Don’t Let Medicare Revalidation Requirements Stop Cash-flow

By Delly E. Parham, AS, CPC

When Medicare requests your provider to certify the accuracy of his or her existing enrollment information with Medicare revalidation, comply in a timely manner. If you don’t, you may lose Medicare billing privileges or disrupt reimbursement.

Revalidate when Requested

Medicare requires revalidation every five years, but also may perform “off cycle” revalidations (including possible site visits). Off cycle revalidations may be triggered by:

  • Random checks
  • Health care fraud problems
  • National initiatives
  • Complaints, or other reasons that cause CMS to question the provider’s/supplier’s compliance with Medicare enrollment requirements
  • CMS is actively targeting the following types of providers for revalidation:
    • Providers who are not registered in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS)
    • Providers who have not updated their enrollment within the last five years
    • Providers located in historically high-risk areas for Medicare fraud
    • Providers who do not receive electronic funds transfer (EFT) payments

Note: Do not submit a revalidation application unless a Medicare contractor contacts you. Upon receipt of the notification, you must respond within 60 days of the request (see 42 Code of Federal Regulations (CFR), chapter IV, §424.515: ).

Certain Changes Require Revalidation

Certain enrollment information changes, such as a change in practice location or a change in the “special payments and correspondence” address on file with Medicare, may affect timely compliance with revalidation requests. Medicare sends its revalidation letters and other correspondence to the “special payment and correspondence address” on file with Medicare. If a correspondence is returned to Medicare marked “undeliverable,” or if a provider does not respond to Medicare’s request within the time specified in the notice, the provider’s billing privileges will be deactivated or revoked.

Prevent or Minimize Deactivation or Revocation

Medicare requires that all changes to your practice be reported within 30 or 90 days of the change to keep your enrollment information current. Make sure to report these changes within the specified time.

To complete the revalidation application or to report a change, the provider or supplier may either use the Internet-based PECOS or a traditional paper application. Regardless of which method is used, the provider must complete the following:

  • The applicable CMS-855 Enrollment Application form:
    • 855B: Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers;
    • 855I: Medicare Enrollment Application for Physicians and Non-Physician Practitioners
    • 855S: Medicare Enrollment Application for Durable Medical Equipment, Prosthetics; Orthotics, and Supplies (DMEPOS) Suppliers
  • CMS-588 Electronic Funds Transfer Authorization Agreement form
  • Certification and other supporting documentation requested by Medicare, such as a copy of IRS CP-575

These forms may be found on the CMS website.

Medicare Part B Update reported that 90 percent of applications and changes of information submitted through PECOS are processed within 45 days of receipt of the signed and dated Certification Statement, versus 80 percent during the same time for paper applications. Processing times may depend on the Medicare administrative contractor (MAC) in your geographic region (depending on the changes made to the application, processing can take over six months). To use PECOS, you must have your organization or individual National Provider Identifier (NPI).

If you use PECOS to make any changes, complete enrollment revalidation, or report a change, and find that you need assistance with your user ID or password, you may contact the help desk using the CMS website or by calling 1-800-465-3203.

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