Friday 9 December 2016

PEOG will review the case file / Zone Program Integrity Contractor (ZPIC) Identified Revocations

Other Identified Revocations 

A.  Zone Program Integrity Contractor (ZPIC) Identified Revocations  

1.  General Procedures  If, through its investigations, the ZPIC believes that a particular provider’s or supplier’s Medicare billing privileges should be revoked, it shall develop a case file - including the reason(s) for revocation - and submit the file and all supporting documentation to the Provider Enrollment & Oversight Group (PEOG).  The ZPIC shall provide PEOG with the information described in (2) below.  

PEOG will review the case file and: 

• Return the case file to ZPIC for additional development, or 
• Consider approving the ZPIC’s recommendation for revocation. 

If PEOG approves the revocation recommendation, PEOG will: (1) ensure that the applicable Medicare Administrative Contractor (MAC) is instructed to revoke the provider’s/supplier’s Medicare enrollment, and (2) notify the applicable contracting officer’s representative (COR) in the Division of Medicare Integrity Contractor Operations of the action taken.  

If the MAC receives a direct request from a ZPIC to revoke a provider’s or supplier’s Medicare enrollment, it shall refer the matter to its PEOG Business Function Lead (PEOG BFL) if it is unsure whether the ZPIC received prior PEOG approval for the revocation.  

2.  Revocation Request Data  The revocation request shall contain the following information:  

• Provider/supplier name; practice location(s); type (e.g., DMEPOS supplier); Provider Transaction Access Number; National Provider Identifier; applicable Medicare Administrative Contractor 

• Name(s), e-mail address(es), and phone number(s) of investigators 

• Tracking number 

• Provider/supplier’s billing status (Active?  Inactive?  For how long?) 

• Whether the provider/supplier is a Fraud Prevention System provider/supplier 

• Source/Special Project 

• Whether the provider/supplier is under a current payment 
suspension 

• Legal basis for revocation 

• Relevant facts 

• Application of facts to revocation reason 

• Any other notable facts 

• Effective date (per 42 CFR § 424.535(g)) 

• Supporting documentation 

• Contractor ID 

• The denial reason (For any applications denied using the ‘Other (CMS Only)’ reason in PECOS, the MAC shall specify the denial reason in column U) 

• If the denial was entered in PECOS (Y/N)  The reports shall be sent to the Provider Enrollment & Operations Group (with a copy to the MAC’s Contracting Officer's Representative (COR)) no later than the 15 of each month; the report shall cover the prior month’s denials (e.g., the February report shall cover all January denials).  

Deceased Practitioners 

A.  Reports of Death from the Social Security Administration (SSA)  Contractors, including DME MACs and the NSC MAC, will receive from CMS a monthly file that lists individuals who have been reported as deceased to the SSA.  To help ensure that Medicare maintains current enrollment and payment information and to prevent others from utilizing the enrollment data of deceased individuals, the contractor shall undertake the activities described below.   

B.  Verification Activities for Individuals Other than Physicians, Non-Physician Practitioners and/or Suppliers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)  (If the person is an owner, managing employee, director, officer, authorized official, etc., the contractor shall verify and document that the person is deceased using the process described in section (C)(1) below.) 

Once the contractor verifies the report of death, it shall notify the provider or supplier organization with which the individual is associated that it needs to submit a Form CMS-855 change request that deletes the individual from the provider or supplier’s enrollment record.  If the provider fails to submit this information within 90 calendar days of the contractor’s request, the contractor shall deactivate the provider’s Medicare billing privileges in accordance with 42 CFR §424.540(a)(2).   

(DMEPOS Suppliers Only - If a DMEPOS supplier fails to submit this information within 30 calendar days of the contractor’s request, the contractor shall deactivate the supplier’s billing privileges in accordance with 42 CFR §424.57(c)(2).)   

The contractor need not, however, solicit a Form CMS-855 change request if:  

• The associate was the sole owner of his or her professional corporation or professional association.  The contractor can simply take steps to deactivate that organization’s enrollment in Medicare pursuant to section 15.27 of this chapter (e.g., seeking CMS approval); or 

• The organization is enrolled with another contractor.  Here, the contractor shall notify (via fax or e-mail) the contractor with which the organization is enrolled of the situation, at which time the latter contractor shall take actions consistent with this section 15.28.  C.  Reports of Death from Third-Parties  

2. Verification  If a contractor, including DME MACs or the NSC MAC, receives a report of death from a third-party (state provider association, state medical society, academic medical institution, etc.), the contractor shall verify that the physician, non-physician practitioner or DMEPOS supplier is deceased by:   

• Obtaining oral or written confirmation of the death from an authorized or delegated official of the group practice to which the physician, non-physician practitioner or DMEPOS supplier had reassigned his or her benefits;  

• Obtaining an obituary notice from the newspaper;   

• Obtaining oral or written confirmation from the state licensing board (e.g., telephone, e-mail, computer screen printout);   

• Obtaining oral or written confirmation from the State Bureau of Vital Statistics; or 

• Obtaining a death certificate, Form SSA-704, or Form SSA-721 (Statement of Funeral Director).  

2.   Post-Confirmation Actions  Once the contractor verifies the death, it shall:  

1.  Undertake all actions normally associated  with the deactivation of a supplier’s billing privileges.   

2.  Search PECOS to determine whether the individual is listed therein as an owner, managing employee, director, officer, partner, authorized official, or delegated official of another supplier.  

3.  If the person is not in PECOS, no further action with respect to that individual is needed.  

4.  If the supplier is indeed identified in PECOS as an owner, officer, etc., the contractor shall notify the organization with which the person is associated that it needs to submit a Form CMS-855 change request that deletes the individual from the entity’s enrollment record.  

If a provider fails to submit this information within 90 calendar days of the contractor’s request, the contractor shall deactivate the provider’s billing privileges in accordance with §424.540(a)(2). (DMEPOS Suppliers Only - If a DMEPOS supplier fails to submit this information within 30 calendar days of the contractor’s request, the contractor shall deactivate the supplier’s billing privileges in accordance with §424.57(c)(2).)  

The contractor need not, however, ask for a Form CMS-855 change request if:  

a. The physician, non-physician practitioner or DMEPOS supplier was the sole owner of his/hers professional corporation or professional association.  The contractor can simply take steps to deactivate that organization’s enrollment in Medicare pursuant to section 15.27 of this chapter ; or   

b. The organization is enrolled with another contractor.  In this situation, the contractor shall notify (via fax or e-mail) the contractor with which the organization is enrolled of the situation, at which time the latter contractor shall take actions consistent with this section 15.28.  The contractor shall place verification documentation in the provider or supplier file in accordance with section 15.7.3 of this chapter.  

D.  Education & Outreach  Contractors, including DME MACs and the NSC MAC, shall conduct outreach to state provider associations, state medical societies, academic medical institution, and group practices, etc., regarding the need to promptly inform contractors of the death of physicians and non-physician practitioners participating in the Medicare program.  

E.  Trustees/Legal Representatives  

1.  NPI - The trustee/legal representative of a deceased physician, non-physician practitioner or DMEPOS supplier’s estate may deactivate the NPI of the deceased provider by providing written documentation to the NPI enumerator.  

2.  Special Payment Address - In situations where a physician, non-physician practitioner or DMEPOS supplier has died, the contractor can make payments to the individual’s estate per the instructions in Pub. 100-04, chapter 1.  When the contractor receives a request from the trustee or other legally-recognized representative of the physician, non-physician practitioner or DMEPOS supplier’s estate to change the physician, non-physician practitioner or DMEPOS supplier’s special payment address, the contractor shall, at a minimum, ensure that the following information is furnished:   

• Form CMS-855 change of information request that updates the “Special Payment” address in the application.  The Form CMS-855 can be signed by the trustee/legal representative.   

• Any evidence – within reason - verifying that the physician, non-physician practitioner or DMEPOS supplier is in fact deceased.   

• Legal documentation verifying that the trustee/legal representative has the legal authority to act on behalf of the provider, non-physician practitioner or DMEPOS supplier’s estate.  The policies in this section 15.28(E)(1) and (2) apply only to physicians, non-physician practitioners and DMEPOS suppliers who operated their business as sole proprietors.  It does not apply to solely-owned corporations, limited liability companies, etc., nor to situations in which the physician or non-physician practitioner reassigned his or her benefits to another entity.  

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