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Home My WebLink About215895 12/25/2012 CITY OF CARMEL, INDIANA VENDOR: 366802 Page 1 of 1 g � ONE CIVIC SQUARE MEDICARE PROVIDER ENROLLMENT ®t CARMEL, INDIANA 46032 PO BOX 8248 CHECK AMOUNT: $532.00 MADISON WI 53708-8248 CHECK NUMBER: 215895 CHECK DATE: 12/25/2012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 4463202 532 . 00 SOFTWARE DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services MSullvrirnsc . a1 1 k : 3^• a,. -.. .---- -....�.. .�. -. /riji,rurcrairrr,�r�r<19�clrrr;rc-J�i�c� !•i�,'�`f,�s•ic•c:F/ccrlrlr(."t;rr!'�•rJ4'.e.+'rr,;trl.+' News Flash—Several fact sheets that provide education to specific provider types on how to enroll in the Medicare Program and maintain their enrollment information using Internet-based Provider Enrollment,Chain, and Ownership System (PECOS)have been recently updated and are available in downloadable format from the Medicare Learning Network®(MLN). Please visit http://www.cros.gov/Medicare/Provider-Enrollment-and- Certification/MedicareProviderSupEnroll/downloads/Medicare Provider- Supplier Enrollment National Education Products.pdf for a complete list of all MLN products related to Medicare provider-supplier enrollment. MLN Matters®Number:SE1126 Revised Related Change Request(CR)#: NIA Related CR Release Date: NIA Effective Date:NIA Related CR Transmittal#: NIA Implementation Date: NIA Further Details on the Revalidation of Provider Enrollment Information Note;:Tl is:article,was revised on December 3,2012,to provide the„calendar year 2013 fee amount of $02.Ob.:All other,in formation,remains the.same.” ;; Provider Types Affected This Medicare Learning Network(MLN) Matters®Special Edition Article is intended for all providers and suppliers who enrolled in Medicare prior to March 25, 2011, via Medicare's Contractors(Fiscal Intermediaries(Fls), Regional Home Health Intermediaries(RHHls), Medicare Carriers,A/B Medicare Administrative Contractors(A/B MACs), and the National Supplier Clearinghouse (NSC)). These contractors are collectively referred to as MACs in this article. r Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations.This article may contain references or links to statutes,regulations,or other policy materials.The information provided is only intended to be a general summary.It is not intended to take the place of either the written law or regulations.We encourage readers to review the specific statutes,regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2010 American Medical Association. tL' Revalidation of Medicare Enrollment Page 1 of 3 Medicare J8 MAC Part B Michigan and Indiana Providers Home J8 MAC Part B Departments Enrollment Revalidation Of Medicare Enrollment Revalidation Of Medicare Enrollment All providers who enrolled with Medicare prior to March 25, 2011,will be required to revalidate their Medicare enrollment by submitting the appropriate CMS-855 Medicare enrollment form(s)to their Medicare contractor in response to notices being sent between September, 2011, and March, 2015.This requirement for revalidation is based on Section 6401 of the Patient Protection and Affordable Care Act.,which also requires that all providers be reevaluated under the new screening guidelines established in Section 6028 of the law. Providers have 60 days from the date of the revalidation notice to submit their complete enrollment information. Providers are to submit their CMS-855 revalidation enrollment applications only after receiving notification that they are required to do so. Wisconsin Physicians Service is sending these notification letters on a regular, intermittent basis. Providers must submit revalidation applications for all provider transaction access numbers(PTANs)reported on the revalidation notice. Revalidation Applications Providers can revalidate their CMS-855 Medicare enrollment applications via Internet-based PECOS or the paper application process with applications downloaded from the CMS website Required Documents: Copies of diplomas and/or academic transcripts, certifications, and any other documents needed to establish that non-physician practitioners meet Medicare's eligibility requirements for their specialty. A CP-575 or other form issued by the Internal Revenue Service to document the provider's legal business name and employer identification number(EIN). 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. Other documents may also be required on a case-by-case basis,e.g., a copy of the provider's driver's license for signature verification purposes. Application Fee: With the exception of physician group practices and non-physician practitioner group practices, organizations submitting a CMS-855B to revalidate their enrollment information must submit documentation of payment of the application fee and/or a request for a hardship exception to the application fee. For Calendar Year 2012,the application fee is$523.00. Providers submitting paper applications should pay the application fee prior to submitting the application via the CMS website . It can be paid by electronic check, http://www.wpsmedicare.com/j 8macpartb/departments/enrollment/revalidation-med-enrollment.s... 12/17/2012 Revalidation of Medicare Enrollment Page 2 of 3 debit card, or credit card. Providers submitting Internet-based PECOS applications will be prompted to pay the fee during the application process. Hardship Exception Request Providers may submit a letter and financial statements to request a hardship exception in lieu of the application fee along with their application or certification statement. Revalidations are processed only when fees have cleared or the hardship exception has been granted. Providers are notified by mail if their hardship exception request has been granted or if a fee is required. Mailing Address: The mailing addresses to which paper applications, and certification statements and required documents for Internet-based PECOS applications, should be sent are: Priority Mailing Address Wisconsin Physicians Service Wisconsin Physicians Service Medicare Provider Enrollment Medicare Provider Enrollment P.O. Box 8248 1707 W. Broadway Madison,WI 53708-8248 Madison,WI 53713-1834 Failure to Revalidate Failure to submit complete enrollment application(s)and all supporting documentation within 60 calendar days of the postmark date of the revalidation notice letter may result in providers'Medicare billing privileges being deactivated. Additional Information The CMS-8550 form cannot be used for revalidation.This form is used only by physicians and practitioners who enroll in Medicare for the sole purpose of being the ordering/referring provider on Medicare claims.The revalidation requirement does not apply to these providers. The revalidation requirement does not apply to physicians and practitioners who have opted out of Medicare. "You are revalidating your Medicare enrollment"should be checked as the Reason for Application in Section 1A of the CMS-8551 or CMS-855B enrollment form. Physicians and nonphysician practitioners who reassign their Medicare benefits to a group practice or organization must submit both a CMS-8551 and CMS-855R to revalidate their Medicare enrollment. One CMS-8551 and CMS-855R may be submitted to revalidate all PTANs for reassignment to the same legal business entity(tax identification number).A separate revalidation application form(s) should be submitted to revalidate PTANs associated with each legal business entity. The revalidation notification letter or a copy of it should be enclosed with the revalidation application or certification statement. A CMS-588 Electronic Funds Transfer(EFT)Authorization Agreement is required only if the provider is not already receiving Medicare payment via electronic funds transfer or if changes are being made to their existing EFT arrangements. A CMS-460 Medicare Participating Physician or Supplier Agreement should not be submitted;the http://www.wpsmedicare.com/j 8macpartb/departments/enrollment/revalidation-med-enrollment.s... 12/17/2012 Revalidation of Medicare Enrollment Page 3 of 3 revalidation process does not affect the current participation status of providers. Providers who receive notification to revalidate a PTAN for a practice at which they are no longer active should submit the appropriate CMS-855 as a change of information to notify us of the termination. Inquiries Questions regarding revalidation may be directed to our Provider Enrollment Department by calling our toll- free telephone number between the hours of 8:00 a.m. and 4:00 p.m. (C.T.) Monday through Friday. Our toll-free telephone number is(855)280-5484. Additional References Centers for Medicare&Medicaid Services(CMS)-Revalidations MLN Matters MM7350, "Implementation of Provider Enrollment Provisions in CMS-6028-FC" MLN Matters SE1126, "Further Details on the Revalidation of Provider Enrollment Information" MLN Matters SE1130, "Implementation of Pay.gov Application Fee Collection Process through PECOS" Page Last Updated Thursday,16-Aug-2012 16.28 01 CDT http://www.wpsmedicare.com/j 8macpartb/departments/enrollment/revalidation-med-enrollment.s... 12/17/2012 VOUCHER NO. WARRANT NO. ALLOWED 20 Medicare Provider Enrollment IN SUM OF $ P.O. Box 8248 Madison, WI 53708-8248 C� '6b ON ACCOUNT OF APPROPRIATION FOR Carmel Fire Department PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members 1120 I 1 102-632.02 I 0 I hereby certify that the attached invoice(s), or .4)Z) 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 DEC 17 2012 b Fire Chief Title Cost distribution ledger classification if claim paid motor vehicle highway fund Prescribed by State Board of Accounts City Form No.201(Rev.1995) ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice or bill to be properly itemized must show: kind of service,where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) $523.00 1 hereby certify that the attached invoice(s), or bill(s), is(are)true and correct and I have audited same in accordance with IC 5-11-10-1.6 20 Clerk-Treasurer