Blank Cms 1513 PDF Template

1. What is the CMS-1513 form?

   The CMS-1513 form is used for disclosing ownership and control interests in entities that participate in health programs like Medicare, Medicaid, and certain others established by the Department of Health and Human Services. It's a way for the Centers for Medicare & Medicaid Services (CMS) to ensure transparency and prevent conflicts of interest.

2. Who needs to fill out the CMS-1513 form?

   This form must be completed by entities seeking participation, certification, or recertification under certain health programs, such as Medicare or Medicaid. This includes providers or suppliers of medical services, as well as any entity that arranges for the furnishing of health services under these programs.

3. What happens if the CMS-1513 form is not submitted?

   Failure to provide the requested information may result in the entity being denied participation in the relevant health programs. Additionally, if an entity is already participating, not submitting the form could lead to termination of their agreement or contract with the state agency or the Secretary of Health and Human Services.

4. What information is required on the CMS-1513 form?

   The form requires detailed disclosure of any individual or organization with a direct or indirect ownership or control interest of 5 percent or more in the disclosing entity. It also asks about changes in management or ownership status, operation by a management company, or affiliation with a chain of health care facilities.

5. How often does the CMS-1513 form need to be completed?

   Entities are required to complete and submit this form annually. Any substantial delays in submitting the form should be promptly reported to the State survey agency.

6. Can additional pages be added to the CMS-1513 if more space is needed?

   Yes, if additional space is needed to provide complete information, you can attach extra sheets. Make sure to reference the item number your information continues from.

7. What should be done if there's been a change in the information provided in a previously submitted CMS-1513 form?

   If there has been a significant change in the information previously provided, such as changes in ownership or management, the disclosing entity should report these changes as soon as possible by submitting an updated CMS-1513 form.

8. Where should the completed CMS-1513 form be sent?

   The original and copies of the completed form should be returned to the State agency mentioned in the instructions, while the submitting entity should retain a copy for their records.

Filling out the CMS-1513 form, which is crucial for disclosing ownership and control interests in entities providing health services under various federal programs, can be intricate. Avoiding common mistakes can ensure timely and accurate submission. Here are five commonly made mistakes:

1. Not providing current information: All questions must be answered with the most up-to-date information. Failing to review and ensure all details are current can lead to inaccuracies, affecting compliance and the approval process.

2. Skipping sections that are considered self-explanatory: Some respondents may overlook or misunderstand the importance of sections labeled as "self-explanatory." However, it is crucial to address every item, as missing data can result in incomplete disclosures.

3. Inadequate explanation of ownership interests: For Section III, detailing direct and indirect ownership or controlling interest is essential. Failure to comprehensively describe these interests, including the nature and extent, can obscure the true ownership structure.

4. Not using the Remarks section or additional sheets when needed: When space provided in the form is insufficient, many mistakenly cram information instead of using the Remarks section or attaching additional sheets. This can lead to unclear or incomplete responses.

5. Omitting related persons or entities: If more than one individual is reported under ownership or control interests, their relationships to each other must be disclosed under Remarks. Omitting these details can lead to a lack of transparency about potential conflicts of interest.

Attention to these details ensures the CMS-1513 form is filled accurately, reflecting the disclosing entity's current ownership and control structure, thus maintaining compliance with federal requirements.

When dealing with the CMS-1513 form, several other forms and documents are commonly utilized in the healthcare regulatory framework. These documents support the completion and submission of the CMS-1513 by providing detailed information about an entity's ownership, control interest, and operational status. Understanding these documents can facilitate compliance with federal health program requirements. Here's a list and brief description of each:

• NPI Application/Update Form (CMS-10114): This document is used to apply for or update a National Provider Identifier (NPI), essential for healthcare providers to submit claims and conduct other transactions as mandated by HIPAA.
• CMS-855A: Medicare Enrollment Application for Institutional Providers, required for entities that provide medical or health services and bill Medicare for those services.
• CMS-855B: For clinics, group practices, and certain other suppliers to enroll in the Medicare program.
• CMS-855I: The enrollment application for individual physicians and non-physician practitioners who wish to bill Medicare.
• CMS-855R: This form is used when reassigning benefits or privileges to another entity or individual.
• CMS-855S: For suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) to enroll in Medicare.
• IRS Form W-9: Request for Taxpayer Identification Number and Certification, used to provide the correct taxpayer identification number (TIN) to entities that must file information returns to report interest, dividends, and certain other income paid.
• Ownership or Control Interest Statement (OCS): This document provides details about individuals or entities that have a 5% or greater ownership or controlling interest in the healthcare entity.
• Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588): This form authorizes Medicare to deposit payments directly into a bank account, a practical necessity for efficiently receiving funds.
• Health Insurance Benefit Agreement (CMS-1561): A contractual agreement with CMS that must be signed by providers participating in the Medicare program to ensure compliance with Medicare laws and regulations.

These documents collectively support a healthcare provider's compliance framework when participating in Medicare, Medicaid, and other federal health programs. By accurately completing and appropriately submitting these forms, healthcare entities can ensure smooth operations and adherence to regulatory standards. Beyond facilitating billing and payments, these documents also help maintain transparency about ownership, control, and significant operational changes which might affect compliance status.

• The CMS-855A form, used by health care providers to enroll in the Medicare program, shares similarities with the CMS-1513 form in that both require disclosure of ownership, control interests, and management structure. Like the CMS-1513, the CMS-855A mandates full transparency regarding individuals or entities with significant control or influence over the health care provider, aiming to ensure compliance with Medicare program requirements.

• The CMS-855B form, designated for clinics, group practices, and certain other suppliers enrolling in Medicare, also parallels the CMS-1513 form in its requirement for disclosing ownership and control details. This includes information on individuals or entities with a 5 percent or greater ownership or controlling interest, mirroring the CMS-1513's aim to maintain integrity within the Medicare system by monitoring those in positions of influence.

• The CMS-855I form, which is required for individual physicians and non-physician practitioners enrolling in Medicare, similarly necessitates the disclosure of financial interests and affiliations, akin to the CMS-1513 form. Although focused on individual practitioners, the intent to identify and manage potential conflicts of interest and ensure compliance with federal program standards remains consistent.

• The CMS-855R form, used for reassigning Medicare benefits, shares the CMS-1513 form's goal of transparency in financial and ownership interests, albeit in a different context. This form allows practitioners to delegate their Medicare billing privileges to an organization, necessitating clear disclosure of the arrangement to prevent fraud or abuse, resonating with the CMS-1513's emphasis on clarity regarding control and ownership.

• The OIG's Provider Self-Disclosure Protocol form, while not part of CMS, operates under a similar ethos to the CMS-1513 by encouraging voluntary disclosure of ownership and financial interests that may influence health care practices. This form facilitates transparency and accountability, aiming to address and rectify compliance issues proactively, in line with the objectives of the CMS-1513 form.

When filling out the CMS-1513 form, individuals and organizations should be mindful of both the actions that are recommended and those that should be avoided to ensure accuracy and compliance. Below are lists that outline these do's and don'ts:

• Ensure that all information provided is current and accurate, as the form must reflect the most up-to-date data regarding ownership and control interests.
• Answer every question on the form, even those that may seem self-explanatory. Leaving sections incomplete can result in processing delays or outright refusal.
• For any item where a "Yes" response is required, provide all requested additional information in the Remarks section, making a clear reference to the item number in question.
• Attach additional sheets if necessary, to adequately provide all pertinent details or to continue explanations that cannot be confined to the space provided on the form.
• Retain the first copy for your records after submitting the original and second and third copies to the State agency as directed.

• Avoid rushing through the form without reviewing the detailed instructions provided for certain questions, as misunderstanding these guidelines can lead to mistakes.
• Do not overlook the requirement to list any changes in provider status, including changes in management, ownership, or control, that have occurred within the last year or are anticipated to happen in the near future.
• Refrain from omitting information about any individuals or organizations with a direct or indirect ownership or control interest of 5 percent or more, regardless of whether the interest seems minor.
• Do not forget to disclose any relationships among individuals reported to have ownership interests if more than one individual is listed.
• Avoid submitting the form without the signature of an authorized representative, as this is a critical component of the form's validity and legality.

• One common misconception about the CMS-1513 form is that it's only relevant for new healthcare providers or suppliers. In reality, the requirement to complete and submit this form applies not just at the initial stage of becoming a provider or supplier. It's also a crucial part of maintaining your status with Medicare, Medicaid, or any related healthcare programs. Whether you're certifying for the first time, recertifying, or changing your information, this form plays a vital role in ensuring transparency in ownership and control interests.

• Another misconception is that all parts of the CMS-1513 form are necessary for every healthcare provider or supplier to fill out. The truth is a bit more nuanced. While it's essential that the form be completed thoroughly, different sections are relevant for different types of providers. For instance, Title XX providers have specific parts to complete that may not apply to Title V providers, and vice versa. Understanding which parts of the form apply to your specific situation is critical to providing accurate and complete disclosure.

• Many believe that once the CMS-1513 form is filled out and submitted, there's no need to update or revisit the document unless explicitly requested. This belief can lead to compliance issues. Healthcare entities must update and resubmit the form annually or whenever there's a significant change in ownership, control, or management information. Keeping this information up to date is not just a regulatory requirement; it also affects the integrity of the provider's or supplier's relationship with Medicare and Medicaid services.

• Finally, some might think that failing to fully complete the CMS-1513 form is a minor oversight that can be easily corrected without any real consequences. This is unfortunately not the case. Incomplete or inaccurate disclosures can lead to serious repercussions, including the refusal of the Secretary or appropriate State agency to enter into or renew an agreement, and in some cases, termination of existing agreements. It's crucial to approach this document with the seriousness it requires, ensuring that all information is current, accurate, and fully disclosed.

Filling out the CMS-1513 form correctly is crucial for entities wishing to participate in, certify, or recertify under federal health programs such as Medicare and Medicaid. Here are key takeaways to ensure accurate and compliant submissions:

• Completion of the CMS-1513 form is mandatory for participation in federal health programs like Medicare and Medicaid. It requires full disclosure of ownership and control interests to avoid penalties or denial of participation.
• The form requires annual submission to the appropriate State agency, with entities retaining a copy for their records. This ensures ongoing compliance with federal regulations.
• For Title XX providers, parts II (a) and (b) are essential, while those offering medical services must also fill out parts II and III. Title V providers have specific sections to complete, underscoring the importance of knowing the program-specific requirements.
• All information must be current and accurate, highlighting the necessity for entities to review and update their disclosures annually or as changes occur.
• Direct and indirect ownership or controlling interests of 5 percent or more must be disclosed, along with details about any changes in provider status or management that could affect the entity's control or ownership.
• Entities must report any affiliations with management companies or if the facility is part of a chain, which can affect the entity's compliance status and eligibility for federal health programs.
• Any anticipated changes in ownership, control, or operational management within the year must be disclosed, allowing for transparency and updated records that reflect current operational structures.
• The document emphasizes the legal implications of failing to provide accurate information, including potential prosecution and termination of participation in federal programs, reinforcing the necessity for honesty and thoroughness in completing the form.

By closely following these guidelines when completing the CMS-1513 form, entities can navigate the disclosure process more efficiently, ensuring compliance with federal health program requirements.