New CMS Provider Revalidation Effort for Top Billing Providers and Suppliers

26 August 2009 Publication
Author(s): Anil Shankar Judith A. Waltz

American Health Lawyers Association

By Anil Shankar and Judith A. Waltz

On August 21, 2009, the Centers for Medicare & Medicaid Services (CMS) announced that it will begin a limited Medicare provider revalidation effort. The effort requires each carrier and Medicare Administrative Contractor (MAC) to begin revalidation proceedings for each of the top fifty billers in each state for each of the following categories: Part B organizational suppliers, individual practitioner suppliers, and skilled nursing facilities (SNFs), as well as for the approximately fifty Slide Preparation Facilities (SPFs) currently enrolled in Medicare nationwide. The effort includes only those entities that do not have an established record in the Provider Enrollment Chain and Ownership System (PECOS) or do not have an Electronic Funds Transfer (EFT) agreement. The PECOS system provides an alternative to the use of the CMS-855 forms used for enrollment, re-enrollment, or change of information, and this revalidation effort is consistent with CMS' previously stated goals to establish a record for all Medicare providers and suppliers in PECOS. Regulations currently require resubmission and recertification of enrollment information every five years, and allow CMS to trigger revalidations as part of national initiatives or for other reasons. 42 C.F.R. § 424.510. As described in four separate change requests,1 all carriers and MACs will compile lists of the affected suppliers and providers and begin the revalidation proceedings on September 22, 2009. The revalidation proceedings are those currently outlined in Section Nine of Chapter Ten of the Program Integrity Manual.

  • The contractors will send notice to the provider/supplier of the revalidation effort and request additional information. Revalidation requires the resubmission of an enrollment application and all supporting documentation, even if it is already on file with the contractor.
  • Contacted providers/suppliers have sixty days to furnish all requested information.
  • All data on the revalidation application will be verified as if it were an initial application. If the contractor believes a case of fraud likely exists, it will be referred to a PSC or ZPIC.
  • Failure to provide requested data within sixty days results in mandatory revocation of the provider/supplier's billing privileges.

  1 CR 6485; CR 6574; CR 6494; CR 6486.

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