Additional Home Health Agency (HHA) Review Activities
As stated in section 15.26.2(B)(3) of this chapter, the contractor must verify that a newly enrolling HHA has the required amount of capitalization after the regional office (RO) review process is completed but before the contractor conveys Medicare billing privileges to the HHA.
Accordingly, the HHA must submit proof of capitalization during this “post-RO review” period. To confirm that the HHA is still in compliance with Medicare enrollment requirements prior to the issuance of a provider agreement, the contractor shall also – during the post RO review period ensure that each entity and individual listed in sections 2, 5 and 6 of the HHA’s Form CMS-855A application is again reviewed against the Medicare Exclusion Database (MED) and the System for Award Management (SAM) (formerly the General Services Administration (GSA) Access Management System).
This activity applies: (1) regardless of whether the HHA is provider-based or freestanding, and (2) only to initial enrollments. The capitalization and MED/SAM re-reviews described above shall be performed once the RO notifies the contractor via e-mail that the RO’s review is complete. (Per sections 15.4.1.6 and 15.19.2.2 of this chapter, a site visit will be performed after the contractor receives the tie-in/approval notice from the RO but before the contractor conveys Medicare billing privileges to the HHA.) If:
a. The HHA is still in compliance (e.g., no owners or managing employees are excluded, capitalization is met):
1. The contractor shall notify the RO of this via e-mail. The notice shall specify the date on which the contractor completed the aforementioned reviews.
2. The RO will: (1) issue a CMS Certification Number (CCN), (2) sign a provider agreement, and (3) send a tie-in notice or approval letter to the contractor. Per section 15.7.7.2.1 of chapter 15, the contractor shall complete its processing of the tie-in notice/approval letter within 45 calendar days of receipt (during which time a site visit will be performed).
b. The HHA is not in compliance (e.g., capitalization is not met):
1. The contractor shall deny the application in accordance with the instructions in this chapter and issue appeal rights. (The denial date shall be the date on which the contractor completed its follow-up capitalization and MED/SAM reviews.)
2. Notify the RO of the denial via e-mail. (PEOG, not the RO, will handle any CAP or appeal related to the contractor’s denial.)
While, therefore, the process of enrolling certified suppliers and certified providers other than HHAs remains the same (i.e., recommendation is made to State/RO, after which the RO sends tie-in notice to contractor, etc.), the HHA process contains additional steps – specifically, Steps 4 and 5, as outlined below:
1. Contractor processes incoming HHA application and either (1) denies application, or (2) recommends approval to State/RO.
2. State performs survey (if applicable) and makes recommendation to RO.
3. If State recommends approval and RO concurs, RO will – instead of issuing CCN, signing provider agreement and sending tie-in notice/approval letter to contractor at this point, as is done with other certified provider and certified supplier applications – notify contractor that its review is complete.
4. Upon receipt of RO’s notification, contractor will perform capitalization and MED/SAM reviews discussed in sections 15.26.2 and 15.26.3 of this chapter.
5. Once contractor completes its review, it will notify RO as to whether HHA is still in compliance with enrollment requirements.
Deactivations and Revocations
If circumstances warrant, a fee-for-service contractor shall deactivate or revoke a provider or supplier’s Medicare billing privileges under certain circumstances.
Deactivation or revocation of Medicare billing privileges will not impact a provider or supplier’s ability to submit claims to non-Medicare payers using their National Provider Identifier.
Deactivations and Reactivations
Deactivations
A. Reasons
Unless indicated otherwise in this chapter or in another CMS instruction or directive, the contractor may - with prior approval from its CMS Provider Enrollment Business Function Lead (PEBFL) - deactivate a provider or supplier's Medicare billing privileges when:
• Per §424.540(a)(1), a provider or supplier does not submit any Medicare claims for 12 consecutive calendar months. The 12 month period begins on the 1 day of the 1st month without a claims submission through the last day of the 12 th month without a submitted claim;
• Per §424.540(a)(2), a provider or supplier fails to report a change to the information supplied on the enrollment application within 90 calendar days of when the change occurred. Changes that must be reported include, but are not limited to, a change in practice location, a change of any managing employee, and a change in billing services; or
• Per § 424.540(a)(2), a provider or supplier fails to report a change in ownership or control within 30 calendar days. The deactivation of Medicare billing privileges does not affect a supplier's participation agreement (CMS-460).
Should the contractor encounter one of the three deactivation situations described above, it shall contact its PEBFL (via any means) and request approval of the deactivation. CMS’ provider enrollment staff will notify the contractor of its decision.
B. Effective Dates
The effective dates of a deactivation are as follows: st
1. Non-Billing – The effective date is the date of the expiration of the applicable 12 month period.
2. Failure to Report Changed Information – The effective date is the date of the expiration of the application 30-day or 90-day reporting period. (See subsection A above.)
3. The “36-Month Rule” for HHAs – CMS’ provider enrollment staff will determine the effective date during its review of the case.
C. Appeals Rights
The Medicare contractor shall not afford a provider or supplier appeal rights when a deactivation determination is made.
D. Miscellaneous Policies
1. In situations where a provider with multiple PTANs is to be deactivated for nonbilling, the contractor shall only deactivate the non-billing PTAN(s). If a provider with multiple PTANs is to be deactivated for any reason other than (1) non-billing or (2) failing to respond to a revalidation request, the contractor shall contact its PEBFL for guidance as to the specific PTANs that should be deactivated.
2. A “no payment” bill with a condition code 21 (billing for denial notice) is considered a Medicare claim for purposes of 42 CFR §424.540.
A “demand bill” (as described in Pub. 100-08, Program Integrity Manual, chapter 3, section 5.4 (Exhibit 1)) is considered a Medicare claim for purposes of 42 CFR §424.540. Thus, for instance, if the provider only submitted “no payment” or “demand” bills over a 12-month period and furnished no claims for payment, the provider still submitted Medicare claims under §424.540.
Deactivation for non-billing would therefore be inappropriate.
3. Consistent with prior CMS direction, Medicare claims administration contractors and the EDCs shall not run the following deactivation jobs:
• Multi-Carrier System - Job names MV50, MV51, MV52 and MV53
• Fiscal Intermediary Shared System – Job name FSSJ9220
CMS, of course, retains the discretion to deactivate a provider or supplier’s Medicare billing privileges if any of the situations described in 42 CFR §424.540(a) are implicated.
4. Prior to deactivating an HHA’s billing privileges for any reason (including under the “36-month rule”), the contractor shall refer the matter to its PEBFL for review and approval.
As stated in section 15.26.2(B)(3) of this chapter, the contractor must verify that a newly enrolling HHA has the required amount of capitalization after the regional office (RO) review process is completed but before the contractor conveys Medicare billing privileges to the HHA.
Accordingly, the HHA must submit proof of capitalization during this “post-RO review” period. To confirm that the HHA is still in compliance with Medicare enrollment requirements prior to the issuance of a provider agreement, the contractor shall also – during the post RO review period ensure that each entity and individual listed in sections 2, 5 and 6 of the HHA’s Form CMS-855A application is again reviewed against the Medicare Exclusion Database (MED) and the System for Award Management (SAM) (formerly the General Services Administration (GSA) Access Management System).
This activity applies: (1) regardless of whether the HHA is provider-based or freestanding, and (2) only to initial enrollments. The capitalization and MED/SAM re-reviews described above shall be performed once the RO notifies the contractor via e-mail that the RO’s review is complete. (Per sections 15.4.1.6 and 15.19.2.2 of this chapter, a site visit will be performed after the contractor receives the tie-in/approval notice from the RO but before the contractor conveys Medicare billing privileges to the HHA.) If:
a. The HHA is still in compliance (e.g., no owners or managing employees are excluded, capitalization is met):
1. The contractor shall notify the RO of this via e-mail. The notice shall specify the date on which the contractor completed the aforementioned reviews.
2. The RO will: (1) issue a CMS Certification Number (CCN), (2) sign a provider agreement, and (3) send a tie-in notice or approval letter to the contractor. Per section 15.7.7.2.1 of chapter 15, the contractor shall complete its processing of the tie-in notice/approval letter within 45 calendar days of receipt (during which time a site visit will be performed).
b. The HHA is not in compliance (e.g., capitalization is not met):
1. The contractor shall deny the application in accordance with the instructions in this chapter and issue appeal rights. (The denial date shall be the date on which the contractor completed its follow-up capitalization and MED/SAM reviews.)
2. Notify the RO of the denial via e-mail. (PEOG, not the RO, will handle any CAP or appeal related to the contractor’s denial.)
While, therefore, the process of enrolling certified suppliers and certified providers other than HHAs remains the same (i.e., recommendation is made to State/RO, after which the RO sends tie-in notice to contractor, etc.), the HHA process contains additional steps – specifically, Steps 4 and 5, as outlined below:
1. Contractor processes incoming HHA application and either (1) denies application, or (2) recommends approval to State/RO.
2. State performs survey (if applicable) and makes recommendation to RO.
3. If State recommends approval and RO concurs, RO will – instead of issuing CCN, signing provider agreement and sending tie-in notice/approval letter to contractor at this point, as is done with other certified provider and certified supplier applications – notify contractor that its review is complete.
4. Upon receipt of RO’s notification, contractor will perform capitalization and MED/SAM reviews discussed in sections 15.26.2 and 15.26.3 of this chapter.
5. Once contractor completes its review, it will notify RO as to whether HHA is still in compliance with enrollment requirements.
Deactivations and Revocations
If circumstances warrant, a fee-for-service contractor shall deactivate or revoke a provider or supplier’s Medicare billing privileges under certain circumstances.
Deactivation or revocation of Medicare billing privileges will not impact a provider or supplier’s ability to submit claims to non-Medicare payers using their National Provider Identifier.
Deactivations and Reactivations
Deactivations
A. Reasons
Unless indicated otherwise in this chapter or in another CMS instruction or directive, the contractor may - with prior approval from its CMS Provider Enrollment Business Function Lead (PEBFL) - deactivate a provider or supplier's Medicare billing privileges when:
• Per §424.540(a)(1), a provider or supplier does not submit any Medicare claims for 12 consecutive calendar months. The 12 month period begins on the 1 day of the 1st month without a claims submission through the last day of the 12 th month without a submitted claim;
• Per §424.540(a)(2), a provider or supplier fails to report a change to the information supplied on the enrollment application within 90 calendar days of when the change occurred. Changes that must be reported include, but are not limited to, a change in practice location, a change of any managing employee, and a change in billing services; or
• Per § 424.540(a)(2), a provider or supplier fails to report a change in ownership or control within 30 calendar days. The deactivation of Medicare billing privileges does not affect a supplier's participation agreement (CMS-460).
Should the contractor encounter one of the three deactivation situations described above, it shall contact its PEBFL (via any means) and request approval of the deactivation. CMS’ provider enrollment staff will notify the contractor of its decision.
B. Effective Dates
The effective dates of a deactivation are as follows: st
1. Non-Billing – The effective date is the date of the expiration of the applicable 12 month period.
2. Failure to Report Changed Information – The effective date is the date of the expiration of the application 30-day or 90-day reporting period. (See subsection A above.)
3. The “36-Month Rule” for HHAs – CMS’ provider enrollment staff will determine the effective date during its review of the case.
C. Appeals Rights
The Medicare contractor shall not afford a provider or supplier appeal rights when a deactivation determination is made.
D. Miscellaneous Policies
1. In situations where a provider with multiple PTANs is to be deactivated for nonbilling, the contractor shall only deactivate the non-billing PTAN(s). If a provider with multiple PTANs is to be deactivated for any reason other than (1) non-billing or (2) failing to respond to a revalidation request, the contractor shall contact its PEBFL for guidance as to the specific PTANs that should be deactivated.
2. A “no payment” bill with a condition code 21 (billing for denial notice) is considered a Medicare claim for purposes of 42 CFR §424.540.
A “demand bill” (as described in Pub. 100-08, Program Integrity Manual, chapter 3, section 5.4 (Exhibit 1)) is considered a Medicare claim for purposes of 42 CFR §424.540. Thus, for instance, if the provider only submitted “no payment” or “demand” bills over a 12-month period and furnished no claims for payment, the provider still submitted Medicare claims under §424.540.
Deactivation for non-billing would therefore be inappropriate.
3. Consistent with prior CMS direction, Medicare claims administration contractors and the EDCs shall not run the following deactivation jobs:
• Multi-Carrier System - Job names MV50, MV51, MV52 and MV53
• Fiscal Intermediary Shared System – Job name FSSJ9220
CMS, of course, retains the discretion to deactivate a provider or supplier’s Medicare billing privileges if any of the situations described in 42 CFR §424.540(a) are implicated.
4. Prior to deactivating an HHA’s billing privileges for any reason (including under the “36-month rule”), the contractor shall refer the matter to its PEBFL for review and approval.
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