new-site/docs/healthcare-filing-tiers-verified.md

# Healthcare filing: Standard (no-login) vs Expedited (surrogate) — VERIFIED matrix

Internal capability map. Confirms how each healthcare service is fulfilled with
**no client login and no credential sharing**, and where the optional
**Expedited (CMS I&A Surrogate)** path applies.

> **Client-facing rule (do not break):** never expose mechanics to the client.
> No "paper", "CMS-855", "CMS-10114", "MAC", "Fargo", or form numbers in any
> client copy. The only client-visible choice is the positive surrogate question
> ("electronically granting us I&A Surrogate access lets us bulk-file faster /
> fewer steps on our end"). Declining is silent; we just "file it for you."
> Same price either way — Expedited is NOT a paid tier.

## Two service tiers (internal)
- **Standard (default):** we complete the official form, client signs ONE
  certification (e-sign link), we submit + track. For CMS-855s the signed form is
  mailed to the provider's MAC; for NPPES-only changes via the NPI Enumerator
  paper path. Daily batched mailing (see §Daily batch).
- **Expedited (if client grants I&A Surrogate):** we file online in PECOS/NPPES
  under our own login (surrogate), same-day tracking. Surrogacy is a delegation,
  NOT a password handover.

## VERIFIED from the official CMS form PDFs in `docs/` (primary source)

### CMS-855I (05/23) — individual practitioner  [CONFIRMED, quoted]
- Valid reasons include: **revalidation**, **reactivation** ("reactivate your
  Medicare billing number to resume billing"), **changes to enrollment info**,
  and enrolling with another MAC. → revalidation/reactivation/enrollment all
  ride the 855I paper path.
- Paper submission: *"Send this completed application with **original signatures**
  and all required documentation to your **designated MAC**. The MAC that services
  your State is responsible for processing your enrollment application."*
  → **no login required; routed by STATE.**
- Signature caveat: *"As an individual practitioner, you are the only person who
  can sign this application. The authority to sign the application on your behalf
  **may not be delegated** to any other person."* → client must personally sign
  (pen/e-sign), but that is NOT a login. A surrogate **cannot** sign the 855 for
  them — surrogacy speeds the *online filing*, the cert signature is still theirs.

### CMS-855B (12/2025) — clinic/group/supplier  [CONFIRMED, quoted]
- Same paper-to-MAC, original-signatures, routed-by-State rule.
- Org signer: a **delegated/authorized official** signs §15B/15D (not the
  individual) — still a signature, no login.
- **Application FEE** required (paid via PECOS feePaymentWelcome) on initial
  enrollment, new location, and revalidation BEFORE mailing. → org standard path
  has a fee-payment step we must handle/route; individual 855I does not.

### CMS-855O (09/23) — ordering/referring only  [CONFIRMED, quoted]
- Paper-to-MAC, original signatures, routed by state. "Sign and date section 8
  using ink."

### NPPES data update / NPI reactivation (CMS-10114 paper path)  [CONFIRMED]
- **VERIFIED firsthand** against the live CMS-10114 PDF (Rev. 02/25, OMB
  0938-0931, exp. 03/2028) downloaded from
  `cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS10114.pdf`, and the CMS
  "How to Apply" page which titles it the **"NPI Application/Update Form"**.
- The form's Section 1A "Reason for Submittal" has four checkboxes:
  **#1 Initial Application, #2 Change of Information, #3 Deactivation,
  #4 Reactivation** — all completed on the SAME paper form, each requiring a
  signed + dated certification (Section 4A individual / 4B organization).
  Verbatim: *"If changing information, check box #2... then sign and date the
  certification... All changes must be reported to the NPI Enumerator within 30
  days."* and *"If you are reactivating the NPI, check box #4... Sign and date
  the certification."*
- So paper CMS-10114 is a valid no-login path for **changes AND reactivation**,
  not just initial enumeration. UNCERTAIN flag resolved.
- **Mailing address (current, printed on the form page 5):**
  ```
  CMS NPI Enumerator Services
  Mail Stop DO-01-51
  7500 Security Blvd.
  Baltimore, MD 21244
  ```
  The previously-documented **Fargo, ND PO Box 6059 address is RETIRED** — code
  (`mac_routing.NPI_ENUMERATOR`) and docs updated to the Baltimore address.
  Enumerator phone for questions: 1-800-465-3203.
- **No electronic no-login equivalent exists for CMS.** Unlike FMCSA (whose
  `ask.fmcsa.dot.gov/app/ticket` accepts an MCS-150 update + attachments with no
  account), CMS has no public web form to submit an NPPES change without a login.
  Probed live: the NPI Registry API (`npiregistry.cms.hhs.gov/api`) is
  **read-only lookup**; PECOS and NPPES I&A both require login. Therefore for
  NPPES changes the two genuine tiers are: **Standard = paper CMS-10114 to
  Baltimore (no login)**, **Expedited = surrogate files in NPPES online**.
- **Decision (updated):** offer Expedited (surrogate → NPPES online) as the fast
  path and the CMS-10114 paper-to-Baltimore path as the Standard default. Build
  `cms10114_pdf_filler.py` to produce the signable form (Reason checkbox driven
  by service: change vs reactivation vs deactivation).

## CMS I&A Surrogate (Expedited path)
- Provider adds Performance West as a **Surrogate** in CMS I&A; we then file in
  PECOS/NPPES under our own credentials. No password shared.
- Scope nuance to verify in copy: confirm a single surrogacy grant covers the
  PECOS and NPPES functions we need (the checkout copy currently asks for both).

## Per-service tier table
| Service | Standard (no-login) | Expedited (surrogate) | Fee? |
|---|---|---|---|
| Medicare revalidation | 855I/B → MAC, client signs | file in PECOS | 855B yes |
| Medicare enrollment | 855I/B/O → MAC, client signs | file in PECOS | 855B yes |
| NPI reactivation | 855I → MAC (reactivation reason) | PECOS/NPPES | no |
| NPPES data update | CMS-10114 → NPI Enumerator (Baltimore), client signs | NPPES online | no |
| OIG/SAM screening | public DBs, **zero client action** | n/a (no portal) | no |
| Provider compliance bundle | spawns reval + screening + NPPES | mixed | per-piece |

## Daily batch (Standard-path mailing)
Each **postal working day morning** (skip weekends + USPS/federal holidays — use
`scripts/workers/business_days.py` calendar): gather all signed+pending paper
filings, **group by destination agency** (each MAC; NPI Enumerator Baltimore; each
state agency), merge each group into ONE print job + a cover sheet (PW sender,
destination, date, enclosed count, per-item order#/provider/NPI/form), one
**Priority Mail** envelope per agency. Mark each order mailed with batch date +
tracking. Phase 1: generate per-agency batched PDF + cover sheet + manifest for a
human to print & drop. Phase 2: wire a print-mail API (Lob/Click2Mail).

## MAC routing
855s route by the provider's **State** (855I/B/O all say "the MAC that services
your State"). Mailing addresses: CMS.gov/Medicare/Provider-Enrollment-and-
Certification. Need a **state → MAC → mailing-address** table to address envelopes
+ to group the daily batch. `practice_state` intake field drives this.

## Implementation status (built + validated)
- **mac_routing.py** — state→MAC (56 jurisdictions, 12 destinations) +
  NPI_ENUMERATOR (NPI Enumerator Services, Baltimore MD — VERIFIED from CMS-10114
  Rev. 02/25). MAC addresses still marked VERIFY before first live mail.
- **npi_provider.py** — two-tier `access` strings; NPPES update/reactivation no
  longer "online-only"; surrogate answer surfaced in the admin todo. nppes-update
  now generates the CMS-10114 for e-signature (Standard path) via
  `_generate_10114_for_signing`.
- **cms10114_pdf_filler.py** — fills the official CMS-10114 (flat PDF, text
  overlay): reason checkbox (change/reactivation/deactivation) + NPI + Section 2A
  identity + Section 4A certification name, with a signature anchor on the cert
  line. The signed form joins the daily batch to the NPI Enumerator (Baltimore).
  `test_cms10114.py` 27/27 pass.
- **checkout.ts + service pages + intake** — client-facing copy stripped of
  mechanics; surrogate is the only optional, positively-framed ask (faster,
  never required, never share password, never mentions paper). Astro build green.
- **Daily batched mail** — migration 089 (`paper_filing_batches` +
  `esign_records.paper_batch_id/filing_destination_key`); `batch_cover_sheet.py`
  (per-agency cover + merged print job); `daily_paper_batch.py` worker
  (group by destination, self-gated to postal working days); `pw-paper-batch`
  systemd timer. `test_paper_batch.py` 15/15 pass.
- **State/adjacent matrix** — A/B/C/D no-login classification added to
  `state-healthcare-compliance-opportunities.md`; CLIA (CMS-116) + state CSR are
  the cleanest A-category additions that reuse the daily batch flow.

## TODO before first live mail (manual / verify)
1. Fill the real MAC provider-enrollment PO Box addresses in `mac_routing.py`
   (marked VERIFY) from each MAC's current enrollment page.
2. ~~Confirm CMS-10114 paper-for-changes acceptance + obtain the form PDF~~
   ~~build `cms10114_pdf_filler.py`~~ **DONE** — verified against CMS-10114
   Rev. 02/25 (address = NPI Enumerator Services, Baltimore MD); filler built +
   wired into `npi_provider._generate_10114_for_signing`; `test_cms10114.py`
   27/27 pass. Remaining nicety: org (Entity Type 2 / Section 4B) overlay path
   (currently flagged for manual completion when NPI-2 detected).
3. Run migration 089 on the DB; confirm the worker picks up a signed test filing
   and produces the per-agency cover + merged PDF in MinIO.
4. Phase 2: wire a print-mail API (Lob/Click2Mail) to auto-mail the merged PDF
   and fill `tracking_number`.