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CMS Provider Enrollment/Revalidation Rule in Effect as of March 25, 2011

by Published On: Mar 22, 2011

Under a final rule set to take effect on March 25, 2011, newly enrolling and revalidating providers and suppliers under the Medicare, Medicaid and CHIP programs, will be placed in one of 3 screening categories by the Centers for Medicare and Medicaid Services (CMS) program according to the level of risk such category of providers poses for fraud waste and abuse. Such categories will determine the level of screening to be performed by the Medicare Administrative Contractor (MAC) in processing the enrollment or revalidation application.

Providers/suppliers that pose the lowest level of risk will be placed in the "limited" screening category and will be subject to the level of screening currently in effect. Providers in the “limited” category include skilled nursing facilities (SNF).

Providers that pose a moderate level of risk will be placed in the "moderate" screening category and will be subject to all current screening measures as well a site visit to determine the legitimacy of the provider and services being provided.  This category includes hospice organizations and revalidating home health agencies (HHA).

Providers that pose the highest level of risk for fraud and abuse will be placed in the "high" screening category and will be subject to all current screening measures, a site visit, and at a future date, a fingerprint-based criminal background check. Included in the "high" category are newly-enrolling HHAs and providers/suppliers that have been reassigned from either the "limited" or "moderate" category as a result of a triggering event, which is defined to include the following instances:

  • Imposition of a payment suspension within the previous 10 years.
  • A provider or supplier has been terminated or is otherwise precluded from billing Medicaid.
  • Exclusion by the Department of Health and Human Services (HHS) Office of Inspector General (OIG).
  • A provider or supplier has had billing privileges revoked by a Medicare contractor within the previous 10 years and such provider/supplier is attempting to establish additional Medicare billing privileges by enrolling as a new provider or supplier or establish billing privileges for a new practice location.
  • A provider or supplier has been excluded from any federal health care program.
  • A provider or supplier has been subject to any final adverse action (as defined in 42 CFR 424.502) within the past 10 years.
  • Instances in which CMS lifts a temporary moratorium for a particular provider or supplier type and a provider or supplier that was prevented from enrolling based on the moratorium, applies for enrollment as a Medicare provider or supplier at any time within 6 months from the date the moratorium was lifted.

CMS notes that any changes in the assignment of specific categories of providers/suppliers to one of the three screening categories will be made by proposed rulemaking; however, changes in the instances constituting trigger events for reassignment of a specific provider/supplier to the "high" risk category will not be subject to formal rulemaking. See 42 C.F.R. § 424.518.

The final rule also includes other important provisions relating to provider/supplier enrollments/revalidations. Specifically, the rule requires payment of a fee for all applications for initial enrollment, addition of a practice location, or revalidation of enrollment information. For calendar year 2011, the fee is $505. See 42 C.F.R. § 424.514.

In addition, the final rule permits CMS to impose a moratorium on the enrollment of new Medicare providers and suppliers of a particular type or the establishment of new practice locations of a particular type in a particular geographic area.  Any such moratorium will be announced in the Federal Register. See 42 C.F.R. § 424.570(a).

42 C.F.R. Section 424.515 requires that all Medicare-enrolled providers or supplies (other than DMEPOS suppliers) must resubmit and recertify the accuracy of their enrollment information every 5 years in order to maintain their Medicare billing privileges. Similar requirements apply to Medicaid-enrolled providers or suppliers.


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