DMEPOS suppliers initially enrolling or submitting an application for a new location are required to complete and submit the current Authorization Agreement for Electronic Funds Transfer (EFT) Agreement (CMS 588).
Note: Suppliers reenrolling should submit the necessary CMS 588 form(s) if not already enrolled to receive payments through EFT.
Suppliers must complete a separate form for each Medicare contractor where it submits claims. The form must list the proper Medicare contractor, the legal business name as indicated on the CMS 855S and have the original signature of an authorized or delegated official listed on the CMS 855S. Also, suppliers must include with each form submitted, one of the following documents to verify the account information:
- A voided check
- Preprinted deposit slip
- Confirmation of account information on bank letterhead for verification of the account number
Suppliers not providing the correct Medicare contractor name in Section V is a major cause of unnecessary development requests. Suppliers should ensure the proper contractor name is listed in Section V of the CMS 588 form. The DME MACs are unable to accept or process this form without the correct contractor indicated. The name listed in this sections should not be the supplier's business name, bank name or the NSC. Below are the names that should be listed in Section V of the CMS 588 form
Jurisdiction A ' NHIC, Corp.
Jurisdiction B ' National Government Services
Jurisdiction C' CIGNA Government Services
Jurisdiction D ' Noridian Administrative Services
The NSC's role is to simply verify the correct contractor has been indicated on the agreement based on the information the supplier has provided on the CMS 855S and to ensure the agreement is signed properly. Once verified, the NSC will send the agreements to the appropriate DME MAC for processing.
The CMS 588 form can be found on the
CMS Web site.