Cahaba GBA Provider Enrollment Top Reasons for Returned Applications

A high percentage of applications are returned to the applicant because the correct information has not been supplied or submitted to Cahaba. We hope to expedite the enrollment process by informing our provider community of the most common reasons an application is immediately returned.

1. Missing and/or Unauthorized Signatures

   Applications must be signed and dated by the appropriate individuals. The application must be signed by the applicant or the authorized or delegated Official. It is important that providers know the difference between the two.

   Applications will be returned if the required sections identified in the table below are not signed by the correct individual. It is important that CAHABA is notified each time there is a change in the Authorized or Delegated official initially listed during the enrollment process. If the individual that signed, and dated section 15 (certification statement) or section 4 (CMS 855R) is not the individual on file, an updated signature page (section 6) must be submitted along with the new signature page (section 15 or section 4). The signature date should not be older than 90 days from the date Medicare receives the application.

   Authorized Official appointed official to whom the supplier has granted the legal authority to enroll it in the Medicare program, to make changes, and/or updates to the supplier's status in the Medicare program (e.g., new practice locations, change of address, etc) and to commit the supplier to fully abide by the laws, regulations, and program instructions of Medicare. The authorized official must be the supplier's general partner, chairman of the board, chief financial officer, chief executive officer, president, direct owner of 5% or more of the supplier, or must hold a position of similar status and authority within the supplier's organization.

   Delegated Official is any individual who has been delegated, by the supplier's Authorized Official, the authority to report changes and updates to the supplier's enrollment record. A delegated official must an individual with an “ownership or control interest” in (as that term is defined in section 1124(a)(3) of the Social Security Act), or be a W2 managing employee of the supplier.

   Additionally, the signature must be original. It cannot be copied or stamped.

   CMS Form	Action	Signature
   855B	Initial Enrollment	Section 15-Authorized Official-Signs and dates
   855B	Change	Section 15-Authorized Official or Section 16-Delegated Official signs and dates
   855I	Initial Enrollment or Change	Section 15-Applicant signs and dates
   855R	Reassignment	Section 4A-Signed and dated by person reassigning their benefits Section 4B-Signed and dated by Group's Authorized Official or Delegated Official
   855R	Terminating a Reassignment by Person	Section 4A-Person that is terming their reassignment signs and dates
   855R	Group is terminating a Reassignment	Section 4B-Authorized Official or Delegated Official signs and dates

2. 855I form not submitted with 855R

   The applicant submits the 855R but does not submit the 855I form. For any group members who are established with Medicare but have not submitted an 855I since 2004, the 855I form must be submitted along with the 855R form.

3. Applications Submitted are not CMS Approved

   CAHABA is required to return any CMS form that does not appear to have been downloaded from CMS's website.

4. Application Submitted to Incorrect Medicare Part B Contractor

   Applicants must submit their application form(s) to the carrier whose jurisdiction the practice is located. CAHABA is the carrier for AL, GA, and MS. When CAHABA receives applications for practice locations outside of our jurisdiction, we must return the application to the provider/entity. CMS offers Contractor Jurisdiction information on their web site.

5. Application Submitted Using an Outdated CMS Form

   CMS issued new applications for providers enrolling with Medicare Part B effective 01/01/09. Currently approved CMS forms are the ones dated (02/08). Any forms received with a different date will be returned. The date is located on the bottom left corner of the application.
   
   

   6. Application Submitted More Than 30 days in advance

   CAHABA can not accept applications received more than 30 days in advance of the effective date listed on the application. (This excludes CMS Certified providers, ASCs, or Portable Xray suppliers).

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