What attachments should be submitted for application processing?
Below are the attachments required to be submitted for application processing on the hard copy CMS 855s or via PECOS. Please note the NSC has the authority to request other types of documentation if needed to confirm compliance with Medicare guidelines.
- All licenses required by the state or federal governments to operate the business. For more information on what licenses are required, please review the Licensure Information area of the website.
- Suppliers are required to list their National Provider Identifier (NPI) on the application and submit a copy of the notification furnished by the National Plan and Provider Enumeration System (NPPES) verifying the NPI. Suppliers should always list their NPI on the CMS 855S and submit a copy of the notification for new applications, additional locations and reactivations. Further, the notification must list the business name and physical address of the location as reported. The legal business name as reported to the NSC must be an exact match with the IRS document and as reported to NPPES.
- Suppliers who are new enrollees or submitting an application for an additional location are required to submit the authorization agreement for electronic funds transfer (CMS 588). Suppliers should submit a separate form for each Medicare contractor where it submits claims. In addition either a voided check, or a letter on bank letterhead verifying the account information must be attached to each CMS 588 form submitted. Further, suppliers that are revalidating are asked to submit the CMS 588 form if they are not already receiving payments electronically.
- Proof of at least $300,000 in general liability insurance coverage. Submitting the Certificate of Insurance is acceptable but it must list the coverage, amount of coverage, effective dates and the locations covered. Also, the NSC must be listed as the certificate holder.
- Document from the IRS showing the legal name of the entity and federal tax identification number for initial enrollment.
- Suppliers should also submit a valid surety bond in the amount of at least $50,000 unless the supplier type is otherwise exempt from this requirement for new locations, additional locations and reactivations.
- Suppliers should also verify accreditation information has been properly reported to the NSC by the accrediting organization(s).