CMS has contracted the Retroactive Processing Contractor (RPC) to perform various tasks on behalf of Plan Sponsors that involves receiving, reviewing, processing and creating information that contains Protected Health Information (PHI). In order for us to exchange PHI through these various tasks we need all Plan Sponsors to complete a valid Point-of-Contact (POC) Agreement.

A Point-of-Contact is to be designated for each role listed on the following pages. All Organizations must complete this POC Agreement to designate those individuals who may receive PHI. When updates are necessary, this form should be re-submitted to the RPC immediately.

Please Note: This POC form must be signed and dated by a designated member of the organization responsible for CMS Enrollment Operations.

Please return this agreement to our office by e-mail, fax or mail:

Reed & Associates, CPAs – CMS RPC / Email: /
Attn: Client Services / Phone: / 402-315-3660
1010 South 120th Street / Fax: / 402-315-3700
Omaha, NE 68154

Passwords

All communication from the RPC to Organizations (including Final Disposition Reports (FDR’s), Error Reports and EDV Requests) will be e-mailed via secure, encrypted software approved by CMS/OIS. The communication you receive from the RPC via email will be encrypted with the unique Password you provide below. In addition, when submitting encrypted packages to the RPC, you must also use the unique Password you provide below.

Your Password must meet the following requirements:

  • Must be at least 8 characters long
  • Must be a maximum of 25 characters
  • Must contain at least 6 alpha characters
  • Must contain at least 2 numerical digits
  • May contain the following special characterswithin the password: @, #, !, &, $, *
  • Must not include obvious information about your organization (i.e. company name)
  • Passwords are case-sensitive

Specific Reason for Request (i.e. adding contacts, deleting contacts, change in roles):

Organization Information

Parent Organization Name:
Contract Number(s):
Street Address 1:
Street Address 2:
City, State, Zip Code:

Enrollment Data Validation (EDV) Information

Note: Only one POC is allowed for each EDV Transaction Group listed below. The point of contacts designated below will be responsible for receiving all EDV materials and expected to respond timely to each EDV Review Request.

Enrollment Data Validation Contact
(Enrollment/Disenrollment Activity – Transaction Types: 51, 61, 80, and 81)
Name:
E-mail Address:
Password:
Phone Number:
Fax Number:
Enrollment Data Validation Contact
(Resident Address Change Activity – Transaction Type: 76 & RPC Medicaid Quality Review Transactions)
Name:
E-mail Address:
Password:
Phone Number:
Fax Number:

Retroactive Processing Information

Primary Contact for Retro Processing
Name:
E-mail Address:
Password:
Phone Number:
Fax Number:
Check the applicable role(s) for Primary Contact:
Retroactive Enrollments/Disenrollments/PBP & Segment Changes
Retroactive Payment Validation Adjustments for SCCs, Medicaids, and ESRDs
Retroactive LIS Deeming Updates
Contact #1
Name:
E-mail Address:
Password:
Phone Number:
Fax Number:
Check the applicable role(s) for Contact #1:
Retroactive Enrollments/Disenrollments/PBP & Segment Changes
Retroactive Payment Validation Adjustments for SCCs, Medicaids, and ESRDs
Retroactive LIS Deeming Updates
Contact #2
Name:
E-mail Address:
Password:
Phone Number:
Fax Number:
Check the applicable role(s) for Contact #2:
Retroactive Enrollments/Disenrollments/PBP & Segment Changes
Retroactive Payment Validation Adjustments for SCCs, Medicaids, and ESRDs
Retroactive LIS Deeming Updates
Contact #3
Name:
E-mail Address:
Password:
Phone Number:
Fax Number:
Check the applicable role(s) for Contact #3:
Retroactive Enrollments/Disenrollments/PBP & Segment Changes
Retroactive Payment Validation Adjustments for SCCs, Medicaids, and ESRDs
Retroactive LIS Deeming Updates

Third Party Contractor (optional):

If you wish to assign any of the above responsibilities to a Third Party Contractor (TPC), please complete the section below and initial here: *

*By initialing here you are authorizing us to disclose PHI to the entity below for purposes strictly related to the work performed on behalf of CMS and related to retroactive services.

Name of Organization:
Street Address 1:
Street Address 2:
City, State, Zip Code
Contact Name:
E-mail Address:
Password:
Phone Number:
Fax Number:
Check the applicable role(s) for the TPC
Retroactive Enrollments/Disenrollments/PBP & Segment Changes
Retroactive Payment Validation Adjustments for SCCs, Medicaids, and ESRDs
Retroactive LIS Deeming Updates

By signing this document, you agree to allow Reed & Associates, the CMS RPC, to disclose PHI to those contact persons listed above. When changes are necessary, a new form will be completed and submitted to the RPC immediately.

Printed Name of Designated Personnel / Title of Designated Personnel
Signature / Date Signed

Point-of-Contact (POC Agreement) Page | 1

CMS/Retroactive Processor Contractor (RPC)