Get Howto-aco-participant-list-template-2015_final. Published Under The Right To Information Act - Cms

This guide provides clear and concise instructions on how to effectively fill out the HowTo-ACO-Participant-List-Template-2015_Final. Following the steps outlined will help ensure that your form is completed correctly and efficiently.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Column A, enter the ACO participant’s Tax Identification Number (TIN). Ensure that each entry is a 9-digit number without any dashes or spaces.
3. In Column B, input the TIN’s legal business name as registered in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS).
4. In Column C, denote whether the TIN is enrolled in Medicare by entering 'Y' for Yes or 'N' for No.
5. In Column D, indicate if the TIN is a merged or acquired TIN by entering 'Y' for Yes or 'N' for No.
6. In Column E, enter the first name of the person authorized to sign the ACO Participant Agreement.
7. In Column F, enter the last name of the person authorized to sign the agreement.
8. For Columns G through N, only fill them out if applicable to Federally Qualified Health Centers (FQHCs) or Rural Health Centers (RHCs). If not applicable, leave them blank.
9. In Column G, enter the Centers for Medicare & Medicaid Services Certification Number (CCN) if applicable, ensuring it is a 6-digit number without dashes.
10. Input the CCN legal name in Column H as registered in PECOS without using abbreviations.
11. If applicable, enter the CCN Identification Code in Column I: F, R, C, or T for the respective provider types.
12. In Column J, enter the Organizational National Provider Identification (NPI) for FQHCs and RHCs, ensuring a 10-digit format.
13. For Column K, provide the Organizational NPI name as registered.
14. In Column L, enter the individual NPI for each physician providing patient care, formatted as a 10-digit number.
15. Provide the first name of the individual NPI in Column M.
16. Finally, enter the corresponding last name in Column N, ensuring consistency with PECOS and NPPES.
17. Save your completed file with the extension '.txt' and the filename in the specified format.
18. Compress the template and other required files, then upload the zip file as instructed.
19. To finalize, review the document for accuracy, then save, download, print, or share the form as necessary.

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