) application.
Section of form |
Helpful hints |
|---|---|
Section 1: Basic information |
Section 1A: Reason for submitting this application Select the reason for submitting the application. Section 1B: Check all that apply and complete the required sections If you are performing a change of information, please select the sections you are changing: • Required sections for the change of information are listed in the right column |
Section 2: Identifying information |
Section 2A: Type of supplier Check the box for "In-person MDPP supplier". Note: Medicare only enrolls in-person MDPP suppliers. Section 2B: Supplier identification information Enter the legal business name as reported to the IRS. Complete the organizational code: • A recognition letter for each organizational code must be submitted with the application Enter the MDPP preliminary recognition or Center for Disease Controls Diabetes Prevention Recognition Program full recognition status. Correspondence address is the address we can contact the supplier directly: • Address cannot be a billing agent or agency's address or a medical management company |
Section 3: Final adverse legal actions or convictions |
Make sure to include a copy of all final adverse legal action documentation and resolution, if applicable. |
Section 4: MDPP location information |
Section 4A: MDPP location information Report all administrative locations and community settings where MDPP services will be furnished. If there is more than one location, copy and complete this section for each: • Select the type of location as either an administrative location or community setting • Specify the type of administrative location Report the CDC organizational code associated with the location. Section 4B: Where do you want remittance notices or special payments sent? Provide address where payment information (e.g., remittance notices, non-routine special payments) should be sent. Section 4C: Where do you keep beneficiaries' medical records? If you store patients' medical records at a location other than the location in section 4A, complete this section with the address of the storage location. P.O. boxes and drop boxes are not acceptable for the medical records storage location. |
Section 5: Ownership interest and/or managing control information (organizations) |
This section only applies to organizations. Any organization that exercised operational or managerial control over the provider or conducts the day-to-day operations, is a managing organization. Section 5A: Organization with ownership interest and/or managing control - Identification information Enter the legal business name as reported to the IRS. If there is another name the provider uses, enter this in the “Doing business as” box. Organization need not have an ownership interest in the provider. Supplier must submit an organizational structure diagram or flowchart identifying all the entities listed in section 5 and their relationships with the supplier and each other. If more than one organization has ownership interest or managing control, copy and complete this section for each organization. Section 5B: Final adverse legal action history Complete this section by answering "Yes" or "No" if the organization has ever had a final adverse legal action imposed against it: • If yes, make sure to include a copy of all final adverse legal action documentation and resolution, if applicable |
Section 6: Ownership interest and/or managing control information (individuals) |
Section 6A: Individuals with ownership interest and/or managing control - Identification information The name, date of birth, and social security number of each person listed must coincide with the individual's information reported to the Social Security Administration. Authorized officials: • Must identify one other relationship of 5% or greater direct or indirect owner, partner, or director or officer • If this application is for initial enrollment, ensure you complete and sign in section 15 • Must identify one other relationship but can select managing employee as other relationship • If this application is for initial enrollment, ensure you complete and sign in section 16 If more than one individual has ownership interest or managing control, copy and complete this section for each individual. Section 6B: Final adverse legal action history Complete this section by answering "Yes" or "No" if the individual in 6A has ever had a final adverse legal action imposed against them: • If yes, make sure to include a copy of all final adverse legal action documentation and resolution, if applicable |
Section 7: Coach roster |
It is critical you review the coach eligibility requirements at 42 CFR 424.205(e). If you are adding a coach, the date should represent the date the coach began furnishing MDPP services (for a coach that is subsequently deemed eligible, this will become their coach eligibility date). If the coach has not yet begun furnishing services, simply include the date the change is being reported. MDPP suppliers must report all changes to the coach roster within 30 days. The name, date of birth, and social security number of each coach listed in this section must coincide with the individual's information as listed with the Social Security Administration. Report the coach's NPI. Copy and complete this page for every coach being added. |
Section 8: Billing agency information |
A billing agency is a company or individual you contract with to prepare and submit your claims: • If you are using a billing agency, you are responsible for the claims submitted on your behalf |
Section 13: Contact person information |
This captures the person we will contact about the application. Be sure to include all information, including the e-mail address. |
Section 14: Penalties for falsifying information on this application |
This section explains the penalties for deliberately furnishing false information: • Read this section as it outlines criminal penalties and civil liability on individuals who knowingly furnish false information |
Section 15: Certification statement |
For initial enrollments, all individuals listed in section 6 as an authorized official must sign section 15B and C. All signatures must be handwritten or an eligible digital signature (e.g., DocuSign, AdobeSign) as well as dated. Stamped signatures are not acceptable. |
Section 16: Delegated official (optional) |
For initial enrollments, all individuals listed in section 6 as a delegated official, must sign section 16A and B. All signatures must be handwritten or an eligible digital signature (e.g., DocuSign, AdobeSign), as well as dated. Stamped signatures are not acceptable. |
Section 17: Supporting documents |
Medicare Enrollment Application - Electronic Funds Transfer Agreement (CMS-588 ):• Voided check or bank letterhead must accompany above application and needs to be in the group's legal business name Written confirmation from the IRS confirming your tax identification number with the legal business name. Copy of certificate or determination letter demonstrating MDPP preliminary or full DPRP recognition status. Copy of all adverse legal action documents (e.g., notifications, resolutions, and reinstatement letters), if applicable. Copy of completed Medicare Enrollment Application - Medicare Participating Physician or Supplier Agreement (CMS-460 ), if applicable.Copy of an attestation for government entities or tribal organizations. Written statement from the bank, if payment due to a provider is being sent to a bank (or other financial institution) with whom the provider has a lending relationship (e.g., loan), that the bank has agreed to waive its right of offset for Medicare receivables. |
