Provider and Supplier Revalidations
The contractor shall follow the guidance provided in sections 15.29.1 through 15.29.10 when processing revalidation applications, unless indicated otherwise in another CMS directive.
Also, this guidance takes precedence over all others instructions in this chapter 15 with respect to revalidation processing unless, gain, another CMS directive specifies otherwise.
Consistent with section 6401(a) of the Patient Protection and the Affordable Care Act (ACA), all existing providers and suppliers are required to revalidate their enrollment information under new enrollment screening criteria. Providers and suppliers are normally required to revalidate their Medicare enrollment every 5 years (every 3 years for suppliers of Durable Medical Equipment, Prosthetics Orthotics and Supplies (DMEPOS)).
However, CMS reserves the right to perform off-cycle revalidations as deemed necessary.
Revalidation Lists
CMS will identify the providers and suppliers required to revalidate during each cycle (List 1). CMS will communicate when new lists become available through the appropriate channels, at which time the contractor shall obtain the list from the CGI Share Point Ensemble website.
This list will also be made available on CMS.gov so that providers and suppliers are aware of who has been selected to revalidate and should be expecting a revalidation notice from their contractor, as well as who has been sent a revalidation notice.
The list is informational only, and providers and suppliers shall not take any action to revalidate until asked by their contractor to do so. CMS will also provide contractors with an additional list (List 2) consisting of large groups (200+ members) accepting reassigned benefits from individual providers identified on the CMS List 1. Large groups will receive a letter from their contractor informing them that providers linked to their group have been selected to revalidate.
A spreadsheet detailing the applicable provider’s Name, National Provider Identifier (NPI) and Specialty will also be provided. The letter and spreadsheet will be mailed to the group’s correspondence address within 15 days of the contractor receiving the CMS list.
This is informational only; groups should not take any action to revalidate their providers until asked by their contractor to do so. Groups with less than 200 reassignments will not receive a letter or spreadsheet from their MAC, but can utilize Internet-based PECOS or the CMS list available on CMS.gov to determine if their providers have been mailed a revalidation notice.
Mailing Revalidation Letters
The contractor shall mail and complete revalidations per enrollment record. Revalidations shall not be completed by National Provider Identifiers (NPIs) or Provider Transaction Access Numbers (PTANs).
When applicable, within 15 days of receiving the CMS list (List 2), the contractor shall mail or email a notification letter to the authorized/delegated official or the enrollment contact to notify them that providers within their group will be receiving a request to revalidate in the next 60 days.
The contractor shall include with the notification letter the spreadsheet identifying the individual providers that will be revalidated. The contractor shall designate an enrollment analyst for each of the large groups to coordinate revalidation activities.
The designated enrollment analyst shall be identified on the group notification letter and shall work directly with the group’s enrollment contact person or the authorized/delegated official on file.
Within 60 days of receiving the list from CMS, the contractor shall mail a revalidation letter to the providers and suppliers identified on the list in a colored envelope (preferably yellow) to distinguish the notice from other correspondence.
The contractor may stagger the mailings however it sees fit to meet the 60-day timeframe. The contractor shall issue one letter and reference all associated Provider Transaction Access Numbers (PTANs). A sample revalidation letter can be found in section 15.24.5 of this chapter.
The contractor shall send the letter to the provider or supplier’s special payment address and correspondence address. If the special payment and correspondence address are the same, the second letter shall be sent to the primary practice location. If only one address is available, the contractor shall only send one letter.
Two letters shall not be sent to the same address. For “individual group member only” providers with one or more reassignments, the contractor shall send the revalidation letter to the provider’s correspondence address and to a special payment address of one of the groups to which they reassign.
Contractor discretion shall be used in determining which group address shall be utilized. If a provider has completed a new reassignment and that PTAN is not on the CMS revalidation mailing list but is attached to the enrollment record being revalidated, the contractor shall not include that PTAN on the revalidation request or develop for the new reassignment/new PTAN as part of the revalidation.
If one of the locations is found to be incorrect or the letter gets returned as undeliverable, the contractor shall re-send the returned letter to an address not used for the initial mailing. If it is determined that all locations are the same and the contractor has exhausted all reasonable means of contacting the provider/supplier, the contractor shall deactivate the provider/supplier’s enrollment in either MCS/FISS or PECOS, whenever possible.
Non-Response to Revalidation Actions
Phone Calls
Providers and suppliers shall be given 60 days from the date of the revalidation letter to submit their revalidation application. If a revalidation application is not received, the contractor shall contact the provider or supplier via telephone regarding the revalidation request between days 60-70 or days 71-80 (DMEPOS suppliers only) of mailing the revalidation notice.
The contractor may place calls prior to the timeframes outlined if the current timeframes fall on a weekend or holiday. The contractor may begin telephone or email contacts to providers/suppliers to communicate non-receipt of the revalidation application earlier if it chooses, so long as the provider/supplier has been contacted by days 60-70.
The contractor shall use the telephone number linked to the
correspondence or practice location address listed in PECOS or another telephone number on file, if available. A minimum of two attempts to contact the provider or supplier telephonically shall be made, unless the first attempt reveals that the telephone number is no longer in service.
If no valid telephone numbers can be found during the first attempt, only one telephone attempt is required. Telephone attempts should generally be made between the hours of 8:00 am and 6:00 pm of the provider’s or supplier’s time zone. Busy signals shall not be considered a successful attempt.
Leaving voicemails is acceptable so long as a name and phone number is left for the provider or supplier to contact someone directly at the contractor site. Consistent with section 15.7.3 of this chapter, all telephone contacts shall be documented with the date and time of each call and noted in the provider’s or supplier’s file.
Pend Status
If a revalidation application has not been received by days 71–75 of mailing the revalidation notice, the contractor shall place the provider or supplier in a pend status; this will hold all paper checks, Standard Remittance Advices (SPRs), and Electronic Funds Transfers (EFT) from being issued. This administrative action shall be applied in PECOS using instructions outlined in other CMS directives. The contractor shall not directly apply this action in the shared systems.
The contractor shall communicate the purpose of the pend status to the individual provider, contact person, or authorized or delegated official of the organization via telephone or letter; the contractor shall use its own discretion in determining the best method. If the method used to communicate the pend status is via telephone, the contractor should forgo sending the pend letter.
The contractor shall use the telephone number linked to the correspondence or practice location address listed in PECOS or another phone number on file, if available. Leaving a voicemail to communicate the pend status is not acceptable.
A minimum of two attempts shall be made to contact the provider or supplier telephonically before a letter is issued. If the letter option is used, the contractor shall use the sample letter found in section 15.24.5.3 of this chapter.
The letter shall be mailed to the provider’s or supplier’s special payment and correspondence addresses. If the correspondence address is not available, the physical practice address shall be used. “Individual group member only” providers who reassign any of their benefits to one or more groups shall not be placed in a pend status.
Instead, they shall be deactivated during this period if no response is received. This action shall not affect the group’s PTANs but only the reassignment arrangement between the group and the deactivated group member.
Deactivation Actions
If a revalidation application has not been received by days 120 – 125 of sending the revalidation notice, the contractor shall end-date the pend status and deactivate the provider’s or supplier’s enrollment record (including all associated PTANs) in PECOS. The contractor shall not revoke a provider/supplier for failing to respond to a revalidation requested unless directed otherwise by CMS.
The contractor shall establish the effective date of deactivation as the same date the action is being taken. When deactivating a group with group members, the contractor shall end-date all group member PTANs linked to that group.
The deactivation of the entire enrollment record shall only occur if a response has not been received for any of the provider’s or supplier’s PTANs.
The contractor shall utilize the sample letter found in section 15.24.5.4 of this chapter to communicate the deactivation action. The letter shall be mailed to the provider’s or supplier’s special payment or correspondence address within 5 business days of the deactivation action.
If an individual provider is deactivated for failure to respond to a revalidation request, the contractor shall search the provider’s associate record to determine if the provider is identified as a supervising physician on any independent diagnostic testing facility (IDTF) enrollments.
If so, the provider shall be disassociated as the supervising physician for that entity. If the deactivated provider is the only supervising physician on file for the IDTF, the contractor shall develop for an active supervising physician to bring the IDTF into compliance.
The contractor shall give the IDTF 30 days to respond. Failure to provide an active supervising physician in the designated timeframe shall result in revocation of the IDTF’s billing privileges for non-compliance with the IDTF standards.
Receipt of Revalidation Application
The contractor shall not return a revalidation application received by a provider or supplier on the CMS revalidation list unless it falls within one of the categories identified in section 15.8.1 of this chapter. The contractor shall also accept and process unsolicited revalidation submissions with an accompanying application fee or hardship request, if applicable.
The contractor may only accept revalidation applications signed by the individual provider or the authorized official (AO) or delegated official (DO) of the provider/supplier organization. If a provider/supplier wishes to voluntary withdrawal from Medicare (including deactivating all active PTANs), the contractor shall accept this request via phone, U.S. mail or fax from the individual provider or the AO/DO (on letterhead); the contractor shall not require the provider/supplier to complete a CMS-855 application.
If the request is made via telephone, the contractor shall document the telephone conversation (in accordance with section 15.7.3 of this chapter) and take the appropriate action in PECOS.
Revalidation Received and Development Required
If the revalidation application is received but requires development (i.e., missing information such as application fee, hardship request, PTANs, documentation, signature), the contractor shall notify the provider or supplier via mail, phone, fax or email.
Providers and suppliers shall be given 30 days to respond to the contractor’s request and may submit the missing information via mail, fax, or e-mail containing scanned documentation (this includes missing signatures and dates).
If licensure and/or educational requirements (i.e., non-physician practitioner’s degree or diploma) can be verified online, the contractor shall not require the provider/supplier to submit this documentation. Residency information shall also not be required as part of revalidation.
The contractor shall not require further development for data that is missing on the provider/supplier’s revalidation application if the information is disclosed (1) elsewhere on the application, or (2) in the supporting documentation submitted with the application with the exception of the following items:
• Adverse legal action data
• Legal business name (LBN)
• Tax identification number (TIN)
• NPI-legacy number combinations
• Supplier/Practitioner type
• “Doing business as” name
• Effective dates of sale/transfer/consolidation or indication of acceptance of assets/liabilities.
In scenarios where a revalidation response is received for a single PTAN within an enrollment record that has multiple PTANs, the contractor shall develop for the remaining PTANs not accounted for. If no response is received, the contractor shall revalidate the single PTAN and end-date the PTAN(s) within the enrollment record that were not revalidated.
The same would apply if the provider or supplier has five PTANs. To illustrate, a response was received for all five. However, two of the five required development, and a response was not received for those two PTANs. The two PTANs would be end-dated and the remaining three revalidated.
In both scenarios, the entire enrollment should not be deactivated; only the non-response PTANs should be end dated and the other PTANs revalidated.) If the provider/supplier fails to disclose (1) all locations on the application that currently exist on file with Medicare or (2) all PTANs in the claims systems, the contractor shall confirm the missing data with the individual provider, the AO/DO, or the enrollment contact person via telephone or U.S. mail without requesting a newly-signed certification statement and end-date the locations or PTANs, if appropriate.
If the provider/supplier requests to collapse its PTANs as a result of revalidation, the contractor shall process those requests, if appropriate (based on payment localities, etc.). If the provider or supplier fails to timely respond to the developmental request by days 50-55, the contractor shall place the provider or supplier in a pend status using the instructions outlined in section 15.29.3.2 of this chapter.
“Individual group member only” providers who reassign any of their benefits to one or more groups shall not be placed in a pend status. Instead, they shall be deactivated during this period if no response to the develop request is received.
This action shall not affect the group’s PTANs but only the reassignment arrangement between the group and the deactivated group member. If, after 60 days from applying the pend flag, the provider or supplier still has not responded to the development request, the contractor shall deactivate the provider’s or supplier’s enrollment record (including all associated PTANs). The contractor shall establish the effective date of deactivation as the same date the action is being taken.
When deactivating a group with group members, the contractor shall end-date all group member PTANs linked to that group. The deactivation of the entire enrollment record shall only occur if a response has not been received for any of the provider’s or supplier’s PTANs.
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