cms site visit form

Medicare Provider Enrollment – Site Verification

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Medicare Provider Enrollment News

CMS contracts with a third party to provide site visit services as an integral part of the Medicare Provider Enrollment process.  The National Sive Visit Contractor (NSVC) will conduct site visits for all providers and suppliers except for Durable Medical Equipment (DMEPOS) which will continue to be inspected by the National Supplier Clearinghouse.  MSM Security Services, LLC has the national site visit contract.  MSM, or one of its subcontractors, will conduct a site verification and screening process according to Medicare guidelines to prevent questionable providers and suppliers from enrolling in the Medicare program.  When an inspector shows up, he or she will have valid ID and a letter of authorization to begin the inspection.  You may not copy or retain the ID or letter of authorization.  You may contact MSM at any point if you have questions at 855-220-1074.

The site verification may be as quick as verifying your business location, or an inspector may physically show up to tour your clinic.  The process ensures that providers aren’t able to Enroll as participating Medicare providers without an appropriate service location.

You may see full details in section 10.6.20 of the Medicare Program Integrity Manual .

Call nCred today at (423) 443-4525 to discuss your Medicare Provider Enrollment needs.  We work with all specialties and have extensive experience processing Medicare applications.

From the Medicare Program Integrity Manual:

10.6.20 – Screening: On-site Inspections and Site Verifications (Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 

The contractor shall review section 10.3 of this chapter for special instructions regarding site visits. In the event of a conflict, those instructions take precedence over those in this section 10.6.20.

A. DMEPOS Suppliers and IDTFs

The scope of site visits of DMEPOS suppliers and IDTFs shall continue to be conducted in accordance with existing CMS instructions and guidance. (For purposes of this section 10.6.20, the term “contractor” refers to the Medicare Administrative Contractor; the term “SVC” refers to the site visit contractor.)

B. Provider and Supplier Types Other Than DMEPOS Suppliers and IDTFs

For provider/supplier types other than DMEPOS suppliers and IDTFs – that must undergo a site visit pursuant to this section 10.6.20 and § 424.518, the SVC will perform such visits consistent with the procedures in this section 10.6.20. This includes all of the following:

(1) Documenting the date and time of the visit, and including the name of the individual attempting the visit.

(2) Photographing the provider/supplier’s business for inclusion in the provider/supplier’s file. All photographs will be date/time stamped.

(3) Fully documenting observations made at the facility, which could include facts such as (a) the facility was vacant and free of all furniture, (b) a notice of eviction or similar documentation is posted at the facility, and (c) the space is now occupied by another company.

(4) Writing a report of the findings regarding each site verification.

(5) Including a signed site visit report stating the facts and verifying the completion of the site verification.

In terms of the extent of the visit, the SVC will determine whether the following criteria are met: (i) the facility is open; (ii) personnel are at the facility; (iii) customers are at the facility (if applicable to that provider or supplier type); and (iv) the facility appears to be operational. This will require the site visitor(s) to enter the provider/supplier’s practice location/site rather than simply conducting an external review. If any of the four elements ((i) through (iv)) listed above are not met, the contractor will, as applicable – and using the procedures outlined in this chapter and in existing CMS instructions – deny the provider’s enrollment application pursuant to § 424.530(a)(5)(i) or (ii) or revoke the provider’s Medicare billing privileges under § 424.535(a)(5)(i) or (ii).

C. Operational Status

When conducting a site verification to determine whether a practice location is operational, the SVC shall make every effort to limit its verification to an external review of the location. If the SVC cannot determine whether the location is operational based on this external review, it shall conduct an unobtrusive site verification by limiting its encounter with provider or supplier personnel or medical patients.

The contractor must review and evaluate the site visit results received from the SVC prior to making a final determination. If it is determined (during the review and evaluation process) that the location is non-operational based on the site visit results but there is reason to proceed with the enrollment, the contractor shall provide the appropriate justification in the comment section of the Validation Checklist in PECOS. (For example, a second site visit determined the location to be operational; the provider only renders services in patient’s homes; etc.).

If the contractor is unsure of how to proceed based on its evaluation of the site visit results, it shall contact its PEOG BFL and copy its contracting officer’s representative (COR).

Site verifications should be done Monday through Friday (excluding holidays) during their posted business hours. If there are no hours posted, the site verification should occur between 9 a.m. and 5 p.m. If, during the first attempt, there are obvious signs that the facility is no longer operational, no second attempt is required. If, on the first attempt, the facility is closed but there are no obvious indications that the facility is non-operational, a second attempt on a different day during the posted hours of operation should be made.

E. Documentation

As indicated previously, when conducting site verifications to determine whether a practice location is operational, the SVC shall:

(i) Document the date and time of the attempted visit and include the name of the individual attempting the visit.

(ii) As appropriate, photograph the provider/supplier’s business for inclusion in the provider/supplier’s file on an as-needed basis. All photographs should be date/time stamped.

(iii) Fully document all observations made at the facility (e.g., the facility was vacant and free of all furniture, a notice of eviction or similar documentation was posted at the facility, the space is now occupied by another company, etc.).

(iv) Write a report of its findings regarding each site verification.

F. Determination

(In the event an instruction in this subsection F is inconsistent with guidance in section 10.6.6, 10.4.7 et seq., or 10.4.8, the latter three sections of instructions shall take precedence.)

If a provider/supplier is determined not to be operational or in compliance with the regulatory requirements for its provider/supplier type, the contractor shall revoke the provider/supplier’s Medicare billing privileges – unless the provider/supplier has submitted a change of information request that notified the contractor of a change in practice location. Within 7 calendar days of CMS or the contractor determining that the provider/supplier is not operational, the contractor shall update PECOS or the applicable claims processing system (if the provider/supplier does not have an enrollment record in PECOS) to revoke Medicare billing privileges and issue a revocation notice to the provider/supplier. The contractor shall afford the provider/supplier applicable appeal rights in the revocation notification letter.

For non-operational status revocations , the contractor shall use either 42 CFR § 424.535(a)(5)(i) or 42 CFR § 424.535(a)(5)(ii) as the legal basis for revocation. Consistent with 42 CFR § 424.535(g), the date of revocation is the date on which CMS or the contractor determines that the provider/supplier is no longer operational. The contractor shall establish a 2-year reenrollment bar for providers/suppliers that are not operational.

For regulatory non-compliance revocations , the contractor shall use 42 CFR § 424.535(a)(1) as the legal basis for revocation. Consistent with 42 CFR § 424.535(g), the date of revocation is the date on which CMS or the contractor determines that the provider/supplier is no longer in compliance with regulatory provisions for its provider/supplier type. The contractor shall establish a 2-year enrollment bar for providers/suppliers that are not in compliance with provisions for their provider/supplier type.

G. Multiple Site Visits

Notwithstanding any other instruction to the contrary in this chapter, the contractor shall not order a site visit if the specific location to be visited has already undergone a successful site visit within the last 12 months and the applicable provider/supplier is in an approved status.

Consider the following illustrations:

Example 1  – A single-site home health agency (HHA) undergoes a revalidation site visit on February 1. The HHA submits a change of information request on July 1 to add a branch location. The contractor shall order this site visit because the visit will occur at a location (i.e., the branch location) different from the main location (i.e., the location that underwent the February 1 revalidation visit).

Example 2  – A DMEPOS supplier undergoes a revalidation site visit on April 1. It submits an initial Form CMS-855S application on May 1 to enroll a second location. The new location shall undergo a site visit because: (1) it is different from the first (revalidated) location; and (2) it is/will be separately enrolled from the first location.

Example 3  – A physical therapy (PT) group has three locations – X, Y, and Z. As part of a revalidation, the contractor elects to order a site visit of Location Y rather than X or Z. The visit was performed on June 1. On October 4, the group submits a Form CMS-855B to report a change of ownership, thus requiring a site visit under this chapter. However, the contractor shall not order a visit for Location Y because this site has been visited within the past 12 months. Location X or Location Z must instead be visited.

Example 4  – An IDTF undergoes an initial enrollment site visit on July 1. On September 24, it submits a Form CMS-855B application to change its practice location; this mandates a site visit under this chapter. The site visit shall be performed even though the initial visit took place within the past 12 months. This is because the second visit will be of the new location, whereas the first visit was of the old location.

H. Certified Providers/Suppliers – Address Validation Error

Notwithstanding any other instruction to the contrary in this chapter, the contractor need not order a site visit for a certified provider/supplier prior to making a recommendation to the state if an address validation error is received in PECOS. The contractor shall override the error message and notate in the referral package that the address was unverifiable. This avoids multiple site visits being performed (that is, pre-enrollment, survey, and post enrollment).

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UnitedHealthcare Community Plan: What to expect during a site visit

Health care professionals who wish to contract with UnitedHealthcare Community Plan may need a site visit as part of the credentialing process. Requirements for site visits are determined by state Medicaid contracts and by NCQA and Centers for Medicare & Medicaid Services (CMS) requirements for facilities.

Site visit requirements are outlined in the UnitedHealthcare Credentialing Plan and State and Federal Regulatory Addendum .

Who requires a site visit? As part of the credentialing process, site visit requirements for health care professionals vary depending on the state and specialty. Some states require visits for initial credentialing only, and others require them for recredentialing as well (every 36 months). 

Here are the requirements for Arizona, Florida, Indiana, Maryland, Mississippi, New Jersey and Pennsylvania :

• Health care professional types/specialties that require a site visit: family practice, geriatric medicine, internal medicine, pediatrics, general practice, obstetrics and gynecology, nurse practitioner, physician assistant
• Note: nurse practitioners and physician assistants will only need a site visit if they work in a primary care physician (PCP) or obstetrics and gynecology office
• Health care professional types/specialties that require a site visit: family practice, geriatric medicine, internal medicine, pediatrics, general practice
• Health care professional types/specialties that require a site visit: family practice, geriatric medicine, internal medicine, pediatrics, general practice, obstetrics and gynecology, nurse practitioner, physician assistant, certified nurse midwife
• Health care professional types/specialties that require a site visit: family practice, geriatric medicine, internal medicine, pediatrics, general practice, adolescent medicine, obstetrics and gynecology 
• Note: nurse practitioners will only need a site visit if they’ve indicated on the application that they are acting as a PCP
• Health care professional types/specialties that require a site visit: family practice, geriatric medicine, internal medicine, pediatrics, general practice, obstetrics and gynecology
• Health care professional types/specialties that require a site visit: family practice, geriatric medicine, internal medicine, pediatrics, general practice, dentist 
• Note: site visits include verifying that the facility complies with Americans with Disabilities Act requirements

What are the site visit requirements for facilities? There are different site visit requirements for facilities. If the facility is not accredited or certified by a recognized agency, a site visit is required. A site visit is not required if CMS or state quality review was conducted within the last 3 years.

What can I expect during the site visit? Site visits are conducted by United Language Group (ULG), a third-party vendor. ULG will call you to schedule the visit. Please ensure the contact information in your application is accurate. Once the visit has been scheduled, ULG will send you a confirmation email and an auditor from ULG will arrive to conduct the visit. 

When the auditor arrives, they’ll use a check list to determine whether your facility complies. Items on the check list include – but are not limited to – physical accessibility, appearance, waiting and examining room cleanliness, record keeping, and policies and procedures.

• Call Provider Services at 877-842-3210
• For state specific contact information, visit UHCprovider.com/contactus

PCA-1-22-01297-PO-News

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MEDICARE PROVIDER ENROLLMENT PRINT-FRIENDLY VERSION

What’s Changed?

• Added site visit information to Enrollment, Step 3

Application Fee

Physicians, non-physician practitioners (NPPs), physician organizations, and non-physician organizations don’t pay an application fee.

Institutional providers and suppliers like Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers, Opioid Treatment Programs (OTPs), and Medicare Diabetes Prevention Program (MDPP) suppliers, in general, pay an application fee when enrolling, re-enrolling, revalidating, or adding a new practice location.

Verify which providers pay a fee and when, using the Application Fee Requirements for Institutional Providers .

Application Fee Amount

The enrollment application fee sent January 1, 2021, through December 31, 2021, is $599.

For more information, refer to the Medicare Application Fee webpage.

Whether you apply for Medicare enrollment online or use the paper application, you must pay the application fee online:

• Online PECOS Application: During the application process, Provider Enrollment, Chain, and Ownership System (PECOS) prompts you to pay the application fee
• CMS Paper Application: Go to the Medicare Provider Application Payment webpage to submit the application fee online

You may request a hardship exception when submitting your Medicare enrollment application via either PECOS or CMS paper form. You must submit a written request with supporting documentation with your enrollment that describes the hardship and justifies an exception instead of paying the application fee. CMS grants exceptions on a case-by-case basis.

MACs don’t process applications without the proper application fee payment or an approved hardship exception.

If you don’t pay the fee or submit a hardship exception request, your MAC sends a letter allowing you 30 days to pay the fee. If you don’t pay the fee on time, the MAC may reject or deny your application or revoke billing privileges as appropriate.

Health care providers must enroll in the Medicare Program to get paid for providing covered services to Medicare patients. Learn how to determine if you’re eligible to enroll and how to do it.

Medicare lists institutional providers on the Medicare Enrollment Application: Institutional Providers (Form CMS-855A) . Institutional providers include:

• Community Mental Health Centers (CMHCs)
• Comprehensive Outpatient Rehabilitation Facilities (CORFs)
• Critical Access Hospitals (CAHs)
• End-Stage Renal Disease (ESRD) Facilities
• Federally Qualified Health Centers (FQHCs)
• Histocompatibility Laboratories
• Home Health Agencies (HHAs)
• Hospice Organizations
• Indian Health Service (IHS) Facilities
• Organ Procurement Organizations
• Opioid Treatment Programs (OTPs)*
• Outpatient Physical Therapy/Occupational Therapy/Speech Pathology Services
• Religious Non-Medical Health Care Institutions
• Rural Health Clinics (RHCs)
• Skilled Nursing Facilities (SNFs)

* OTPs are institutional providers and pay an application fee; however, they use Form CMS-855B to enroll.

Physicians, Non-Physician Practitioners (NPPs), clinics/group practices, and specific suppliers who can enroll as Medicare Part B providers, defined in enrollment Forms CMS-855I and CMS-855B .

Who Is an NPP?

NPPs include nurse practitioners, clinical nurse specialists, and physician assistants who practice with or under the supervision of a physician.

Physicians/NPPs/Suppliers (Form CMS-855I)

• Anesthesiology Assistants
• Audiologists
• Certified Nurse-Midwives
• Certified Registered Nurse Anesthetists
• Clinical Nurse Specialists
• Clinical Social Workers
• Mass Immunization Roster Billers, individuals
• Nurse Practitioners
• Occupational/Physical Therapists in private practice
• Physicians (Doctors of Medicine or Osteopathy, Doctors of Dental Medicine; Dental Surgery; Podiatric Medicine; Chiropractic Medicine or Optometry)
• Physician Assistants
• Psychologist, Clinical
• Psychologists billing independently
• Registered Dietitians or Nutrition Professionals
• Speech-Language Pathologists

Clinics/Group Practices and Specific Suppliers (Form CMS-855B)

• Ambulance Service Suppliers
• Ambulatory Surgical Centers (ASCs)
• Clinics/Group Practices
• Hospital Department(s)
• Home Infusion Therapy Suppliers
• Independent Clinical Laboratories
• Independent Diagnostic Testing Facilities (IDTFs)
• Intensive Cardiac Rehabilitation Suppliers
• Mammography Centers
• Mass Immunization Roster Billers, entities
• Opioid Treatment Programs (OTPs)
• Physical/Occupational Therapy Group in Private Practice
• Portable X-ray Suppliers
• Radiation Therapy Centers

Medicare Diabetes Prevention Program (MDPP) Suppliers

MDPP suppliers must use Form CMS-20134 to enroll in the Medicare Program.

If you don’t see your provider type listed, contact your MAC’s provider enrollment center before submitting a Medicare enrollment application. For your state’s MAC contact information, refer to the Medicare Fee-For-Service Provider Enrollment Contact List .

Medicare provider and supplier organizations have business structures, such as corporations, partnerships, Professional Associations (PAs), or Limited Liability Companies (LLCs) that meet the “provider” and “supplier” definitions. Provider and supplier organizations don’t include organizations the IRS defines as sole proprietorships.

Examples of provider and supplier organizations include:

• Medical group practices and clinics
• Portable X-Ray Suppliers (PXRSs)

You must have a provider or supplier Employer Identification Number (EIN) to enroll in Medicare. An EIN is the same as the provider or supplier organization’s IRS-issued Taxpayer Identification Number (TIN).

Sole Proprietorships and Disregarded Entities

For more information about “sole proprietorships” and “disregarded entities,” refer to the Medicare Program Integrity Manual Chapter 15, Section 15.2 (A) and 15.5.5 (5)(i) , respectively.

Medicare “participation” means you agree to accept claims assignment for all Medicare-covered services to your patients. By accepting assignment, you agree to accept Medicare-allowed amounts as payment in full. You may not collect more from the patient than the Medicare deductible and coinsurance or copayment . The Social Security Act says you must submit patient Medicare claims whether you participate or not.

To participate as a Medicare Program provider or supplier, submit the Medicare Participating Physician or Supplier Agreement (Form CMS-460) upon initial enrollment. You’ve 90 days after your initial enrollment approval letter is sent to decide if you want to be a participating provider or supplier. The only other time you may change your participation status is during the open enrollment period, generally from mid-November through December 31 of each year.

Participating Provider or Supplier

• Medicare pays 5% more to participating physicians and other suppliers
• Because these are assigned claims, Medicare pays you directly
• Medicare forwards claim information to Medigap (Medicare supplement coverage) insurers

Non-Participating Provider or Supplier

• Medicare pays 5% less to non-participating physicians and other suppliers
• You can’t charge the patient more than the limiting charge, 115% of the Medicare Physician Fee Schedule amount
• You may accept assignment on a case-by-case basis
• You have limited appeal rights

For more information, refer to the Medicare Claims Processing Manual, Chapter 12 .

Step 1: Get a National Provider Identifier (NPI)

You must get an NPI before enrolling in the Medicare Program. Apply for an NPI in 1 of 3 ways:

• Online Application: Get an I&A System user account. Then apply in the National Plan and Provider Enumeration System (NPPES) for an NPI.
• Paper Application: Complete, sign, and mail the NPI Application/Update Form (Form CMS-10114) paper application to the address on the NPI Enumerator form. To request a hard copy application, call 1-800-465-3203, TTY 1-800-692-2326, or email [email protected] .
• Bulk Enumeration: Apply for Electronic File Interchange (EFI) access and upload your own comma-separated values (CSV) files.

Not Sure If You Have an NPI?

Search for your NPI on the NPPES NPI Registry .

Multi-Factor Authentication

To better protect your information, CMS started I&A System Multi-Factor Authentication (MFA) for the following 4 public facing applications:

• I&A (started September 2019)
• NPPES (started December 2019)
• PECOS and EHR will require MFA soon

CMS Provider Enrollment Systems:

• Identity & Access Management (I&A) System
• National Plan and Provider Enumeration System (NPPES)
• Provider Enrollment, Chain, and Ownership System (PECOS)
• Electronic Health Record (EHR) Incentive Payments

Institutional providers must choose an I&A System Authorized Official (AO) to work in CMS systems. An AO may authorize I&A Access Managers, surrogates, and Staff End Users (SEUs) to work in CMS systems.

Step 2: Complete the Proper Medicare Enrollment Application

After you get an NPI, you can complete the Medicare Program enrollment, revalidate your enrollment, or change your enrollment information. Before applying, be sure you have the necessary enrollment information . Complete the actions using PECOS or the paper enrollment form.

A. Online PECOS Application

After CMS approves your I&A System registration, submit your PECOS application.

PECOS offers a scenario-driven application. It asks questions to recover the information needed for your specific enrollment scenario. You can use PECOS to submit all supporting documentation. Follow these instructions:

• Log in to PECOS .
• Continue with an existing enrollment or create a new application.
• When PECOS determines your enrollment scenario and you confirm it's correct, it shows the topics for submitting your application. To complete each topic, enter the necessary information.
• Confirms you entered all necessary data
• Lists the MAC documents to submit for review
• Gives the option to electronically sign and certify
• Shows your MAC’s name and mailing address
• Allows you to print a copy of your enrollment application for your records; don't submit a paper copy to the MAC
• Sends the application electronically to the MAC
• Emails you to confirm the MAC got the application

When you electronically submit your PECOS application, it’s “locked,” meaning you can’t edit it unless your MAC requests corrections.

Enrolling physicians, NPPs, or other Part B suppliers must choose 1 of the application descriptions below. Choose the “Group Member Only” if you’re re-assigning all your benefits to a group practice or clinic.

• Sole Owner of a Professional Association (PA), Professional Corporation (PC), or Limited Liability Company (LLC): You're the only owner of a business, set up as a corporation, where you provide health care services. Your business is legally separate from your personal assets.
• Self-Employed/Sole Proprietor: You provide all health care services from a facility you own, lease, or rent. You're the only owner of a business that provides health care services. You and your business are legally one and the same. You're personally responsible for the business’ financial obligations. You report the business’ income and losses on your personal tax return.
• Group Member Only: You provide all health care services as an employee of a group practice or clinic. You have an arrangement with your employer to send in Medicare claims and get paid for your services.
• Group Member and Is Self-Employed: You provide health care services as an employee of a group practice or clinic. You agreed with your employer to send in Medicare claims and get paid for your services. You also provide health care services from a facility that you own, lease, or rent. The income you make through self-employment is part of your personal assets.
• Disregarded Entity: You're the only owner of a business, set up as a corporation, where you provide health care services. Your corporation doesn't file taxes; instead, you file taxes on your personal tax filing.

B. Paper Medicare Enrollment Applications

You may submit the appropriate paper enrollment application if you're unable to use PECOS. Carefully review the paper application instructions to decide which form is right for your practice. The Medicare paper enrollment application collects your information, including the documentation verifying your Medicare Program enrollment eligibility.

If you submit a paper application, your MAC processes your approved Medicare Enrollment and creates a PECOS record.

• Medicare Enrollment Application: Institutional Providers (Form CMS-855A) : Institutional providers begin the Medicare enrollment/revalidation process or change Medicare enrollment information with this form.
• Medicare Enrollment Application: Physicians and Non-Physician Practitioners (Form CMS-855I) : Individual physicians or NPPs, as well as individual physicians and NPPs that are sole proprietors or sole owners of a corporation that provides services, use this form to begin the Medicare enrollment/revalidation process or change Medicare enrollment information.

Most physicians and NPPs complete Form CMS-855I to begin the enrollment process. If you re-assign your benefits to another entity, such as a medical group or group practice that gets paid for your services, you must complete Form CMS-855R or the associated PECOS enrollment applications.

• Medicare Enrollment Application: Clinics/Group Practices and Certain Other Suppliers (Form CMS-855B) : Group practices and other organizational suppliers, except DMEPOS suppliers, begin the Medicare enrollment/revalidation process, or change Medicare enrollment information with this form.
• Medicare Enrollment Application: Eligible Ordering, Certifying, and Prescribing Physicians and Other Eligible Professionals (Form CMS-855O) : Physicians and other eligible NPPs use this form to enroll in the Medicare Program solely to order or certify items or services for Medicare patients. This includes those physicians and other eligible NPPs who don’t send billed services claims to a MAC.
• Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers (Form CMS-855S) : DMEPOS suppliers begin the Medicare enrollment/revalidation process or change Medicare enrollment information with this form.
• Medicare Enrollment Application for Medicare Diabetes Prevention Program (MDPP) Suppliers (Form CMS-20134) : MDPP suppliers begin the Medicare enrollment/revalidation process or change Medicare enrollment information with this form.

After you submit an enrollment application and all required supporting documentation to your MAC, they will send their recommendations to the State Survey Agency and CMS’ Regional Office (RO). The CMS RO decides if specific types of providers meet Medicare enrollment conditions.

After a MAC makes a recommendation, the State Survey Agency or a CMS-recognized Accreditation Organization conducts a survey. Based on the survey results, the agency or organization recommends the RO approve or deny the enrollment (a certification of compliance or non-compliance).

Certain institutional provider types may elect voluntary accreditation by a CMS-recognized Accrediting Organization instead of a State Survey Agency. You must notify the State Survey Agency of the Accrediting Organization’s decision.

The State Survey Agency forwards survey results to the CMS RO Division of Survey & Certification. The CMS RO approves or denies the enrollment application, supporting documentation, and survey results, and works with the Office for Civil Rights to get necessary clearances.

If approved, you must sign a provider agreement.

Electronic Funds Transfer (EFT)

If enrolling in Medicare, revalidating, or making certain changes to their enrollment, CMS requires EFT. The most efficient way to enroll in EFT is to complete the PECOS EFT information section. When submitting a PECOS web application:

• Complete the EFT information for your organization (if appropriate) or as an individual
• Include a copy of a voided check or bank letter that has your individual or business legal name
• Include applicable account and routing numbers

Step 3: Respond to MAC Requests for More Information

MACs pre-screen and verify enrollment applications but may need additional information. Respond to information requests within 30 days; otherwise, the MAC may reject your enrollment.

Your MAC won’t fully process your PECOS enrollment application without your electronic or uploaded signature, application fee (if applicable), and necessary supporting documentation. The effective application enrollment filing date is when the MAC gets your enrollment application.

You can check your PECOS enrollment application status 2 ways:

• Log in to PECOS and click the “View Enrollments” link. In the “Existing Enrollments” section, find the application. The system shows the application status.
• To see your enrollment status without logging in, go to the PECOS homepage and under “Helpful Links” click “Application Status.”

When your MAC approves your application, it switches the PECOS record to an “approved” status and sends you an approval letter.

Provider Enrollment Site Visits

In 2011, CMS implemented a site visit verification process using a National Site Visit Contractor (NSVC). A site visit is a screening to prevent questionable providers and suppliers from enrolling or staying enrolled in the Medicare Program. The NSVC conducts unannounced site visits for all Medicare Part A and B providers and suppliers, including DMEPOS suppliers. The NSVC may conduct an observational site visit or a detailed review to verify enrollment-related information and collect other details based on pre-defined CMS checklists and procedures.

During an observational visit, the inspector has minimal contact with the provider or supplier and doesn’t hinder the facility’s daily activities. The inspector may take facility photographs as part of the site visit. During a detailed review, the inspector enters the facility, speaks with staff, takes photographs, and collects information to confirm the provider’s or supplier’s compliance with CMS standards.

Inspectors performing site visits will carry a photo ID and a CMS-issued signed letter of authorization the provider or supplier may review. If the provider or its staff want to verify CMS ordered a site visit, contact your MAC .

Make your office staff aware of the site visit verification process. An inspector’s inability to perform a site visit may result in your Medicare enrollment application denial or Medicare billing privileges revocation.

Step 4: Use PECOS to Keep Enrollment Information Up to Date

Report a Medicare enrollment change using PECOS. Providers and suppliers must report a change of ownership or control, a change in practice location, and final adverse legal actions (such as revocation or suspension of a federal or state license) within 30 days of the change and report all other changes within 90 days of the change.

DMEPOS suppliers must report changes in information on their enrollment application within 30 days of the change.

Independent Diagnostic Testing Facilities (IDTFs) must report changes in ownership, location, general supervision, and adverse legal actions within 30 days of the change and report all other changes within 90 days of the change.

MDPP providers must report changes in ownership including AO or Access Manager, location, coach roster, and adverse legal actions within 30 days, and report all other changes within 90 days of the change.

For more information, refer to MLN Matters Article SE1617 .

PECOS Users

• CMS allows various organizations and users to work in their systems. The type of user depends on the individual’s relationship with you and the duties they perform in your practice.

You may choose other users to act for your organization to manage connections and staff, including appointing and approving other system-authorized users. Depending on your professional relationships with other providers, the CMS External User Services (EUS) Help Desk may ask you for additional information for validation.

One Account, Multiple Systems

CMS uses several provider enrollment systems. Organizational providers and suppliers must use the Identity & Access Management (I&A) System to name an Authorized Official (AO) to work in CMS systems. The I&A System allows you to:

• Use the National Plan and Provider Enumeration System (NPPES) to apply for and manage National Provider Identifiers (NPIs)
• Use PECOS to complete Medicare enrollment or update or revalidate your current enrollment information
• Register to get Electronic Health Record (EHR) incentive payments for eligible professionals and hospitals that adopt, use and upgrade, or demonstrate meaningful EHR technology

Authorized Officials, Access Managers, Staff End Users and Surrogates

Organizational providers or suppliers must appoint and authenticate an Authorized Official (AO) through the I&A System to work in PECOS for them. That individual must meet the AO regulatory definition. For example, an AO is a chief executive officer, chief financial officer, general partner, chair of the board, or direct owner to whom the organization allows legal authority to enroll in the Medicare Program.

Respond to your employer’s AO invitation or initiate the request yourself. After you're the confirmed AO, use PECOS for your provider or supplier organization. As an AO, you're responsible for approving PECOS user system requests to work on behalf of the provider or supplier organization. Regularly check your email and take the requested actions.

AOs may delegate their responsibilities to an Access Manager , who can also initiate or accept connections, and manage staff for their organizations.

In 2020, CMS renamed the role “Delegated Official (DO)” to “Access Manager.”

AOs or Acess Managers may invite a Staff End User (SEU) or Surrogate to access PECOS for their organization. Once registered, an SEU or Surrogate may log in to access, view, and modify CMS system information, but they may not represent the practice, manage staff, sign enrollment applications, or initiate or accept connections.

CMS recommends using the same I&A System-appointed AO and any PECOS Access Managers. The assigned AO and Access Managers must have the right to legally bind the company, are responsible for approving the system staff, and are CMS approved in the I&A System.

Only AOs can sign an initial organization enrollment application. An Access Manager can sign changes, updates, and revalidations.

For detailed instructions on managing system users, refer to the I&A System Quick Reference Guide .

PECOS Technical Help

Using the Provider Enrollment, Chain, and Ownership System (PECOS) may require technical support. Knowing which CMS contractor to contact is the first step toward a solution.

Common Problems and Who to Contact

When you experience: system-generated error messages, trouble navigating through PECOS screens, issues accessing PECOS, printing problems, or you have a valid Identity & Access Management (I&A) System user ID and password but can't access PECOS because of malfunction (for example, the website operates slowly or not at all, or a system-generated error message prevents data entry).

A system-generated error message doesn't include messages created when you enter data incorrectly or ignore system prompts.

Solution: Contact CMS EUS Help Desk

Find information on common problems, ask a question, or look up previous support history on the External User Services (EUS) website .

Phone: 866-484-8049 (TTY 866-523-4759)

Email: [email protected]

Live Chat: Go to the EUS website screen, and on the right side choose “Live Chat.”

EUS Hours of Operation: Monday–Friday, 6 am–6 pm CT; Saturday–Sunday, closed

Before you log in to PECOS, you need a valid I&A System user ID and password.

Passwords expire every 60 days. You can't log in to the I&A System (and PECOS) until you reset your password. The I&A System tells you the number of days until your password expires. Go to the “My Profile” tab and see the password section. If you attempt to log in to PECOS with an expired password, the system redirects you to the I&A System to reset your password.

Solution: Access I&A System or Contact I&A System Help

The I&A System website lets you create an I&A System user ID and password, change your password, and recover forgotten login information. Additionally, you can access several resources:

• I&A FAQs helps you resolve common I&A System problems
• I&A System Quick Reference Guide provides step-by-step instructions, including screenshots about I&A System features and tools

On the I&A System website, choose the “Help” button in the upper right corner of any webpage for more information on the topic of that webpage.

While using PECOS, you have questions, experience problems enrolling, or need guidance on completing specific sections of the PECOS enrollment application.

Solution: Contact Your Medicare Enrollment Contractor

For detailed enrollment contact information, refer to Medicare Provider Enrollment Contact List or if you have questions, contact your MAC .

Solution: Refer to the CMS Provider Enrollment Assistance Guide

If you don't know who to call for help, refer to the “Who should I call?” CMS Provider Enrollment Assistance Guide .

CMS uses several provider enrollment systems. Specifically, the Identity & Access Management (I&A) System allows you to:

• Apply for and manage National Provider Identifiers (NPIs) in the National Plan and Provider Enumeration System (NPPES)
• Use PECOS to enroll in Medicare or update or revalidate your current enrollment information
• Register to get Electronic Health Record (EHR) incentive payments for eligible professionals and hospitals that adopt, use and upgrade, or show meaningful use with certified EHR technology

Before completing enrollment in PECOS, you must have an I&A System account. Organizational providers and suppliers must designate an Authorized Official (AO) to work in these systems.

Organizational providers and suppliers must designate a provider enrollment AO to work in CMS systems. These systems include the I&A System , NPPES , and PECOS . The AO may also authorize Access Managers, surrogates, and Staff End Users (SEUs) to use PECOS. Individual providers and suppliers don't require an AO but can authorize surrogates and SEUs to work in PECOS. For more information on registering for an I&A System account or enrolling as an AO, refer to the I&A System Quick Reference Guide and I&A FAQs .

Use the same information to enroll in Medicare using PECOS as you do for a paper enrollment application. If you don't have an I&A System account, create your user name and password. Use your user name and password to log in to NPPES to register for an NPI. All Medicare provider enrollees must have an active NPI.

Based on your provider type, you may also need the following information:

• Personal identifying information; this includes your legal name on file with the SSA, date of birth, and SSN
• Legal Business Name (LBN) of the provider or supplier organization
• Tax Identification Number (TIN) of the provider or supplier organization
• Professional license information
• School degrees
• Certificates
• Accreditation information
• Surety Bond information
• Specialty and secondary specialty information
• Current medical practice location
• Federal, state, and local (city or county) business and professional licenses, certificates, and registrations specifically required to operate as a health care facility
• Medical record storage information
• Special payment information
• Bank account information
• A Medicare-imposed revocation of Medicare billing privileges
• A suspension, termination, or revocation of a license to provide health care by a state licensing authority or the Medicaid Program
• A conviction of a federal or state felony within the 10 years preceding enrollment, revalidation, or re-enrollment
• An exclusion or debarment from federal or state health care program participation by the Office of Inspector General (OIG) or other federal or state offices with authority to exclude or sanction a provider

An application is the paper or electronic form you submit for Medicare Program enrollment approval. After the MAC processes the application, PECOS houses the enrollment record that includes all your enrollment application data.

You can't use PECOS to:

• Change your SSN
• Change a provider’s or supplier’s TIN
• A solely owned Professional Association (PA), Professional Corporation (PC), or Limited Liability Company (LLC) can’t be changed to a sole proprietorship
• A sole proprietorship can’t be changed to a PA, PC, or LLC
• Reassign benefits to an unenrolled PECOS provider

Submit changes noted above using the appropriate paper Medicare enrollment application .

No. All Fee-for-Service (FFS) providers can apply in PECOS.

The PECOS Provider Interface is available 24 hours a day, Monday through Saturday, with scheduled downtime on Sunday. CMS technical support is available daily 5 am to 8 pm CT.

CMS prefers that you submit your enrollment application through PECOS because it’s faster and easier, but you may complete and mail the appropriate paper Medicare enrollment application to the address on the Medicare Fee-For-Service Provider Enrollment Contact List :

• Parts A and B Providers: Send forms to your Part A or Part B MAC
• Home Health and Hospice Providers: Send forms to the Home Health and Hospice Contractor
• Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers: Send forms to the National Supplier Clearinghouse (NSC)

Even if you submit your application on a paper form, your MAC creates an enrollment record in PECOS.

When you electronically submit your Medicare enrollment application, you’ll get a “Submission Confirmation” page. The “Submission Confirmation” page reminds you that the individual provider, or the provider or supplier organization AO/Access Manager, must electronically sign the application or upload their signature. PECOS emails each address in the “Contact Person” section of the application of the web tracking ID for the submitted application. Remember to verify all your completed signatures with either an electronic signature or uploading certification. Mail required supporting documentation not uploaded before submission to the MAC with reference to the PECOS tracking ID.

When to create a new enrollment:

• If you change your services, such as changing specialties
• If you change your location where new state surveys and other documentation may be required by your MAC (your MAC can determine if you need a new enrollment based on a new state survey or other documentation)
• If you have provider-based vs. freestanding requirements. For more information, contact your MAC .

Application Fee and Supporting Documentation

Institutional providers and DMEPOS suppliers, Opioid Treatment Programs (OTPs), and Medicare Diabetes Prevention Program (MDPP) suppliers, in general, pay an application fee when enrolling, re-enrolling, revalidating, or adding a new practice location. Use the Application Fee Requirements for Institutional Providers to verify which providers need to pay a fee and when.

An approved hardship exception exempts you from paying the application fee for the current application. If you request a hardship exception, you must submit the written request (and supporting documentation) describing the hardship and why the hardship justifies an exception with your CMS paper application or PECOS application. CMS decides whether to grant these requests on a case-by-case basis. For more information on hardship exceptions, refer to MLN Matters® Article MM7350 .

MACs won’t process applications without the proper application fee or an approved hardship exception.

If you don’t pay the fee or submit a hardship exception request when you submit your enrollment application, your MAC will send a letter explaining if you don’t pay the application fee through the Medicare Enrollment Application Information webpage within 30 days from the date of the letter, Medicare may reject your application or revoke your existing billing privileges.

If you pay the fee during the 30-day period, the MAC processes the application in the usual manner.

No. When you electronically submit the provider or supplier organization Medicare enrollment application, a page appears that lists the supporting documentation to complete the enrollment. You may submit all this documentation electronically through PECOS.

Yes, either one is acceptable. You must send this information either electronically (as supporting documentation uploaded into PECOS).

During the PECOS application process, the “Penalties for Falsifying Information” page has the same text as the paper Medicare enrollment application , and lists the consequences for providing false information. These consequences include criminal and civil penalties, fines, civil monetary penalties, exclusion from federal health care programs, and imprisonment, among others. You must acknowledge the “Penalties for Falsifying Information” page by clicking the “Next Page” button before continuing the PECOS submission process.

Enrollment Application Issues

First, make sure you entered your correct SSN, legal name, and date of birth. If you believe you entered the correct information, but PECOS doesn't accept this information, contact SSA .

You must report an SSN to enroll in Medicare. If you don't want to report your SSN over the web, use the appropriate paper Medicare enrollment application .

An “Invalid Address” error indicates the address entered doesn't comply with the U.S. Postal Service address standards. This page lets you continue by either saving the address you entered or by selecting the address PECOS displays.

As a security feature, PECOS will time out if you’re inactive (you don’t hit any keys on your computer keyboard) for 15 minutes. The system warns you of inactivity after 10 minutes, and if it gets no response after 5 additional minutes, the system automatically logs you off. Save your work if you anticipate inactivity while applying in PECOS. If you don’t save your work and the system times out, you must restart from the beginning.

Submitting Reportable Events

No. If you report a change to existing information, check “Change,” include the effective date of change, and complete the appropriate fields in the sections that changed.

Yes. Following your initial enrollment, you must report certain changes (reportable events) to the MAC within 30 calendar days of change. Report all other changes to your MAC within 90 days.

Report a Medicare enrollment change using PECOS. Physicians and NPPs must report a change of ownership or control, a change in practice location, and any final adverse legal actions (such as revocation or suspension of a federal or state license) within 30 days of the change and report all other changes within 90 days of the change.

For more information, refer to MLN Matters® Article SE1617 .

Since Medicare pays claims by EFT, the Special Payments address should indicate where all other payment information must go (for example, paper remittance notices or special payments).

Providers and suppliers should report most changes using PECOS or the applicable paper Medicare enrollment application .

No. If you have a new business location, complete a new PECOS or paper application. Each DMEPOS enrollment record can only have 1 current business location.

Revalidations

Revalidation means resubmitting and recertifying your enrollment information.

DMEPOS suppliers must revalidate every 3 years. All other providers and suppliers generally revalidate every 5 years. CMS can also conduct off-cycle revalidations according to 42 CFR Section 424.515 . You can revalidate using PECOS or by submitting the appropriate Medicare enrollment application .

If currently enrolled, check the Medicare Revalidation Lookup Tool to find your revalidation due date. If you see a due date, submit your revalidation prior to that date. Your MAC will also send you a revalidation notice.

Due dates are:

• Updated in the Medicare Revalidation Lookup Tool every 60 days at the beginning of the month
• Listed up to 7 months in advance or listed as to be determined (TBD) if more than 7 months prior to the due date

Yes. Your MAC will send a revalidation notice as early as possible, generally no later than 3–4 months prior to your revalidation due date.

If there’s no listed due date on the Medicare Revalidation Lookup Tool or you didn’t get a MAC letter requesting revalidation, don’t submit your revalidation application. Your MAC will return these revalidation applications to you.

However, if you’re within 2 months of the due date listed on the Medicare Revalidation Lookup Tool and didn’t get a MAC notice to revalidate, submit your revalidation application.

Yes. Using PECOS to revalidate allows you to review information currently on file and update and submit your revalidation electronically. If you use PECOS, you only need to update changed information.

If you submit your revalidation after the due date, the MAC may place a hold on your Medicare payments or deactivate your Medicare billing privileges. If the MAC requests additional documentation, respond within 30 days; otherwise, they may deactivate your Medicare billing privileges.

Revalidation ensures all provider enrollment records are accurate and up to date. Generally, CMS doesn't take administrative action against a provider or supplier for updating their records even though it wasn't timely. However, CMS could take administrative actions, including recovery of prior Medicare payments, where a provider or supplier failing to report the change would cause Medicare Program enrollment ineligibility.

PECOS users can no longer mail documents that require a signature. When submitting your application, be prepared to send an e-signature or upload your signed documents.

Protect Your Identity and Privacy

• You can help protect your health care professional medical identifiers from identity thieves attempting to defraud the Medicare Program.

PECOS is an electronic Medicare enrollment system where providers and suppliers can:

• Submit Medicare enrollment applications
• View and print enrollment information
• Update enrollment information
• Complete the enrollment revalidation process
• Withdraw from the Medicare Program voluntarily
• Track a Medicare enrollment application

This protects your Medicare enrollment information.

Keep PECOS Enrollment Information Up to Date

Log in to PECOS and review your Medicare enrollment information several times a year to ensure there are no unauthorized changes.

PECOS Provides Security

Only you, authorized surrogates, authorized CMS officials, and MACs may enter and view your Medicare PECOS enrollment information. CMS officials and MACs get security standards training and must protect your information. CMS doesn't disclose your Medicare enrollment information to anyone, except when authorized or required by law.

Review and Protect Enrollment Information

Review your Medicare enrollment information in PECOS frequently to ensure it's accurate, current, and unaltered.

Protect Yourself and CMS Programs from Fraud

Your National Provider Identifier (NPI) and Tax ID are publicly available information. Use extra caution to monitor and protect your professional and personal information to help prevent fraud and abuse. You must also ensure your patients’ personal health information is secure. CMS has the following resources:

• Medicare Fraud & Abuse: Prevent, Detect, Report
• Office of Inspector General
• Help Fight Medicare Fraud (for patients)

Use your I dentity & Access Management (I&A) System user ID and password to access PECOS. Keep your ID and password secure. Take these steps to verify your Medicare enrollment information:

Ensure Your Enrollment Record is Accurate

Accurate and complete PECOS data is critical to CMS business functions, including the ability to:

• Combat fraud, waste, and abuse in Medicare and other health care programs
• Make informed provider enrollment decisions
• Pay claims accurately

Update and review your provider enrollment information whenever you make a change to your practice, including address changes .

Report suspicious information (for example, information you did not submit) to your MAC provider enrollment division.

If you suspect your PECOS profile is incorrect due to unauthorized account access, contact your MAC, law enforcement authorities, and your bank. Your MAC and bank can flag your respective accounts for possible fraudulent activity and law enforcement can begin investigating if and how your accounts were compromised.

Additional Privacy Tips

Take the following additional actions to protect your Medicare enrollment information:

• Change your password in the I&A System before accessing PECOS the first time. You can't change your user ID, but you must change your password every 60 days.
• Review your Medicare enrollment information several times a year to ensure no one altered information without your knowledge. Immediately report changes you didn't submit.
• Maintain your Medicare enrollment record. You must report Medicare enrollment changes known as reportable events. Reportable events include change of ownership or control , change in practice location, banking arrangements, and any final adverse legal actions.
• Store PECOS copies or paper enrollment applications in a secure location. Don't allow others access to this information. It contains your personal information, including your date of birth and SSN. Don't leave copies on a copy machine or on your workspace.
• Enroll in electronic Medicare payments and ensure they deposit directly into your bank account. CMS requires all providers to use Electronic Funds Transfer (EFT) if enrolling in Medicare, revalidating, or making changes to their enrollment. The most efficient way to enroll in EFT is to complete the EFT information section in PECOS and provide required supporting documentation. Using EFT allows Medicare to send payments directly to your bank account.

DMEPOS Supplier Requirements

Dmepos supplier standards, accreditation, and surety bond.

To enroll or keep your Medicare billing privileges, all DMEPOS suppliers (except certain exempted professionals) must meet supplier and DMEPOS Quality Standards to become accredited. Certain DMEPOS suppliers must also submit a surety bond .

DMEPOS suppliers (except those exempted eligible professionals and “other persons”) must have accreditation from a CMS-approved Accrediting Organization prior to submitting a Medicare enrollment application to the National Supplier Clearinghouse (NSC). For more information on these conditions, refer to the CMS DMEPOS Enrollment webpage or review the DMEPOS Accreditation fact sheet. It lists exempted eligible professionals.

Each enrolled DMEPOS supplier covered under the Health Insurance Portability and Accountability Act (HIPAA) must name each practice location (if it has more than one) as a sub-part and make sure each sub-part gets its own NPI.

Individual DMEPOS Suppliers (for example, sole proprietorships)

Physicians, NPPs, and DMEPOS suppliers may use their I&A System user ID and password to access PECOS . If you do not already have an I&A System account, refer to the I&A System User Registration page and enter the information to open an account. For help, refer to the I&A System Quick Reference Guide and click the “How to Setup Your Account if you are a Sole Owner” link.

As an individual DMEPOS supplier, you don’t need an Authorized Official (AO) or other authorized user.

Organizational DMEPOS Suppliers System Users

A DMEPOS supplier organization must appoint an AO to manage connections and staff, including appointing and approving other authorized PECOS users. The organization must identify the AO in the enrollment application. The AO must have ownership or managing control in the DMEPOS supplier organization.

Providers Who Solely Order or Certify

Recent legislation says physicians and other eligible professionals must enroll in the Medicare Program or have a valid opt-out affidavit on file to solely order or certify Medicare patient items or services.

Those physicians and other eligible professionals enrolled solely as ordering or certifying providers don't send billed service claims to a MAC.

Ordering and Certifying Terms

Medicare Part B claims use the term “ordering/certifying provider” (previously “ordering/referring provider”) to identify the professional who orders or certifies an item or service reported in a claim. The following are technically correct terms:

• A provider orders non-physician patient items or services, such as Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); clinical laboratory services; or imaging services.
• A provider certifies patient home health services.

The health care industry uses the terms “ordered,” “referred,” and “certified” interchangeably. To see terminology comments, refer to the Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements Final Rule .

Who Are Eligible Ordering or Certifying Providers?

Physicians or eligible professionals who order or certify Part A or Part B services but don't want to submit Medicare claims.

An individual already enrolled as a Medicare Part B provider may submit claims listing themselves as the ordering or certifying provider without re-enrolling using Form CMS-855O .

Those who enroll as eligible providers using Form CMS-855O may not bill Medicare or get paid by Medicare for their services. They have no Medicare billing privileges.

Eligible providers must meet these 3 basic conditions:

• Have an individual National Provider Identifier (NPI)
• Be enrolled in Medicare in either an “approved” or an “opt-out” status
• Be an eligible specialty type to order or certify

Organizational NPIs don’t qualify and you can’t use them to order or certify.

Denial of Ordering or Certifying Claims

If claims lack a valid individual NPI, MACs deny them if they are:

• Claims from clinical laboratories for ordered tests
• Claims from imaging centers for ordered imaging procedures
• Claims from DMEPOS suppliers for ordered DMEPOS
• Claims from Part A HHAs that aren't ordered or certified by a Doctor of Medicine (MD), Doctor of Osteopathy (DO), or Doctor of Podiatric Medicine (DPM)

If you bill a service that needs an eligible provider and one isn’t on the claim, the MAC denies the claim. The claim must have a valid NPI, and the eligible provider’s name as it appears in the PECOS.

If a provider on the Preclusion List prescribes a drug, Part D plans deny Part D covered drugs.

Requirement 1: You Must Have an Individual NPI

There are 2 types of NPIs: Type 1 (individual) and Type 2 (organizational). Medicare allows only Type 1 NPIs for solely ordering items or certifying services. Apply for an NPI in 1 of 3 ways:

• Online Application: Get an Identity & Access Management (I&A) System user account. Then apply in the National Plan and Provider Enumeration System (NPPES) for an NPI.
• Paper Application: Complete, sign, and mail the NPI Application/Update Form (Form CMS-10114 ) paper application to the address on the Enumerator form. To request a hard copy application, call 1-800-465-3203 or TTY 1-800-692-2326, or email [email protected] .

Requirement 2: You Must Enroll in Medicare in an “Approved” or “Opt-Out” Status

When you have an NPI, use PECOS to verify current Medicare enrollment record information, including your NPI and that you have an “approved” status, or go to the Opt Out Affidavits list to check for “opt-out” status. To “opt-out” of Medicare, you must submit an affidavit expressing your decision to opt-out of the program.

Since June 15, 2018, CMS no longer says Part C and Part D providers must enroll in Medicare in an “approved” or “opt-out” status.

* Medicare denies certain PMD claims if the ordering provider isn't on Medicare’s eligible providers list. For more information, refer to MLN Matters® Article MM2398 .

Requirement 3: You Must Be Eligible to Order or Certify

The physicians and eligible professionals who may enroll in Medicare solely for ordering or certifying include, but aren't limited to, those physicians and eligible professionals who are:

• Department of Veterans Affairs (DVA) employees
• Public Health Service (PHS) employees
• Department of Defense (DOD)/TRICARE employees
• Indian Health Service (IHS) or a Tribal Organization employee
• Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), or Critical Access Hospitals (CAHs) employees
• Licensed Residents in an approved medical residency program defined in 42 CFR Section 413.75(b)
• Dentists, including oral surgeons
• Pediatricians
• Retired, licensed physicians

If you're unsure whether your specific provider specialty qualifies to enroll as an ordering or certifying provider, refer to Section 4 of Form CMS-855O or contact your MAC before submitting a Medicare enrollment application.

Interns and Residents

Claims for items or services ordered or certified by licensed or unlicensed interns and residents must specify the NPI and name of a teaching physician. State-licensed residents may enroll to order or certify, and claims may list them. If states offer provisional licenses or otherwise permit residents to order or certify, CMS allows interns and residents to enroll consistent with state law.

Requirement 4: Respond to MAC Requests for More Information

MACs pre-screen and verify enrollment applications. During processing, your MAC may need additional information. Respond to information requests within 30 days; otherwise, the MAC may reject your enrollment.

Your MAC won't fully process your PECOS enrollment application without your electronic or uploaded signature, application fee, and necessary supporting documentation. The effective application enrollment filing date is when the MAC gets your enrollment application.

• To see your enrollment status, go to the PECOS homepage and under “Helpful Links” click “Application Status.” You don't need to log in to PECOS to use this application status feature.

Requirement 5: Use PECOS to Keep Enrollment Information Up to Date

Report a Medicare enrollment change using PECOS. Providers and suppliers must report a change of ownership or control, a change in practice location, and any final adverse legal actions (such as revocation or suspension of a federal or state license) within 30 days of the change and report all other changes within 90 days of the change.

DMEPOS suppliers must report any changes in information on their enrollment application within 30 days of the change.

For more information, refer to MLN Matters Article® SE1617 .

Revalidation

Revalidation, or re-submitting and recertifying enrollment information accuracy, is an important anti-fraud tool. All Medicare-enrolled providers and suppliers must periodically revalidate their enrollment information .

Generally, physicians, including physician organizations, Opioid Treatment Programs (OTPs), Medicare Diabetes Prevention Program (MDPP) suppliers, and institutional providers revalidate enrollment every 5 years or when CMS requests it. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers must revalidate their enrollment information every 3 years.

PECOS is the most efficient way to revalidate information.

If you're currently and actively enrolled, go to the Medicare Revalidation Lookup Tool to find your revalidation due date. If you see a due date, submit your revalidation prior to that date. Your MAC notifies you to revalidate. If you submit your revalidation application after the due date, the MAC may hold your Medicare payments or deactivate your billing privileges.

Rebuttal Process

MACs issue Medicare billing privilege deactivations and CMS permits providers/suppliers to file a rebuttal .

For more information refer to:

• Medicare Provider-Supplier Enrollment and Certification: Revalidations webpage
• Provider Enrollment Revalidation – Cycle 2 MLN Matters® Article SE1605
• Provider Enrollment Revalidation Cycle 2 FAQs

Large Group Coordination

Groups with more than 200 members can use the Medicare Revalidation Lookup Tool and search by their organization’s name to download group information. They will get a letter and spreadsheet from their MAC listing the providers linked to their group who must revalidate within 6 months. Large groups should work together to ensure they submit only 1 application from each provider/supplier.

Key Takeaways & Resources

Key takeaways.

• Institutional providers pay an application fee when enrolling, re-enrolling, revalidating, or adding a new practice location. Generally, individual providers don’t pay an application fee.
• Health care providers must enroll in the Medicare Program to get paid for providing covered services to Medicare patients. Multiple CMS systems work together to process enrollment functions.
• Technical help is available if you experience problems with the automated CMS enrollment systems.
• To enroll or keep Medicare billing privileges, all DMEPOS suppliers (except certain exempted professionals) must meet supplier and DMEPOS Quality Standards to become accredited.
• Some physicians and other eligible professionals don’t bill Medicare services but must enroll in the Medicare Program or have a valid opt-out affidavit on file to solely order or certify patient items or services.
• You must periodically revalidate your Medicare enrollment information.

Use these resources to learn how to enroll in the Medicare Program, revalidate your enrollment, or change your enrollment information. You must enroll in the Medicare Program to get paid for providing covered services to Medicare patients. You must enroll if you solely order items or certify services, and you won’t submit claims for these services.

You can enroll online by using the Provider Enrollment, Chain, and Ownership System (PECOS) or the appropriate paper enrollment application submitted to a MAC. CMS wants providers to use PECOS instead of the paper Medicare enrollment application.

• Get an Identity & Access Management (I&A) System user account.
• Apply for your National Provider Identifier (NPI) in the National Plan and Provider Enumeration System (NPPES) .
• Enroll in PECOS .

Enroll in Medicare

Medicare enrollment varies for each provider or supplier type. This tool sends you to the enrollment forms, process descriptions, and resources appropriate to your provider or supplier type.

We encourage you to use PECOS instead of the Medicare paper enrollment application. PECOS advantages include:

• Paperless process, including electronic signature and digital document feature
• Faster enrollment
• Submitting only relevant information
• More control over your enrollment information, including re-assignments
• Easy to check and update information
• Less staff time and administrative costs

Protect Your Identity and Information

NPIs and Tax IDs are publicly available information. Use extra caution to monitor and protect professional and personal information to help prevent fraud and abuse. This includes securing your patient's personal health information. CMS has the following resources:

Problems Enrolling?

You may have questions or problems that need additional help or technical support.

Enrollment Forms

Medicare makes enrollment forms as fillable PDF files. If you enroll using a paper application instead of PECOS , search the CMS Forms List for the form you need, select a form, and read “Who Should Complete This Application” on page 1 of the CMS-855 form. Check to ensure you use the correct application.

Additional Resources

• Provider Enrollment and Certification
• MLN Matters® Article MM7350, Implementation of Provider Enrollment Provisions in CMS-6028-FC (Hardship Exception)
• MLN Matters Special Edition Article SE1417, Implementation of Fingerprint-Based Background Checks
• MLN Matters Special Edition Article SE1520, National Site Visit Verification (NSV) Initiative
• MLN Matters Special Edition Article SE17016, Modernized National Plan and Provider Enumeration System

Commonly Used Terms

For a complete list of terms, go to the CMS Glossary .

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Frequently asked questions.

Have questions on the Site Visit Protocol? View Frequently Asked Questions .

Site Visit Tools

SVP tools to assist health centers prepare for a site visit:

• Health Center Self-Assessment Worksheet for Form 5A: Services Provided (PDF - 3 MB)
• Examples of Credentialing and Privileging Documentation
• Operational Site Visit Documents Provided by HRSA
• Consolidated Documents Checklist (PDF - 561 KB)
• Operational Site Visit (OSV) Exit Conference Tracking Resource (PDF - 268 KB)
• The Operational Site Visit (OSV): Answers to commonly asked questions (Video)
• Onsite Interviews and Interactions
• Sampling Review Resource Guide

Additional tools are added as they become available.

Virtual OSV Supplement

In response to the COVID-19 pandemic, HRSA/BPHC implemented the use of technology to conduct virtual site assessments. As the pandemic continues, HRSA/BPHC continues to conduct site assessments virtually through virtual Operational Site Visits (vOSV). To support the continuation of virtual site visits, HRSA developed virtual site visit supplements to the Site Visit Protocol (SVP) to help health centers and Look-alike Initial Designation applicants preparing for virtual site assessments. Virtual site assessments will be conducted using the SVP and the information in these supplements.

• Supplement to the Health Center Program Site Visit Protocol: Guidelines and Logistics for Virtual Operational Site Visits
• Supplement to Health Center Program Site Visit Protocol: Guidelines and Logistics for Virtual HRSA/BPHC Look-Alike Initial Designation Visits

Health Center Program Compliance Manual

HRSA’s Bureau of Primary Health Care (BPHC) is responsible for effective and efficient oversight of the Health Center Program. This includes ensuring that health centers are compliant with statutory and regulatory requirements for the Health Center Program. The Health Center Program Compliance Manual is the principal resource to assist health centers in understanding and demonstrating compliance with Health Center Program requirements. View the Health Center Program Compliance Manual .

Progressive Action Conditions Library

Health centers that fail to demonstrate compliance as described in the Health Center Program Compliance Manual will receive a condition of award/designation. The Health Center Program uses a standard set of conditions outlined in the Progressive Action Conditions Library that describes how health centers can demonstrate compliance with health center program requirements. View the Progressive Action Conditions Library .

Archived Site Visit Protocol

Need to access an archive copy of the Site Visit Protocol that was effective May 2022 to April 2023? Submit a request through the BPHC Contact Form , and select: “Site Visit Protocol General Inquiry.”

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CMS awards extension to National Site Visit Contractor

Notice ID: GS-15F-0059MHHSM-500-2012-00009G

Contract: GS-15F-0059M

The Centers for Medicare & Medicaid Services (CMS) implemented certain provisions of the Affordable Care Act to establish additional screening requirements for providers/suppliers.

The CMS Rule 6028-FC published February 2, 2011 (http://federalregister.gov/a/2011-1686) which is now implemented in 42 CFR 424.510, 424.517, 424.530 and 424.535 improves screening mechanisms to prevent questionable providers/suppliers from enrolling in the Medicare program, and requires scheduled, unscheduled or unannounced site visits to providers/suppliers. In addition to fulfilling regulatory requirements, the site verification initiative will also continue to address and support other collaborative efforts with the Office of Inspector General (OIG) and other CMS program integrity initiatives.

The site visit verification process is a screening mechanism to prevent questionable providers/suppliers from enrolling in Part A and Part B of the Medicare program. The initiative described in the SOW builds upon existing site visit programs to create a more efficient, effective, national program to respond to the provisions of the Affordable Care Act, as well as meeting the site-visit requirements described in CMS Publication 100-08, chapter 10 and 15, pertaining to independent diagnostic testing facilities (IDTFs).

Securitas (formerly MSM Security Services, LLC) has been performing as the National Site Visit Contractor (NSVC) for Medicare Parts A and B for 8 years. Previous Limited Source Justifications (LSJs) were executed to maintain continuity while a procurement for multiple award indefinite delivery, indefinite quantity (MA-IDIQ) contracts for Provider Enrollment and Oversight (PEO) services, including two initial task orders for site visit services, was underway. Award of the MA-IDIQ contracts and two task orders for site visit services were completed in August 2020, however, in response to the award, multiple protests were filed with the Government Accountability Office (GAO), necessitating that CMS issue stop work orders for the site verification services task orders. Because on-site visits are required for not only the entire continental United States (U.S.), but also Alaska, Hawaii, and any territories owned by the U.S, Securitas is the only company that is in a position to maintain continuity of site visit services at a reasonable price. Therefore, to maintain continuity of services it is necessary to extend the current task order until the protests are resolved and the work can be transitioned to the new task orders.

Market research was conducted as part of acquisition planning for the PEO MA-IDIQ Contract, which is the vehicle that the new task orders for Site Verification Services (SVS) task orders were awarded under, through a full and open competitive procurement. The current NSVC task order, held by Securitas, was anticipated to run concurrent with the newly awarded task orders to facilitate a transition period. However, a stop work order was issued for the task orders making it necessary for CMS to extend the current GSA task order held by Securitas until the protests can be resolved. Securitas has been providing the services for over eight years and has a record of satisfactory performance as documented via the Contractor Performance Assessment Reporting System (CPARS).

Extension of the current task order is the most suitable and efficient method for maintaining continuity of services. The optional period (January 5, 2021 – May 4, 2021) is included in an attempt to minimize the impact of any delays in resolving the current protests and/or receiving additional protests.

Read more here.

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Are You Ready for a CMS Site Visit?

Whether you are a new provider or you have been in practice for some time, the Centers for Medicare & Medicaid Services (CMS) may pay enrolled providers a visit for a medical record review and audit.

Would you be prepared if this audit were to happen next week?

The goal of CMS onsite audits is to find any fraud or abuse in the healthcare payment system. Some insurance payers are now joining in on-site audit visits. During the visit, CMS will make sure that your physical address matches the address on your electronic records and that your business is clearly labeled with street and number signs. They will also check that the proper licensed staff is providing professional services and that medical records are unaltered.

Checklist To Prepare for CMS Onsite Visit

You will receive a warning letter from CMS or from an insurance payer announcing your site visit . An unannounced visit may occur as well. Take action right away:

Check the credentials and photo ID of the auditors.

Let your attorney know about the audit and ask if they have any preparation advice or if they want to be present.

You may request that the appointment be rescheduled to a less busy time for your office.

Determine the exact purpose of the office visit and what issues they have observed in other providers.

Ask in advance whether any of your staff will be interviewed. If yes, brief them on how to answer questions accurately – but don’t volunteer any additional information.

Prepare a secure room in which the auditors can work.

If the audit is for only for medical records, ask for a patient list in advance.

Keep copies of all material that you supply to the auditors.

As a good practice drill for your staff, do a self-audit. Make sure that HIPAA standards are being met and that certificates are properly displayed. While you are at it, include safety standards in your audit for both OSHA and health department standards.

The auditors are only doing their jobs! Healthcare providers and suppliers must have policies and procedures in place for full compliance. When you are prepared for an audit at any time, you and your staff are confident that all proper HIPAA and other mandates are in place.

Let Us Manage All Your Payer Enrollment and Credentialing Services

If you require medical credentialing and payer enrollment needs for your practice or medical facility, please contact 1st Assistant. Our experienced and dedicated specialists will provide all credentialing and enrollment services quickly and will monitor your account for ongoing updates and re-attestations. Heidi Henderson , Vice President of Credentialing, is eager to meet you and discuss your payer enrollment needs. Please call us at 512.201.2668 or contact us via the website .

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The Centers for Medicare and Medicaid Services (CMS), through its contractors, often perform medical record reviews and audits for new and existing providers and suppliers. These audits are conducted to detect potential fraud and abuse within the healthcare payment system. In the past, the records reviews started with a letter from CMS to the provider with a list of patients. The provider then copied the records and sent them to the CMS contractor. Now, there has been a recent uptick in on-site visits, either scheduled or unannounced. Many insurance payers are following suit and conducting random site visits.

There are many reasons for the on-site visits. For starters, an onsite visit and records inspection would prevent a provider or supplier from unlawfully altering the medical records. In addition, the payers also want to see for themselves the type of equipment being used to verify that it is coded properly. Payers also want to see who is providing services within the office. Sometimes, unlicensed staff is providing professional services or licensed providers are acting outside their scope. These problems are revealed during an on-site inspection.

If a provider receives a letter or fax from a CMS contractor or insurance payer for a site visit, or if an unannounced visit occurs, there are things that a provider should so.

1.Verify that the auditors are who they say they are. Check their credentials including photo ID.

2.If you receive a letter or fax, verify that it is legitimate. If there is an email or call back number, use them as part of your verification process.

3. Immediately call your attorney. You may want your attorney to appear at the site visit or at least your attorney can advise you and your staff how to conduct yourself.

4.Try to arrange another, more convenient time. If auditors appear or want to appear during busy patient hours, you should politely try to re-schedule with them.

5.Clean your office.

6.Perform your own self-audit including making sure certificates are displayed and HIPAA standards are met.

7. Perform a self-audit for safety standards including health department standards and OSHA.

8. Arrange a clean, secure room for the auditors to give them work space. Lead them directly to the room and close all other doors in the office.

9. Try to arrange a time when employees are not there. If the audit is for medical records only, try to obtain a list of patients in advance and have only one person present during the copying/scanning of the records.

10.Keep copies of everything provided to the auditors.

11. Understand your rights and responsibilities. Does your staff have to be interviewed? If so, instruct them how to answer questions truthfully and accurately.

12. Ask the auditors questions to determine why they are there. Do they suspect something? What issues have they been seeing in other offices?

13. Do not volunteer any information.

14. Be pleasant and courteous.

Compliance and proactivity should go hand in hand. Health care providers and suppliers should implement policies and procedures to prevent, detect and correct instances of mistakes, fraud or abuse within the practice. Contacting an attorney to implement a Compliance Program within the office should be the first step. Then, the practice can feel comfortable and secure even when an office site visit occurs.

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