical professional then complete the CMS form 855 I. If an individual has already completed his or her enrollment and he simply wants to be reassign benefits to a facility, then complete the CMS form 855 R. In order to complete this form  you will need the National Provider Identifier or NPI of the supplier or organization. The first thing we recommend is gathering the form. As previously mentioned, you will need to CMS form  8 5 5 B.   The form is available on the CMS website in the Forms section.   The path is located on this slide.  If you do not have the form, please pause this training and locate the form before moving  on. The form will look like this. The form itself does have instructions which you can follow. As we move through the pages of this presentation,   each page number given will represent the form on the CMS website. In section 1 A Basic information,  check that you are a new enrollee in Medicare. Note: the required sections. All enrollees must complete the entire application. Ambulance suppliers must complete Attachment 1, and the independent diagnostic testing facilities or  IDTFs must complete Attachment 2.   As a new enrollee, you do not need to complete section 1 B.  Move to page 8 and complete section 2 A.   Check the box for the type of supplier or organization you are enrolling. You are only allowed to check one box. If you need to enroll more than one type  of supplier or organization, complete separate applications. WPS GHA recommends that you contact  us before checking other and completing the line below it.  The next section is 2 B 1 on page 8, complete the business information. The first field is for the legal business name as reported to the  Internal Revenue Service or IRS,   then complete the Tax Identification Number issued by the IRS. Complete other names for organizations, such as doing business as names. If you choose other, please  specify the type of other business name.  Next, check the box for how you are registered with the IRS.    Complete your organization's structure. Remember to only check one box.    Complete the incorporation date and the state where the incorporation date occurred. Note, the incorporation date and state  where it occurred are not required.   Not all organizations or suppliers are incorporated. Last, indicate if the supplier or organization is part of an Indian Health Facility. [silence] Continue on page 9, for completing the group license information or certification information. If you are not state licensed, check the box for not applicable. If you are state licensed, complete the license number and state where the license was issued.  Add the effective and termination dates of the license. If you have a certification, complete the next section.  if you do not, then check the box for this.  Add your certification number and state where it was issued.  Also, complete the effective and expiration date for the certification.   Remember, if either of these are applicable a copy must be included with the application. To avoid delays and development, be sure to attach the group information for the license or certification  and not an individual's information. Complete the correspondence address. The person listed here must be an employee of the organization and able to answer questions related  to the organization. He or she cannot be part of a billing agency and the address cannot be to a billing agency.   Complete the street address for the correspondence to be mailed to. Complete the city, state, and ZIP code for the address listed. Add a telephone number for the contact  person, and if you want, a fax [number] or email address.   Note: WPS GHA always recommends adding an email address  as it is the fastest way to communicate any correspondence to your organization. We will discuss 2 C on an upcoming slide.    Section 2 D is an explanation of any information about unique  circumstances for your organization.  This section is not required, if it does not apply to you. There are areas of section 2 that are only completed by certain provider types. Let's explore each one of these areas individually. Hospitals must complete section 2 C. Physical and occupational therapy groups complete section 2 E.   Ambulatory surgical centers complete section 2 F. When an organization is terminating a physician's assistant, complete section 2 G. Advanced diagnostic imaging suppliers  complete section 2 H.   Please note: you do not need to complete any of these sections if they are not applicable to you; however, if they are applicable, they must be completed. Section 2 C is completed  by hospitals that need to enroll certain services.   These include hospitals requiring Part B numbers to bill for practitioners or pathology services to provide purchase tests to other Part B billers. Check the box if it applies to you, then move on to question 1. Choose one of the two options. If you  choose the first option, then move on to 2 D. If you choose the second option, then complete the chart for each department needing a Part B number.   Physical therapy and occupational therapy groups will complete section 2 E.    Answer each question with yes or no.  If you answer yes to any of the questions two through five, submit a copy of the lease agreement. Section 2 F is completed for  all ambulatory surgery centers [ASCs]. Indicate if the ASC is accredited or exempt. If you are accredited, check the top box and complete the chart with the name of the accrediting organization, effective and expiration dates.   If the organization is exempt, check the second box and send a copy  of the exemption statement.  As a new enrollee, you can skip section 2G for groups wishing to terminate one or more physician's assistants.   In 2H, advanced diagnostic imaging suppliers must complete what type of imaging they supply by checking the appropriate box for each type of imaging they apply. Please note: you may check more than one box. Complete fields for each type  of imaging you checked.   Complete the name of the accrediting organization, effective and expiration date of your accreditation. Section 3 is about the providers adverse legal action. If you check no, move on to the next section on page 4.   If you select yes, then complete the chart below for each action.   Also include a copy of the final adverse legal action documentation when you mail in the application.   After this has been completed, you will need to move to the practice location information. Section 4 is for practice location. If you have more than one practice location, copy and complete this section for each location.   Check the add box and enter the date you started using the practice location. Complete the name of the practice location. Use the doing business as name,   which is the name the patient sees upon arrival. Enter the location street address and  city, state, and ZIP code of the address. Add the telephone number for the address and if applicable, a fax number and email address. Next, indicate the date the first Medicare patient was seen at this location.  As a new enrollee, the Medicare identification field should be blank. Complete the National Provider Identifier (NPI). Select the type of practice at this location. If you have a lab at this location, complete the CLIA number.   If you have an FDA number for mammography, enter the  number.   If you complete either certification fields, be sure to attach a copy of the certificate to the application. Section 4 B is completed with information regarding where you want your   remit notices sent and special payment checks sent such as incentive bonuses. Remember, Medicare issues electronic funds transfer (EFTs) for payments for billed services. As you are completing the application for the first time, check add and complete the date. If your address is the same as what's in 4 A, check the first box. If the address is different than what's in 4 A, check the second box and complete the address fields. Section 4 C on page 16 is completed for where your medical records are stored. You must have at least one address in this section. Check the add box and complete the date field.   Next, complete the street address for the storage facility. You may need to add a second location as well and this can be done on the same page.  In 4 D, complete the information if you provide services in the patient's home.   First, check add and enter the day your organization started seeing patients in the home. If you see patients in the entire state,  check the box and enter the name of the state. If you only see patients in portions of the state, complete the chart with the city, state, and ZIP code for each location you see patients in. Some providers have mobile operations as part of his or her practice, complete 4 E if this applies to  you. Check add and complete the date for the first time you saw a patient in your mobile location. If the base of operation is the same as the practice location, then check the applicable box. If not, leave it blank and complete the chart with the address for the base of operation. Once this is complete, move to section 4 F and complete the vehicle information.  Check the add box and enter the effective date for the use of the vehicle.  Next, enter the type of vehicle and the manufacturer's vehicle identification number  or VIN. Be sure to submit a copy of the vehicles state healthcare license, permits, or registration when mailing the application. After entering the vehicle information, complete 4G with the geographical area the vehicle services. If you service the entire state, then check the box, enter the state,   and move to section 5. If you only service a portion of the state, then complete the chart with a city, state, and ZIP code for the areas you service.  Section 5 is used for organizations that have ownership interest or managing control. You will need to copy and complete section 5 for each organization with ownership or control interest. If only an individual has this, then check the not applicable box and skip to section 6. Check the add box and enter the date if an organization has this. Next, check the box or boxes that apply to your situation. For instance, the organization may be a partner and have managing control. Move on and enter the legal business name as reported to the Internal Revenue Service (IRS)  and then complete the doing business as name, if applicable. Complete the street address for the organization. Complete the city, state, and ZIP code related to the street address.    Add a phone number to the organization  and if you choose, a fax number or email address.   Next, complete the National Provider Identifier, if issued, Tax Identification Number, and Medicare Identification Number, if issued. Next, complete the dates the owner acquired ownership of this provider. Last, add the date the organization  acquired managing control. Complete section  5 B for each organization. You will not need to check change, as you are enrolling for the first time.  Choose yes or no under question 1. If you answer no, move on to section 6 on page 25.   If you answer yes, then move to the chart. Complete the final adverse legal action, date the action was taken,   who took the action, and the final resolution. Be sure to send a copy of the adverse legal action documentation with the application.  Section 6 is similar to section 5,  except for it is for individuals having ownership managing control.  Complete this section for each person, which means you may need to include additional copies. Check the add box and complete the date below.   Enter the person's name and title. Complete his or her date  of birth, state or place of birth, and country of birth. Next, add his or her Social Security Number, and if issued, Medicare Identification Number    or National Provider Identifier. Check all boxes that apply, including how the individual is related to the supplier.  Add the effective date of ownership and when the individual acquired managing control. Complete section 6 B for each individual  with managing control. You will not need to check change as you are enrolling for the first time. Choose yes or no under question 1. If you answer no,   move on to section 8 on page 27. If you answer yes, then move to the chart. Complete the adverse legal action,  date the action was taken,  who took the action, and the final resolution. Be sure to send a copy of the adverse legal action documentation with the application. Next, Medicare will need to know if you have a billing agency. If you do not, check the appropriate box and move to section 13. If you do have a billing agency, check add and enter the date below the box. Enter the legal business name of the organization or the person's name. If you have a person, then complete his or her date of birth. If the person or organization has a  doing business as name, enter it here. Enter the tax ID of the organization or the individual's Social Security Number.   Next, complete the street address, city, state, and ZIP code. Complete the telephone number, and if applicable, fax number or email address. Move to section 13, contact person on page 28. The contact person will be responsible for answering any questions related to the application. He or she will need knowledge of, and access to, all enrollment information. Start by indicating if the contact person is an authorized or delegated official.  Complete the contact person's  name. Include the contact telephone number,  and if applicable, the fax number and email address. Enter the street address, city, state, and ZIP code of the address. After completing this section, move to  page 32, section 15, for authorized officials.   Please note: WPS GHA always recommends adding an  email address to this section.   The communication is more effective and efficient using email. You can add 2 authorized officials in section 15 B and C.  The two sections are completed the same  so these directions apply to both. Check the add box and enter the date below it. Complete the person's name, with suffix if applicable.   Enter the person's phone number and title or position. Have the person sign and date the form. CMS and WPS GHA recommend blue ink,   as this help designate that it is an original signature. Section 16 is for delegated officials. You are not required to add a delegated official, but WPS GHA recommends that at least one person be listed. This person can have access to change or update the file.   On the application you can list two delegated officials.  The sections A and B are completed the same.   Check add and enter the date. Enter the complete name of the delegated official. Have the delegated official sign and date the form. Check the box to indicate if the delegated official is a W-2 employee. Enter the delegated official's phone number. Last, have an authorized official listed in section 15 sign and date the form.  Remember, all signature requirements  must be met. The requirements include: signatures must be dated within a hundred and twenty days  prior to WPS GHA receiving the application,   must be dated to be valid and should be signed in blue  ink. Next, look at the checklist. Check applicable boxes and complete the items you are attaching,  then send a copy of the information with the application. Ambulance suppliers will complete Attachment 1 with the geographical information of their service areas. Check the add box and complete the date. Complete the chart under Attachment 1 A 1. You will not use the deletion section as you are enrolling for the first time. Next, move on to Attachment 1 B for state license information.  Check the add box and enter the date.  If you are state licensed, check yes.   If you are not state licensed, check no and explain why the organization is not state licensed. If you check yes, enter the license information. Start with a license number, state, and city issuing the license. Enter the effective and expiration date of the license.  Next, move on to Attachment 1 C for paramedic intercept services. A paramedic intercept, also referred to as a joint response by CMS, is when a basic life support BLS company   has an agreement with an advanced life support ALS company. The basic life support company does not have the staff to provide higher level services and provides the rig for transportation. The ALS company supplies the staff and the staff boards the BLS rig to treat the patient at a higher level of care. If you have this type of agreement, check yes.  If you do not, then check no. Ambulance suppliers must also complete the vehicle information in Attachment 1 D for each rig used to transport and treat patients. Page 38 of the application may need to  be copied and included multiple times. Check the add box and complete the date the ambulance rig began to be used. Enter the type of vehicle, vehicle identification number, make, model, and year. Last, select from the check boxes to indicate which type of services the vehicle provides. You must check yes or no for each line. The last section of the application is Attachment 2 and is used by independent diagnostic testing facilities. IDTFs indicate what services they provide, who does the service, and the physicians associated to the facilities. Complete the date when the IDTF first  met the CMS standards. Check the add box and enter the date. Next, complete the chart for the procedure codes you will bill. Each procedure code must be included on a line and followed by the equipment  and model number used to perform the task. Move on to page 43 and 44 to enter the physician or  physicians who will interpret the test. If the IDTF does not employ the physicians and will not bill for it, check the box does not apply and move on to section D on page 44. If the IDTF will bill for the interpretation, then each physician must be listed. Copy page 43 if you need more than  three interpreting physicians.  The physician must first be enrolled or being enrolled with  Medicare.  Check add and complete the date. All fields are required. Enter the physician's name,  Social Security Number, and date of birth.   Next, complete the Medicare Identification Number and National Provider Identifier (NPI). Section D is used for the technician, non physician personnel,  who perform the test. Check the add box and enter the date the person began performing the test. Complete the personal information    include his or her name, Social Security Number, and date of  birth. Next, answer if the technician is state licensed or certified. If you answer yes, complete the number and date issued. If the technician is nationally credentialed, check yes and complete the name of the credentialing organization and type of credentials.  If the technician is employed by a hospital, check yes and enter the name on a line.   If not, check no. Remember to complete this section for each technician and copy it as many times as needed.    Next, tell us who is the IDTF's  supervising physician. You may have more than one supervising physician, so complete this section for each one. Copy and complete pages 46 and 47 for each physician. Check add and then complete the date. Enter the physician's name, Social Security Number, and date of birth. Enter the Medicare number and NPI of the physician. Complete the phone and fax number or email address, if applicable. Scroll down the page and complete the type of supervision performed.  If you are not sure what type of supervision each one is, read the definitions on the bottom of page 45. Once you choose one of three types of supervision, scroll down and indicate only the option that the physician is responsible for. Note, you must have a physician responsible for each item, so again, copy this section and  complete it for each physician. On the bottom of page 46, complete if the physician provides  supervision at a different IDTF. Check yes or no. If the answer is yes complete the chart below.  Enter the name, address, tax identification, and level of supervision for each facility. The last section is for the supervising physician to attest that he or she supervises the services listed.  On the line, add the name of the IDTF. Complete the chart with each procedure code the physician  supervises. Last, have the physician sign and date this section. Here are some reminders to help you  avoid delays in processing. Be sure the authorized and/or delegated officials have signed and dated at the appropriate sections. Complete reassignment for any individuals being reassigned to your new group. All groups must have at least one provider with a reassignment. Effective dates cannot be more than 60 days from the date of receipt in our office.  Attach a copy of all required items. There are many different tutorials to help you through your specific enrollment situations  on both the CMS website and WPS GHA portal.   Please take time to review the ones applicable  to the actions you are taking. Have a great day