A delegated official must be a W-2 managing employee of the provider, or an individual with a 5% or greater direct ownership interest in the enrolling provider. A section 6 must be provided on a delegated official. The provider can have no more than 3 delegated officials at any given time.
Type of Change
Adding a Delegated Official
CMS 855A Sections Required
Section 1 (A.1,A.2,A.3)
Section 6 (for delegated official)
Section 6 (for authorized representative, if no application is on file.)
Section 15 Signed by Authorized Representative
Section 16 Delegated Official - Complete entire section.
Type of Change
Deleting a Delegated Official
CMS 855A Sections Required
Section 1 (A.1,A.2,A.3)
Section 6 (for delegated official being deleted.)
Section 6 (for authorized representative, if no application is on file.)
Section 15 Signed by Authorized Representative
Section 16 Delegated Official - Complete 16.B.1.
Actions Taken By Intermediary
Providers will receive a confirmation letter notifying them that the delegated official has been changed.