Last Modified: 5/24/2019
Location: FL, PR, USVI
Business: Part A, Part B
Certified registered nurse anesthetists (CRNA) must meet all of the following criteria to provide services for Medicare beneficiaries:
• Licensed as registered professional nurse by the state in which he or she practices
• Be in compliance with all applicable requirements of state law, including any licensure requirements the state imposes on non-physician anesthetists
• Be a graduate of a nurse anesthesia educational program that meets the standards of either the Council on the Accreditation of Nurse Anesthesia Programs or of another accreditation organization designated by the Secretary of the Department of Health & Human Services (HHS)
• Passed a certification examination or graduated from one of the nurse anesthesia educational programs offered by one of the following organizations: Council on Certification of Nurse Anesthetists, the Council on Recertification of Nurse Anesthetists, or any other certification organization that may be designated by the Secretary of the Department of HHS
• 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.
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 or U.S. Virgin Islands must include a copy of his or her Letter of Good Standing. The letters for Puerto Rico providers/suppliers will be considered valid if it was issued within 12 months of First Coast Service Options’ (First Coast’s) receipt of the enrollment application. The letters for U.S. Virgin Islands providers/suppliers 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)
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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