Industry Insights

Second Cycle of CMS Medicare Provider Enrollment Revalidation

May 2016
Author:  Susan Ryan

Susan Ryan

Managing Consultant

IT Risk Services

Health Care

910 E. St. Louis Street, Suite 200
P.O. Box 1190
Springfield, MO 65801-1190 (65806)

Springfield
417.865.8701

In March 2016, the Centers for Medicare & Medicaid Services (CMS) entered into a second cycle of provider enrollment revalidation. The initial process began as part of a provision outlined in the Patient Protection and Affordable Care Act of 2010 to prevent fraud within the Medicare system by ensuring accuracy of enrollment information for Medicare providers. The initial round of revalidation notices were mailed by March 23, 2015, as part of Cycle 1. CMS will resume the enrollment screening in Cycle 2, continuing to streamline the revalidation process across Medicare Administrative Contractors (MAC) and attempting to reduce potential burdens on providers and suppliers.

The second revalidation cycle has established due dates for providers and suppliers to submit their applications to their MAC—usually the last day of a month. The due dates are based on the last successful revalidation or initial Medicare enrollment (approximately three years for durable medical equipment suppliers and five years for others) and will stay with providers and suppliers through subsequent revalidation cycles.

A full list of currently enrolled providers and suppliers, along with their revalidation due dates, can be accessed up to six months before the due date using the Medicare Revalidation Lookup Tool. All other providers and suppliers will have a “TBD” due date until they reach six months prior to the revalidation date. The listing identifies only billing providers and suppliers required to revalidate with Medicare. Providers that opted out of Medicare or enrolled solely to order, certify and/or prescribe via the CMS-855O application won’t be required to revalidate and won’t be on the list.

The CMS Medicare Revalidation Lookup Tool has search fields for individual providers (by last or first name) or organizations (by organization name or National Provider Identifier) and includes an option to download the revalidation due date list and reassignment list with additional data-filtering functions.

MACs will notify providers and suppliers approximately two to three months before their revalidation due date through email or mail. The email revalidation notice will include “URGENT:  Medicare Provider Enrollment Revalidation Request” in the subject line. If all email addresses on file for the provider or supplier are returned as undeliverable, the MAC will send a paper revalidation notice to at least two reported addresses, e.g., the correspondence, special payments or primary practice address.

The most efficient way to submit the revalidation information and review current information on file is using the Medicare Provider Enrollment, Chain and Ownership System (PECOS).

Providers and suppliers are responsible for revalidating by their due date, even if they don’t receive any correspondence from their MAC. If providers or suppliers haven’t received a revalidation notice from their MAC within two months of the listed due date, they should contact their MAC Provider Enrollment department.
Please note:  All unsolicited revalidation applications submitted more than six months in advance of the due date will be returned. Don’t submit a revalidation application if there isn’t a listed due date, unless specifically requested by the MAC.

It’s crucial to keep track of revalidation dates and use the CMS list and tools to avoid a hold on Medicare payments and possible deactivation of billing privileges. If providers or suppliers fail to revalidate by the due date, they’ll have an additional 60 to 75 days to submit their application before becoming deactivated. A payment hold can be applied within 25 days of the due date.

Another change in the second revalidation cycle is that deactivated providers or suppliers no longer will have a 120-day grace period before a gap in coverage begins, which will occur from the deactivation until the receipt of the new full and complete application. In addition, deactivated providers and suppliers won’t be issued a new Provider Transaction Access Number (PTAN)—they’ll maintain their original PTAN. However, billing will be interrupted during the deactivation period, and retroactive billing privileges won’t be granted.

As part of the Medicare revalidation process, institutional providers must keep in mind the enrollment fee when submitting the CMS-855 paper application or its online PECOS equivalent. This fee changes each calendar year (CY) based on adjustments to the Consumer Price Index for Urban Areas. The new application fee for CY 2016 is $554. To determine if you’re required to pay this fee based on provider type and category of Medicare provider enrollment change, refer to the Application Fee Requirement Matrix on the CMS website.

Below are examples of helpful Cycle 2 revalidation information from the CMS website:

  • MLN Matters SE1605®, Provider Enrollment Revalidation – Cycle 2
  • Sample revalidation letter
  • Revalidation checklist
  • Medicare Revalidation Lookup Tool
  • Revalidation due date list
  • Frequently asked revalidation questions

For more information, contact your BKD advisor.

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