Revalidating Enrollment Information

All providers and suppliers enrolled with Medicare prior to the March 25, 2011, implementation date for the new screening enrollment criteria must revalidate their enrollment information under the new screening criteria by March 2013, but only after receiving notification from their Medicare Administrative Contractor (MAC). As required by Section 6401(a) of PPACA and published on February 2, 2011, as a final rule with comment period, the Centers for Medicare & Medicaid Services' (CMS's) new screening criteria will include three levels:

  • "Limited risk" providers, including, but not limited to, physicians, nonphysician practitioners and medical groups or clinics, will have enrollment requirements, license and database verifications;
  • "Moderate risk" providers/suppliers, including comprehensive outpatient rehabilitation facilities, independent diagnostic testing facilities and currently enrolled home health agencies, will have the above verifications plus unscheduled site visits; and
  • "High risk" providers/suppliers, including prospective DMEPOS suppliers and home health agencies, will have verifications, unscheduled site visits, criminal background checks and fingerprinting.

Upon receipt of the MAC notification to revalidate, providers should:

  • Update their enrollment through internet-based Provider Enrollment, Chain and Ownership System (PECOS) or complete the paper CMS 855;
  • Sign and date the certification statement on the application;
  • If applicable, pay the fee ($505 for calendar year 2011) through http://www.pay.gov and print a copy of payment receipt; and
  • Mail their supporting documents, receipt of application fee payment, if applicable, and certification statement to the MAC.

Upon receipt of the revalidation request letter, providers and suppliers have 60 days from the date of the letter to submit complete enrollment forms or risk deactivation of Medicare billing privileges.

CMS Revisions to Provider-Supplier Enrollment Applications

CMS has published revised versions of the Medicare Provider-Supplier Enrollment Applications (CMS 855) for all provider and supplier types. Although the new forms provide an effective date of July 1, 2011, the previous versions may be used through October 2011. However, as there was no prior version of the 855O to be used for physician and nonphysician enrollment that is solely for the purpose of ordering/referring patients for Medicare benefits, such providers and suppliers should use the new 855O immediately.

The revisions applicable to the 855A new form for institutional providers contain new requirements regarding reporting ownership and managing control interests, including, for physician-owned hospitals, the completion of a separate attachment to the 855A that requires information to be completed for every organization and individual that has any percentage of ownership or investment interest in the provider. Additionally, the new form CMS 855A requires identification of the existence of a hospital's compliance plan and the supplier as proprietary or nonprofit. The revisions to the CMS 855A regarding reporting of ownership and investment interests are not included in the other new forms.

The revised forms 855B, 855S, and 855I require:

  • Identification of the supplier as proprietary or nonprofit;
  • Reporting of accreditation for independent diagnostic testing facility suppliers that will bill the Medicare program for advanced diagnostic imaging services; and
  • The place and country of birth for individuals that have an ownership or managing control interest in the supplier.

See the new CMS 855A, 855B, 855I, 855S, 855R and 855O forms.