Last Modified: 4/28/2014 Location: FL, PR, USVI Business: Part A, Part B
Occupational therapist (OT) in private practice
Occupational therapists (OT) who are in private practice must meet all of the following criteria to provide services for Medicare beneficiaries:
• Licensed as an occupational therapist by the state in which he or she is in private practice
• Maintains a private office -- even if services are always furnished in patients’ homes
Note: If services are furnished in private practice office space, that space would have to be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice. If the applicant is an organization, it must be wholly owned by one or more occupational therapist(s) practicing at the location.
• Meets one of the following sets of criteria regarding education, experience, and/or professional registrations:
• Graduate of an educational program with an occupational therapy curriculum that has been accredited by the Committee on Allied Health Education of the American Medical Association and the American Occupational Therapy Association
• Eligible for the National Registration Examination of the American Occupational Therapy Association
• Completed two years of experience as an occupational therapist and achieved a satisfactory grade on a proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service -- not applicable to occupational therapists who were initially licensed by a state or sought initial qualification as an occupational therapist after December 31, 1977
Documentation requirements and recommendations
• Completed CMS-855I form
Note: To expedite the processing of your provider enrollment application, you may use the Internet-based Provider Enrollment Chain and Ownership System (PECOS) , which will automatically select the appropriate form and allow you to complete the application process online.
• Signed and dated Certification Statement -- all signatures must be original and signed in ink (blue ink preferred). Stamped, faxed, or copied signatures will not be accepted.
Note: If you submitted your application through Internet-based PECOS, you may sign the application electronically or you must submit your paper Certification Statement within fifteen days of your electronic submission.
• Completed Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588) and associated documentation (e.g., copy of a voided check and/or a deposit slip). Please click here for more information.
Note: If a provider/supplier already receives payments electronically and is not making a change to his/her banking information, the CMS-588 is not required. In addition, physicians and non-physician practitioners who are reassigning their benefits to another entity are not required to submit the CMS-588.
• Include copies of the following supporting documents:
• A notarized copy or a certified “true copy” of the practitioner’s state medical license:
• A notarized copy must include the stamp that states “official seal” and the name of the notary public as well as the state, county, and date the notary’s commission expires.
• A certified “true copy” of an original document has a raised seal that identifies the state and county in which it originated or is stored.
Note: A provider/supplier located in Puerto Rico must include a copy of his or her Letter of Good Standing from the Puerto Rico Board of Medicine -- the letter will be considered valid if it was issued within six months of First Coast Service Options’ (First Coast’s) receipt of the enrollment application.
• Certificate of completion, transcript, and/or diploma from accredited educational program(s) required for certification and/or licensure (please refer to Qualification requirements section at the top of the page.)
Additional documentation requirements (when applicable)
Medicare may require additional documentation, when applicable, to validate key information contained within the enrollment application (e.g., name change, tax identification number, proof of citizenship) or to address specific issues that could adversely affect a practitioner’s potential eligibility for enrollment (e.g., adverse legal actions, financial relationships).
• Driver’s license
• Social security card
• Marriage license
• U.S. passport
• National provider identifier (NPI) verification from National Plan and Provider Enumeration System (NPPES) -- only durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers are required to submit this type of documentation
• Written confirmation from the Internal Revenue Service (IRS) verifying provider’s tax identification number (TIN) is associated with the provider’s legal business name (e.g., IRS CP 575)
• Final adverse action documentation: Please include copies of legal documents associated with any final adverse action(s) taken against the provider as well as copies of any the legal documents showing its resolution (e.g., notifications, reinstatement letters).
Note: Documents containing a summary of the adverse actions taken or their resolution will not be accepted.
• Statement in writing from the practitioner’s bank (or other financial institution) -- if Medicare payments will be sent to a practitioner’s bank with which he or she has a lending relationship (i.e., any type of loan), then the practitioner must provide a statement in writing from the bank -- which must be specified in the loan agreement -- that the lender has agreed to waive its right of offset for Medicare receivables.
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