MEDICARE ENROLLMENT APPLICATION

1 MEDICARE ENROLLMENT APPLICATION . Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers CMS-855S. SEE PAGE 1 FOR A LIST OF THE DMEPOS supplier STANDARDS. TO ENROLL IN THE MEDICARE . PROGRAM AND BE ELIGIBLE TO SUBMIT CLAIMS AND RECEIVE PAYMENTS, EVERY DMEPOS supplier . APPLICANT MUST MEET AND MAINTAIN THESE ENROLLMENT STANDARDS. SEE PAGE 2 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION . SEE PAGE 4 FOR INFORMATION ON WHERE TO MAIL THIS APPLICATION . SEE SECTION 12 FOR A LIST OF SUPPORTING DOCUMENTATION TO BE SUBMITTED WITH THIS. APPLICATION .

2 TO VIEW YOUR CURRENT MEDICARE ENROLLMENT RECORD GO TO: Form Approved DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB No. 0938-1056. CENTERS FOR MEDICARE & MEDICAID SERVICES Expires: 05/19. DMEPOS supplier STANDARDS FOR MEDICARE ENROLLMENT . Below is an abbreviated summary of the standards every MEDICARE DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, including the surety bond provisions, are listed in 42 section (c) and (d) and can be found at #topofpage. 1. A supplier must be in compliance with all applicable 14.

3 A supplier must maintain and replace at no charge or federal and state licensure and regulatory repair cost either directly or through a service contract requirements. with another company, any MEDICARE -covered items it 2. A supplier must provide complete and accurate has rented to beneficiaries. information on the DMEPOS supplier APPLICATION . Any 15. A supplier must accept returns of substandard (less changes to this information must be reported to the than full quality for the particular item) or unsuitable National supplier Clearinghouse within 30 days. items (inappropriate for the beneficiary at the time it 3.)

4 A supplier must have an authorized individual whose was fitted and rented or sold) from beneficiaries. signature is binding sign the ENROLLMENT APPLICATION for 16. A supplier must disclose these standards to each billing privileges. beneficiary it supplies a MEDICARE -covered item. 4. A supplier must fill orders from its own inventory 17. A supplier must disclose any person having ownership, or contract with other companies for the purchase financial or control interest in the supplier . of items necessary to fill orders. A supplier cannot 18. A supplier must not convey or reassign a supplier contract with any entity that is currently excluded from number; , the supplier may not sell or allow another the MEDICARE program, any state health care programs, entity to use its MEDICARE billing number.

5 Or any other federal procurement or non-procurement 19. A supplier must have a complaint resolution protocol programs. established to address beneficiary complaints that 5. A supplier must advise beneficiaries that they may rent relate to these standards. A record of these complaints or purchase inexpensive or routinely purchased durable must be maintained at the physical facility. medical equipment, and of the purchase option for 20. Complaint records must include: the name, address, capped rental equipment. telephone number and health insurance claim number 6. A supplier must notify beneficiaries of warranty of the beneficiary, a summary of the complaint, and coverage and honor all warranties under applicable any actions taken to resolve it.

6 State law, and repair or replace free of charge 21. A supplier must agree to furnish CMS any information MEDICARE covered items that are under warranty. required by the MEDICARE statute and regulations. 7. A supplier must maintain a physical facility on an 22. A supplier must be accredited by a CMS-approved appropriate site and must maintain a visible sign accreditation organization in order to receive and with posted hours of operation. The location must retain a supplier billing number. The accreditation must be accessible to the public and staffed during posted indicate the specific products and services for which hours of business.

7 The location must be at least 200 the supplier is accredited in order for the supplier to square feet and contain space for storing records. receive payment for those specific products and services 8. A supplier must permit CMS or its agents to conduct (unless an exception applies). on-site inspections to ascertain the supplier 's 23. A supplier must notify their accreditation organization compliance with these standards. when a new DMEPOS location is opened. 9. A supplier must maintain a primary business telephone 24. All supplier locations, whether owned or listed under the name of the business in a local subcontracted, must meet the DMEPOS quality directory or a toll free number available through standards and be separately accredited in order to bill directory assistance.

8 The exclusive use of a beeper, MEDICARE . answering machine, answering service or cell phone 25. A supplier must disclose upon ENROLLMENT all products during posted business hours is prohibited. and services, including the addition of new product 10. A supplier must have comprehensive liability insurance lines for which they are seeking accreditation. in the amount of at least $300,000 that covers both 26. A supplier must meet the surety bond requirements the supplier 's place of business and all customers and specified in 42 section (d) (unless an employees of the supplier . If the supplier manufactures exception applies).

9 Its own items this insurance must also cover product 27. A supplier must obtain oxygen from a state-licensed liability and completed operations. oxygen supplier . 11. A supplier is prohibited from direct solicitation to 28. A supplier must maintain ordering and referring MEDICARE beneficiaries. For complete details on this documentation consistent with provisions found in 42. prohibition see 42 section (c)(11). section (f). 12. A supplier is responsible for delivery of and must 29. A supplier is prohibited from sharing a practice location instruct beneficiaries on the use of MEDICARE covered with other MEDICARE providers and suppliers.

10 Items, and maintain proof of delivery and beneficiary instruction. 30. A supplier must remain open to the public for a minimum of 30 hours per week except physicians (as 13. A supplier must answer questions and respond defined in section 1848(j) (3) of the Act), physical and to complaints of beneficiaries and maintain occupational therapists or DMEPOS suppliers working documentation of such contacts. with custom made orthotics and prosthetics. CMS-855S (05/16) 1. WHO SHOULD SUBMIT THIS APPLICATION The following types of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers must complete this APPLICATION to enroll in the MEDICARE program and receive a MEDICARE Billing number.