Before filling out NABP’s DMEPOS application, gather the following information and supporting documentation required to complete the application.
Information needed to complete the application:
- Legal Business Name (as it appears on your National Supplier Clearinghouse (NSC) application)
- Doing Business As (DBA) or Site Name (as it appears on your NSC application)
DBA/Site Pharmacy Information (as it appears on your NSC application):
a. Street Address
c. State (2 letter abbreviation)
d. Zip (5-digit zip only)
e. Phone Number
f. Fax Number
- Customer Service Phone Number
Contact Person’s Information
a. First (or preferred), Middle and Last
b. Phone Number (numbers only)
c. E-mail Address
- Medicare Billing or NSC Number. This must be a 10-digit number.
- Federal Employer Identity number (EIN) or Tax ID. This must be a 9-digit number.
- Medicaid Provider Number
- National Provide Identifier (NPI) Number. This must be a 10-digit number
- NCPDP Number
a. Date of most recent Board of Inspection
b. State of Domicile
c. Pharmacy License Number (s)
Pharmacist in Charge (or Pharmacy Manager) Information
a. First (or Preferred), Middle, and Last Name
b. State (s)of Licensure
c. License Number (s)
The documents summarized below are required to support your application for DMEPOS accreditation. NABP will review this material to verify compliance with the CMS Quality Standards. Documents must be uploaded electronically as part of the application submission process. Please note that documentation should only be submitted in the following file formats: Adobe PDF (.pdf), Microsoft Word (.doc), and Microsoft Excel (.xls). Submission of other file types can result in delays or extended processing time. Additional information about required supporting documentation is available in the application.
- Organizational Chart of DMEPOS Pharmacy
Description of Corporate Structure/Ownership and Control Information:
a. Sections 5 and 6 of the Medicare Enrollment Application (also known as form CMS855S). Or, if you do not have a copy of your CMS-855S, please submit a written statement confirming that a copy of CMS-855S is not available.
b. A narrative that includes/describes:
i. Names of anyone with more than 5% ownership interest in the business;
ii. Any relationship between owners. For example, please disclose if owners are married, father/son, or brother/sister; and
iii. Ownership/control interest in any other DME companies. If there is ownership interest in other DME, please provide the name and address of the business(es) and indicate the percentage owned.
- Job Description/Requirements for Compliance Officer
- Job Description/Requirements/Education for DMEPOS Staff
Financial information. All three documents noted below must be for same fiscal year/12- month period and should be for the current or most recent fiscal year:
a. Fiscal year Operating Budget
b. Fiscal year Balance Sheets
c. Fiscal year Profit/Loss Statements
- Performance Management Plan
- Disaster/Contingency Plan
- Business practices such a risk management, satisfaction audits, compliance rules, etc.
- Beneficiary complaint reporting, response and notification
- Equipment and item management (specifically, procedure for handling recalls)
- Initiation of investigation of complaints
- DMEPOS training/instruction/consultation provided to beneficiaries
Medicare/3rd Party Billing Policy and Procedure