- Medicare Provider/Supplier Specialty Codes
- CMS-855I Completion Tips for Managing Employee Information in Section 6
- CMS-20134 Completion Tips for Medicare Diabetes Prevention Program Suppliers
- CMS-855I Completion Tips for Physicians and NPPs that Reassign All Benefits Revalidation Application
- Medicare Provider/Supplier Provider Type Codes
- CMS-855O Completion Tips for Physicians or Eligible Professionals for the Sole Purpose of Ordering, Certifying or Prescribing Part D Drugs
- CMS-855B Completion Tips for Clinics/Group Practices and Other Suppliers Revalidation Application
- PECOS Starter Guide
- Resolving PECOS Common Errors and Warnings
- CMS-855B Completion Tips for Ownership Interest and/or Managing Control Information
- CMS-855I Completion Tips for Physicians and NPPs in Private Practice (Sole Owner or Sole Proprietor) Revalidation Application
- Supporting Documentation Required for Enrollment Revalidations
- Understanding Participating, Nonparticipating and Opt Out Status
CMS-855B Completion Tips for Ownership Interest and/or Managing Control Information
Table of Contents
- Section 5 – Ownership interest and/or managing control information
- Instructions for Completing Section 5
- Section 6 – Ownership interest and/or managing control information (individuals)
- Instructions for Completing Section 6
Section 5 – Ownership interest and/or managing control information
This section is to be completed with information about any organization that has direct or indirect ownership of, a partnership interest in, and/or managing control of the provider identified in Section 2 (applicant). The applicant itself should not be listed in Section 5.
All entities that must be listed include but not limited to any organizations that have:
- Five percent or greater direct or indirect ownership
- Owning/managing control organizations
- Corporations (profit or nonprofit)
- Partnerships and limited partnerships (general or limited)
- Limited liability companies
- Charitable and/or religious organizations
- Governmental and/or tribal organizations
- Managing control (conducts day-to-day operations)
Ownership/managing control of organizations need to follow state regulations and guidelines.
In additional to furnishing the information in this section, the provider must submit:
- An organizational diagram identifying all of the entities listed in this section and their relationships with the provider and with each other.
- Each nonprofit organization should submit a copy of a 501(c) (3) document verifying its nonprofit status.
- Governmental/tribal organizations must submit a letter on the letterhead of the responsible organization that attests that the government or tribal organization will be legally and financially responsible of any outstanding debt owed to CMS.
Instructions for Completing Section 5
Section 5A - Ownership/Managing Control Organization
- Complete section per organizational relationship.
- Indicate if action is a change, add, or delete and state effective date if applicable or Mark -Not Applicable and go to section 6.
- Indicate the type of organizational relationship. Check all that apply.
- Complete with the identifying information of the organization.
- Provide effective date for either acquired ownership and/or acquired managing control. Furnish both dates if applicable.
Each organization listed in Section 5A must have a Section 5B. Report any final adverse legal action imposed against organization identified in Section 5A.
Section 5B - Final Adverse Legal Action History
- Question 1 must be answered by selecting Yes or No.
- If yes, report details in Questions 2 and submit a copy of the adverse legal action documentations and resolutions.
Section 6 – Ownership interest and/or managing control information (individuals)
This section is to be completed with information about any individual that has direct or indirect ownership of, a partnership interest in, and/or managing control of the provider identified in Section 2 (applicant). Note that the applicant must have at least one owner and/or managing employee.
All individuals that must be listed include but not limited to any individual that have:
- Five percent or greater direct or indirect ownership interest
- Partnership interest (general and limited)
- Officers and directors, trustees or board of directors
- W-2 or contracted managing employee
- Authorized officials
- Must have another relationship indicated: owner, partner, or director/officer
- Delegated officials
- Must have another relationship indicated: owner, partner, director/officer, or managing employee
Note: Governmental or tribal organization only need to report managing control employees as well as indicating the authorized official and if any delegated officials.
Instructions for Completing Section 6
Section 6A - Ownership/Managing Control Organization
- Complete section per individual with ownership and/or managing control.
- Indicate if action is a change, add, or delete and state effective date if applicable.
- Complete with the identifying information of individual.
- Indicate the type of ownership and/or managing control of individual. Check all that apply.
- Provide effective date for either acquired ownership and/or acquired managing control. Furnish both dates if applicable.
Each individual listed in Section 6A must have a Section 6B. Report any final adverse legal action imposed against individual identified in Section 6A.
Section 6B - Final Adverse Legal Action History
- Question 1 must be answered by selecting Yes or No.
- If yes, report details in Questions 2 and submit a copy of the adverse legal action documentations and resolutions.
Revised 7/29/2024