Below is a list of terms commonly used in the Medicare enrollment process:
Accredited provider/supplier means a supplier that has been accredited by a CMS-designated accreditation organization.
Advanced diagnostic imaging service means any of the following diagnostic services:
(i) Magnetic Resonance Imaging (MRI).
(ii) Computed Tomography (CT).
(iii) Nuclear Medicine.
(iv) Positron Emission Tomography (PET).
Applicant means the individual (practitioner/supplier) or organization who is seeking enrollment into the Medicare program.
Approve/Approval means the enrolling provider or supplier has been determined to be eligible under Medicare rules and regulations to receive a Medicare billing number and be granted Medicare billing privileges.
Authorized official means an appointed official (e.g., chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization’s status in the Medicare program, and to commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
Billing agency means an entity that furnishes billing and collection services on behalf of a provider or supplier. A billing agency is not enrolled in the Medicare program. A billing agency submits claims to Medicare in the name and billing number of the provider or supplier that furnished the service or services. In order to receive payment directly from Medicare on behalf of a provider or supplier, a billing agency must meet the conditions described in § 1842(b)(6)(D) of the Social Security Act. (For further information, see CMS Publication 100-04, chapter 1, section 30.2.4.)
Change in majority ownership occurs when an individual or organization acquires more than a 50 percent direct ownership interest in a home health agency (HHA) during the 36 months following the HHA’s initial enrollment into the Medicare program or the 36 months following the HHA’s most recent change in majority ownership (including asset sales, stock transfers, mergers, or consolidations). This includes an individual or organization that acquires majority ownership in an HHA through the cumulative effect of asset sales, stock transfers, consolidations, or mergers during the 36-month period after Medicare billing privileges are conveyed or the 36-month period following the HHA’s most recent change in majority ownership.
Change of ownership (CHOW) is defined in 42 CFR §489.18 (a) and generally means, in the case of a partnership, the removal, addition, or substitution of a partner, unless the partners expressly agree otherwise, as permitted by applicable State law. In the case of a corporation, the term generally means the merger of the provider corporation into another corporation, or the consolidation of two or more corporations, resulting in the creation of a new corporation. The transfer of corporate stock or the merger of another corporation into the provider corporation does not constitute a change of ownership.
CMS-approved accreditation organization means an accreditation organization designated by CMS to perform the accreditation functions specified.
Deactivate means that the provider or supplier’s billing privileges were stopped, but can be restored upon the submission of updated information.
Delegated official means an individual who is delegated by the “Authorized Official” the authority to report changes and updates to the provider/supplier’s enrollment record. The delegated official must be an individual with an ownership or control interest in (as that term is defined in section 1124(a)(3) of the Social Security Act), or be a W-2 managing employee of, the provider or supplier.
Deny/Denial means the enrolling provider or supplier has been determined to be ineligible to receive Medicare billing privileges.
Enroll/Enrollment means the process that Medicare uses to establish eligibility to submit claims for Medicare-covered items and services, and the process that Medicare uses to establish eligibility to order or certify Medicare-covered items and services.
Enrollment application means a paper CMS-855 enrollment application or the equivalent electronic enrollment process approved by the Office of Management and Budget (OMB).
Final adverse action means one or more of the following actions:
(i) A Medicare-imposed revocation of any Medicare billing privileges;
(ii) Suspension or revocation of a license to provide health care by any State licensing authority;
(iii) Revocation or suspension by an accreditation organization;
(iv) A conviction of a Federal or State felony offense (as defined in §424.535(a)(3)(i)) within the last 10 years preceding enrollment, revalidation, or re-enrollment; or
(v) An exclusion or debarment from participation in a Federal or State health care program.
Accredited provider/supplier means a supplier that has been accredited by a CMS-designated accreditation organization.
Advanced diagnostic imaging service means any of the following diagnostic services:
(i) Magnetic Resonance Imaging (MRI).
(ii) Computed Tomography (CT).
(iii) Nuclear Medicine.
(iv) Positron Emission Tomography (PET).
Applicant means the individual (practitioner/supplier) or organization who is seeking enrollment into the Medicare program.
Approve/Approval means the enrolling provider or supplier has been determined to be eligible under Medicare rules and regulations to receive a Medicare billing number and be granted Medicare billing privileges.
Authorized official means an appointed official (e.g., chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization’s status in the Medicare program, and to commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
Billing agency means an entity that furnishes billing and collection services on behalf of a provider or supplier. A billing agency is not enrolled in the Medicare program. A billing agency submits claims to Medicare in the name and billing number of the provider or supplier that furnished the service or services. In order to receive payment directly from Medicare on behalf of a provider or supplier, a billing agency must meet the conditions described in § 1842(b)(6)(D) of the Social Security Act. (For further information, see CMS Publication 100-04, chapter 1, section 30.2.4.)
Change in majority ownership occurs when an individual or organization acquires more than a 50 percent direct ownership interest in a home health agency (HHA) during the 36 months following the HHA’s initial enrollment into the Medicare program or the 36 months following the HHA’s most recent change in majority ownership (including asset sales, stock transfers, mergers, or consolidations). This includes an individual or organization that acquires majority ownership in an HHA through the cumulative effect of asset sales, stock transfers, consolidations, or mergers during the 36-month period after Medicare billing privileges are conveyed or the 36-month period following the HHA’s most recent change in majority ownership.
Change of ownership (CHOW) is defined in 42 CFR §489.18 (a) and generally means, in the case of a partnership, the removal, addition, or substitution of a partner, unless the partners expressly agree otherwise, as permitted by applicable State law. In the case of a corporation, the term generally means the merger of the provider corporation into another corporation, or the consolidation of two or more corporations, resulting in the creation of a new corporation. The transfer of corporate stock or the merger of another corporation into the provider corporation does not constitute a change of ownership.
CMS-approved accreditation organization means an accreditation organization designated by CMS to perform the accreditation functions specified.
Deactivate means that the provider or supplier’s billing privileges were stopped, but can be restored upon the submission of updated information.
Delegated official means an individual who is delegated by the “Authorized Official” the authority to report changes and updates to the provider/supplier’s enrollment record. The delegated official must be an individual with an ownership or control interest in (as that term is defined in section 1124(a)(3) of the Social Security Act), or be a W-2 managing employee of, the provider or supplier.
Deny/Denial means the enrolling provider or supplier has been determined to be ineligible to receive Medicare billing privileges.
Enroll/Enrollment means the process that Medicare uses to establish eligibility to submit claims for Medicare-covered items and services, and the process that Medicare uses to establish eligibility to order or certify Medicare-covered items and services.
Enrollment application means a paper CMS-855 enrollment application or the equivalent electronic enrollment process approved by the Office of Management and Budget (OMB).
Final adverse action means one or more of the following actions:
(i) A Medicare-imposed revocation of any Medicare billing privileges;
(ii) Suspension or revocation of a license to provide health care by any State licensing authority;
(iii) Revocation or suspension by an accreditation organization;
(iv) A conviction of a Federal or State felony offense (as defined in §424.535(a)(3)(i)) within the last 10 years preceding enrollment, revalidation, or re-enrollment; or
(v) An exclusion or debarment from participation in a Federal or State health care program.
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