Medicare Provider Enrollment

The Medicare provider and supplier enrollment process is a continuous process in which the provider community must focus their attention, lest you be impacted by an interruption in reimbursement.

Here are just a couple of the more popular items that providers find themselves contending with regarding their Medicare enrollments:

 

Changes of Information

Changes of information to your CMS-855 enrollments should be submitted if you are changing, adding, or deleting information under your current tax identification number.  The CMS Provider Integrity Manual or PIM Chapter 15 is the guide to follow when you have questions regarding requirements for your Medicare enrollment.  Additionally, specifically for changes of information, in accordance with 42 C.F.R. 424.516(e), unless otherwise noted below, changes in your existing enrollment data must be reported to CMS within 90 days of the effective date of the change.

Information changes to be reported include (but are not limited to):

• Legal business name or doing business as (dba) name
• Change of ownership – all sections must be submitted and must be reported within 30 days of the effective date of the change
• Adverse history – must be reported within 30 days of the effective date
• Main practice location change, to add an additional location or to delete a location – must be reported within 30 days of the effective date
• Ownership interest or managing control information
• Billing agency information
• Authorized or delegated officials

 

An individual or entity (group) reporting a change of information may be required to submit a complete CMS-855I or CMS-855B to update their Medicare enrollment information. If the required CMS-855I or CMS-855B is not submitted within 60 days of the request, the change of information will not be processed, and the provider’s Medicare enrollment will be subject to revalidation requirements per 42 CFR § 424.515.

 

Revalidations

If you have spent any time in Medicare enrollment over the last decade, you know what revalidations are and the pitfalls that can befall you if you are not prepared.  CMS began the second round of revalidations in 2016 and will continue this process through the completion of Round 2.

Section 6401 (a) of the Affordable Care Act established a requirement for all enrolled providers/suppliers to revalidate their Medicare enrollment information.  CMS has completed its initial round of revalidations and has resumed regular revalidation cycles in accordance with 42 CFR §424.515.

In an effort to help providers/suppliers in this second round of revalidations, CMS has provided multiple resources for your reference purposes.  A few of these can be found via these references.

Revalidation Resources¹

• CMS Revalidations web page
• Revalidation Due Date List
• MLN Matters SE1605, Provider Enrollment Revalidation – Cycle 2
• Internet Based PECOS
• Revalidation Checklist

Other assistance provided by CMS includes:

• End-of-month due dates
• The ability to  revalidate an enrollment up to 6 months before it is due
• Early notifications via the PECOS Revalidation Notification Center

Therefore, with all of these tools at your disposal, as well as the Lutz enrollment team, you should be able to keep your Medicare enrollment in good standing with CMS.  We don’t want any preventable enrollment issue to negatively impact your reimbursement.

 

1 - As provided on the WPS GHA Provider Enrollment website