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Home My WebLink About314599 8/8/2017 a C�gMe CITY OF CARMEL, INDIANA VENDOR: 366802 `= WPS GHA MEDICARE PROVIDER ENROLL�VIFA>$ AMOUNT: S.......560.00* ONE CIVIC SQUARE CHECK NUMBER: 314599 =4; CARMEL, INDIANA 46032 PO DIS 8248 Wl ,,�,TON�, MADISON WI 53708-8248 CHECK DATE: 08!08/17 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTIOTHER EXPENSESON 102 5023990 560.00 VOUCHER NO. WARRANT NO. ALLOWED 20 p r IN SUM OF $ rov�de�' E-r Y-ollme $ `5 D DO--- ON ACCOUNT OF APPROPRIATION FOR " / ` O Board Members PO#or INVOICE NO. ACCT#/TITLE AMOUNT I hereby certify that the attached invoice(s), or DEPT.# bill(s) is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except -20 Signature Title Cost distribution ledger classification claim paid motor vehicle highway fund �d CITY EL JA Y's BRAINARD, MAYOR August 8, 2017 WPS GHA MEDICARE PROVIDER ENROLLMENT PO BOX 8248 MADISON, WI 53708-8248 PROVIDER ENROLLMENT: Please accept the enclosed check $560.00 Medicare application fee for 2017. Revalidation application has been submitted online by the PECOS system. City of Carmel Fire Department NPI -1154325579, Tax ID- 356000972 and PTAN- 317470. Please feel free to contact me if you have any questions. Sincerely �wl Michelle Harrington EMS Billing Administrator 317-571-2604 CARMEL Fuze: DITARTMENT S-nrXi-y A. Coors Ht:Ax2i A1ZT1:xs Tvxo CIVIC SQUARE, CARMEL, IN 46032 OfTlu- 317.571.2600. FAQ; 317.571.2615 Medicare Enrollment Application Information Page 1 of 1 Medicare Enrollment for P-rvido-s and SL;Ppl!eF$ Welcome Application Fee Information Institutional Providers who are submitting applications for the following reasons are required to pay the Provider Enrollment Medicare Application Fee: • Initial Enrollment Revalidation • Change of Information-Adding Practice Location • Change of Ownership via CMS-855A-Buyer not accepting assignment of current Provider Agreement All DMEPOS suppliers(including physicians and non-physician practitioners)are required to pay the fee for: • New Applications • Enrolling an additional location • Revalidations • Reactivations,unless the deactivation was a result of non-submission of claims for four consecutive quarters Providers who are enrolled in Medicare but have not yet established a record in PECOS may be required to submit an Initial Enrollment application to establish a record in PECOS.If the reason for the application submittal is to change the information on the existing Medicare enrollment,and is not for the purpose of adding a practice location, then the Provider is not required to pay the application fee. Year: 2017 Amount:$560 CONTINUE Medicare Application Fee Factsheet[PDF,42KB] I Pay.gov Factsheet[PDF,46KB] I Pay.gov FAQs[PDF,57KB] Medicare Fee-for-Service Contact Information [PDF,250KB] Web Policies&Important Links Department of Health&Human Services t I CMS.gov P I PECOS FAQs 0 I Accessibility p CENTERS FOR MEDICARE&MEDICAID SERVICES,7500 SECURITY BOULEVARD,BALTIMORE,MD 21244 https://pecos.cros.hhs.gov/pecos/feePaymentWelcome.do 8/8/2017 Revalidation of Medicare Enrollment Page 1 of 3 Revalidation of Medicare Enrollment Tags: Featured Guides and Resources,J8A,Revalidation,JSA,Provider Enrollment,J8B,75B Information about and instructions for revalidating Medicare enrollments. Section 6401 (a) of the Affordable Care Act established a requirement for all enrolled providers/suppliers to revalidate their Medicare enrollment information under new enrollment screening criteria. CMS has completed its initial round of revalidations and will be resuming regular revalidation cycles in accordance with 42 CFR§424.515. Providers can use the resource links listed here to obtain specific information related to Provider Enrollment Revalidations-Cycle 2 Revalidation Resources • CMS Revalidations web page • Revalidation Due Date List' • MLN Matters SE1605,Provider Enrollment Revalidation-Cycle 2 • Internet Based PECOS ' • Revalidation Checklist Established Due Dates for Revalidation CMS has established due dates by which the provider/supplier's revalidation application must reach their MAC in order for them to remain in compliance with Medicare's provider enrollment requirements. The due dates will generally be on the last day of a month (for example,June 30,July 31 or August 31). Submit your revalidation application to your MAC within 6 months of your due date to avoid a hold on your Medicare payments and possible deactivation of your Medicare billing privileges. Generally, this due date will remain with the provider/supplier throughout subsequent revalidation cycles. Unsolicited Revalidation Submissions All unsolicited revalidation applications submitted more than 6 months in advance of the provider/supplier's due date will be returned. If your intention is to submit a change to your provider enrollment record, you must submit a change of information application using the appropriate CMS-855 form. Submitting Your Revalidation Application Important: Each provider/supplier is required to revalidate their entire Medicare enrollment record. A provider/supplier's enrollment record includes information such as the provider's individual practice locations and every group that benefits are reassigned (that is,the group submits claims and receives payments directly for services provided).This means the provider/supplier is recertifying and revalidating all of the information in the enrollment record, including all assigned National Provider Identifiers(NPIs)and Provider Transaction Access Numbers(PMNs). If you are an individual who reassigns benefits to more than one group or entity,you must include all organizations to which you reassign your benefits on one revalidation application. If you have someone else completing your revalidation application for you, encourage coordination with all entities to which you reassign benefits to ensure your reassignments remain intact. https://www.wpsgha.com/wps/portal/mac/site/enrollment/guides-and-resources/revalidation... 8/8/2017 Revalidation of Medicare Enrollment Page 2 of 3 Deactivations Due to Non-Response to Revalidation or Development Requests It is important that you submit a complete revalidation application by your requested due date and you respond to all development requests from your MAC timely. Failure to submit a complete revalidation application or respond timely to development requests will result in possible deactivation of your Medicare enrollment. Required Documents: • Copies of licenses,certifications,and any other documents needed to meet Medicare's eligibility requirement. • A CP-575 or other form issued by the Internal Revenue Service to document the provider's legal business name and employer identification number(El N). • A CMS-588 Electronic Funds Transfer (EFT.) Authorization Agreement, if ........... the provider (other than those reassigning their benefits) is not already receiving Medicare benefits electronically, or if the provider is making a change to existing EFT arrangements. • Documents relating to adverse legal actions reported in Section 3 of the application. • Copies of other documents, if applicable, as specified in Section 17 or elsewhere on the CMS-855 form. Application Fee: Institutional providers of medical or other items or services and suppliers are required to submit an application fee for revalidations.The application fee is $560.00 for Calendar Year (CY) 2017. CMS has defined "institutional provider" to mean any provider or supplier that submits an application via PECOS or a paper Medicare enrollment application using the CMS-855A, CMS-8558(except physician and non-physician practitioner organizations),or .......... CMS-855S forms.. All institutional providers (that is, all providers except physicians, non- physicians practitioners, physician group practices and non-physician practitioner group practices) and suppliers who respond to a revalidation request must submit the 2016 enrollment fee (reference 42 CFR 424.514) with their revalidation application. You may submit your fee by Automated Clearing House(ACH)debit,or credit card.To pay your application fee,go to httn Pecos cms hhs aov/oecos/feePaymentWelcome do,w and submit payment as directed. A confirmation screen will display indicating that payment was successfully made.This confirmation screen is your receipt and you should print it for your records. CMS strongly recommends that you include this receipt with your uploaded documents on PECOS or mail it to the MAC along with the Certification Statement for the enrollment application. .......... CMS will notify the MAC that the application fee has been paid. Revalidations .......... are processed only when fees have cleared. Mailing Address: Paper applications, and certification statements and required documents for Internet-based PECOS applications,should be mailed to: Regular Mail Overnight Delivery Mailing Address WPS GHA WPS GHA ................ Provider Enrollment Provider Enrollment P.O. Box 8248 1717 W.Broadway Madison,WI 53708 Madison,WI 53713-1834 8248 https://www.wpsgha.com/wps/portal/mac/site/enroliment/guides-and-resources/revalidation... 8/8/2017