Reactivations - Deactivation for Reasons Other Than Non-Submission of a Claim

Reactivations 

Sections 15.27.1.2.1 through 15.27.2.2 below discuss the requirements for reactivating a provider or supplier’s billing privileges.  If the contractor approves a provider or supplier’s reactivation application or reactivation certification package (RCP) for a Part B non-certified supplier, the reactivation effective date shall be the date the contractor received the application or RCP that was processed to completion.  

Also, upon reactivating billing privileges for a Part B non-certified supplier, the contractor shall issue a new Provider Transaction Access Number (PTAN).  With the exception of HHAs, reactivation of Medicare billing privileges does not require a new State survey or the establishment of a new provider agreement or participation agreement. Per 42 CFR § 424.540(b)(3)(i), an HHA must undergo a new State survey or obtain accreditation by an approved accreditation organization before its billing privileges can be reactivated.  (See section 15.26.3 of this chapter for more information.)  

Reactivations - Deactivation for Reasons Other Than Non-Submission of a Claim 

A.  Background 

To reactivate its billing privileges, a provider or supplier deactivated for failing to timely notify the contractor of a change of information (see section 15.27.1.1(A) above) must either:  

1.Submit a complete Medicare enrollment application, or  

2.Recertify that its enrollment information currently on file with Medicare is correct.  

B.  Certification 

Option  1.  General Requirements  To utilize option (A)(2) above, the provider or supplier must submit to the contractor (a) a hard copy print-out of its PECOS Web enrollment data, (b) a hard copy Form CMS-855 certification statement signed and dated by the enrolled individual practitioner or, as applicable, the provider or supplier’s authorized or delegated official, and (c) a letter certifying as to the data’s accuracy.  

The letter must:  

(i) Be on the provider or supplier’s letterhead.  

(ii) List the provider or supplier’s birth name or legal business name, doing business as name (if applicable), National Provider Identifier, and the Provider Transaction Access Number(s) (PTAN) in the provider or supplier’s enrollment record to be reactivated. 

(iii) Must state that the provider is seeking to reactivate his/her/its billing privileges.  

(iv) Be signed and dated by the enrolled individual practitioner or, as applicable, the provider or supplier’s authorized or delegated official (who must be the same person who signed the Form CMS-855 certification statement).  

(v) Contain the following language:  

For Individual Practitioners 

“I, _______________, certify that all of the information contained in Medicare enrollment record (the record’s PAC ID number) is truthful and accurate.  I understand that by this statement and by my signature below, I am bound by all of the terms and conditions of the attached, signed Form CMS-855 certification statement and agree to abide by them.” 

 For Authorized/Delegated Officials 

“I, _______________, in my capacity as an authorized or delegated official of (provider/supplier), certify on behalf of (provider/supplier) that all of the information contained in (provider/supplier’s) Medicare enrollment record (the record’s PAC ID number) is truthful and accurate.  

I understand that by this statement and by my signature below, (provider/supplier) is bound by all of the terms and conditions of the attached, signed Form CMS-855 certification statement and agrees to abide by them.” 

A separate Form CMS-855 certification statement and letter must be submitted with each PECOS enrollment record (and the PTANs in that record) the provider or supplier seeks to have reactivated. 

To illustrate, suppose a supplier has three separate enrollments it wants to reactivate.  Each enrollment has its own PECOS enrollment record.  Two of the records have one PTAN; the third record contains two PTANs.  

The supplier must submit three separate PECOS Web printouts, three separate certification statements, and three separate letters. (The letter pertaining to the third enrollment record must list both PTANs.)  

The certification statement and letter should be attached to the PECOS Web printout to which it pertains – meaning, per our example, that there would be three separate “reactivation certification packages” (RCPs).  All RCPs must be submitted via mail.  They cannot be faxed or e-mailed. 

The provider or supplier cannot utilize the certification option and must submit a complete Form CMS-855 application if: 

• There is any information in the provider or supplier’s PECOS Web enrollment record that is not correct. 

• The provider or supplier cannot produce a printout of the applicable PECOS Web enrollment record (e.g., provider has no enrollment record in PECOS).  

• The provider or supplier cannot otherwise produce a valid RCP. 

 2.  Contractor Processing  

Upon receipt of an RCP, the contractor:  

• Shall ensure that it is complete and contains all of the elements identified in (B)(1) above.  If the RCP is in any way deficient or incomplete, the contractor shall develop for the missing/incomplete information or documentation consistent with existing procedures (e.g., requesting the submission of a revised letter).  

Examples of a deficient RCP include, but are not limited to, the following: 

(1) the package is missing the printout, certification statement, or letter; 

(2) the letter does not contain the required language or contains verbiage that offsets the required language; 

(3) the certification statement or letter is signed by an individual who is not on record as an authorized or delegated official; 

(4) the certification statement or letter is undated; 

(5) the letter refers to the incorrect PAC ID number.  The contractor may reject the RCP if the provider fails to furnish the requested material within 30 days of the request.  

• Shall review all names listed in the provider’s enrollment record against the Medicare Exclusion Database (MED) and the System for Award Management (SAM).   

• Shall ensure that the provider is still appropriately licensed and/or certified (e.g., the contractor can check State Web sites).  

• Consistent with section 15.19.2.4 of this chapter, shall perform a site visit if the provider is in the moderate or high screening category.  

• Reserves the right to request a full Form CMS-855 application if the contractor has reason to believe that any data in the provider’s enrollment record is inaccurate or outdated.  However, it shall obtain the approval of its CMS Provider Enrollment Business Function Lead (PEBFL) before making this request. 

The contractor need not prescreen the RCP. 

If the contractor determines that (1) the RCP complies with the requirements of this section 15.27.1.2.1(B), (2) remains appropriately licensed and/or certified, (3) none of the names in the provider or supplier’s enrollment record are excluded or debarred, (4) the provider is operational per the site visit, and (5) for HHAs, has undergone a new State survey or accreditation, the contractor may reactivate the provider’s Medicare billing privileges in accordance with existing procedures.  

If the contractor determines that any of these criteria are not met, it shall deny the reactivation application in accordance with existing procedures.  (As stated earlier, though, rejection is appropriate if the provider does not adequately respond to the provider’s developmental request.)  If the contractor believes that a denial ground other than the aforementioned exists, it shall contact its CMS Provider Enrollment Business Function Lead (PEBFL) for guidance.  

Reactivations - Deactivation for Non-Submission of a Claim 

To reactivate its billing privileges, a provider or supplier deactivated for non-billing must recertify that its enrollment information currently on file with Medicare is correct. This section 15.27.1.2.2 discusses this requirement.  

A.  All of Provider’s Data in Enrollment Record Is Correct  

1.  General Requirements  

If all of the data in the provider or supplier’s enrollment record is correct, the provider must submit to the contractor: 

(a) a hard copy print-out of its PECOS Web enrollment data, 

(b) a hard copy Form CMS-855 certification statement signed and dated by the enrolled individual practitioner or, as applicable, the provider or supplier’s authorized or delegated official, 

(c) the claim data described in section 15.27.1.2.3(B) of this chapter, and 

(d) a letter certifying as to the data’s accuracy.  

The letter must:  

(i)  Be on the provider or supplier’s letterhead. 

(ii)  List the provider or supplier’s birth name or legal business name, doing business as name (if applicable), National Provider Identifier, and the Provider Transaction Access Number(s) (PTAN) in the provider or supplier’s enrollment record to be reactivated. 

(iii)  Must state that the provider is seeking to reactivate his/her/its billing privileges.  

(iv)  Be signed and dated by the enrolled individual practitioner or, as applicable, the provider or supplier’s authorized or delegated official (who must be the same person who signed the Form CMS-855 certification statement).  

(v)  Contain the following language:  

For Individual Practitioners 

“I, _______________, certify that all of the information contained in Medicare enrollment record (the record’s PAC ID number) is truthful and accurate.  I understand that by this statement and by my signature below, I am bound by all of the terms and conditions of the attached, signed Form CMS-855 certification statement and agree to abide by them.” 

For Authorized/Delegated Officials  

“I, _______________, in my capacity as an authorized or delegated official of (Provider/Supplier), certify on behalf of (Provider/Supplier) that all of the information contained in (Provider/Supplier’s) Medicare enrollment record (the record’s PAC ID number) is truthful and accurate.  I understand that by this statement and by my signature below, (Provider/Supplier) is bound by all of the terms and conditions of the attached, signed Form CMS-855 certification statement and agrees to abide by them.” 

As explained in section 15.27.1.2.2(A), a separate Form CMS-855 certification statement and letter must be submitted with each PECOS enrollment record the provider or supplier seeks to have reactivated.  The certification statement and letter should be attached to the PECOS Web printout to which it applies.  All such “reactivation certification packages” (RCPs) must be submitted via mail.  They cannot be faxed or e-mailed.   

2.  Contractor Processing  

Upon receipt of an RCP, the contractor:  

• Shall ensure that it is complete and contains all of the elements identified in (A)(1) above.  If the RCP is in any way deficient or incomplete, the contractor shall develop for the missing/incomplete information or documentation consistent with existing procedures (e.g., requesting the submission of a revised letter).  Examples of a deficient RCP include, but are not limited to, the following: 

(1) the package is missing the printout, certification statement, or letter; 

(2) the letter does not contain the required language or contains verbiage that offsets the required language; 

(3) the certification statement or letter is signed by an individual who is not on record as an authorized or delegated official; 

(4) the certification statement or letter is undated; 

(5) the letter refers to the incorrect PAC ID number.  

The contractor may reject the RCP if the provider fails to furnish the requested material within 30 days of the request.  

• Shall review all names listed in the provider’s enrollment record against the Medicare Exclusion Database (MED) and the System for Award Management (SAM).  

• Shall ensure that the provider is still appropriately licensed and/or certified (e.g., the contractor can check State Web sites).  

• Consistent with section 15.19.2.4 of this chapter, shall perform a site visit if the provider is in the moderate or high screening category.  

The contractor need not prescreen the RCP. If the contractor determines that (1) the RCP complies with the requirements of this section 15.27.1.2.2(A), (2) remains appropriately licensed and/or certified, (3) none of the names in the provider or supplier’s enrollment record are excluded or debarred, (4) the provider (if in the moderate or high screening category) is operational per the site visit, and (5) for HHAs, the provider has undergone a new State survey or accreditation, the contractor may reactivate the provider’s Medicare billing privileges in accordance with existing procedures. 

If the contractor determines that any of these criteria are not met, it shall deny the reactivation application in accordance with existing procedures.  (Rejection is appropriate, however, if the provider does not adequately respond to the contractor’s developmental request.)  If the contractor believes that a denial ground other than the aforementioned exists, it shall contact its CMS Provider Enrollment Business Function Lead (PEBFL) for guidance.  

B. Some of Provider’s Data in Enrollment Record Is Incorrect 

1.  General Requirements  

If any data in the provider or supplier’s enrollment record is incorrect, the provider must submit to the contractor: 

(a) a hard copy print-out of its PECOS Web enrollment data, 

(b) applicable hard-copy page(s) of the Form CMS-855 containing the corrected information (e.g., new section 8 reporting a change to the billing company address), 

(c) a certification statement signed and dated by the enrolled individual practitioner or, as applicable, the provider or supplier’s authorized or delegated official, 

(d) the claim data described in section 15.27.1.2.3(B) of this chapter, and 

(e) a letter certifying as to the rest of the enrollment data’s accuracy.  

The letter must:  

(i)  Be on the provider or supplier’s letterhead.  

(ii)  List the provider or supplier’s birth name or legal business name, doing business as name (if applicable), NPI, and PTAN(s). 

(iii)  Must state that the provider is seeking to reactivate his/her/its billing privileges.  

(iv)  Be signed and dated by the enrolled individual practitioner or, as applicable, the provider or supplier’s authorized or delegated official (who must be the same person who signed the Form CMS-855 certification statement).  

(v)  Contain the following language:  

For Individual Practitioners 

“I, _______________, certify that - with the exception of (list the data elements that are currently incorrect and are being updated via the submitted Form CMS-855 pages) - all of the information currently contained in Medicare enrollment record (the record’s PAC ID number) is truthful and accurate.  I understand that by this statement and by my signature below, I am bound by all of the terms and conditions of the attached, signed Form CMS-855 certification statement and agree to abide by them.”  

For Authorized/Delegated Officials 

“I, _______________, in my capacity as an authorized or delegated official of (provider/supplier), certify on behalf of (provider/supplier) that - with the exception of (list the data elements that are currently incorrect and are being updated via the submitted Form CMS-855 pages) - all of the information contained in (provider/supplier’s) Medicare enrollment record (the record’s PAC ID number) is truthful and accurate.  I understand that by this statement and by my signature below, (provider/supplier) is bound by all of the terms and conditions of the attached, signed Form CMS-855 certification statement and agrees to abide by them.” 

As explained in section 15.27.1.2.2(B), a separate Form CMS-855 certification statement and letter must be submitted with each PECOS enrollment record the provider or supplier seeks to have reactivated.  The certification statement and letter should be attached to the PECOS Web printout to which it applies.  All RCPs must be submitted via mail.  They cannot be faxed or e-mailed.  

2.  Contractor Processing  Upon receipt of an RCP, the contractor:  

• Shall ensure that it is complete and contains all of the elements identified in (B)(1) above.  If the RCP is in any way deficient or incomplete, the contractor shall develop for the missing/incomplete information or documentation consistent with existing procedures (e.g., requesting the submission of a revised letter).  Examples of a deficient RCP include, but are not limited to, the following: 

(1) the package is missing the printout, certification statement, or letter; 

(2) the letter does not contain the required language or contains verbiage that offsets the required language; 

(3) the letter does not identify the information in the enrollment record that is incorrect; 

(4) the certification statement or letter is signed by an individual who is not on record as an authorized or delegated official; 

(5) the certification statement or letter is undated; 

(6) the letter refers to the incorrect PAC ID number.  The contractor may reject the RCP if the provider fails to furnish the requested material within 30 days of the request.  

• Shall review all names listed in the provider’s enrollment record against the MED and the SAM.    

• Shall ensure that the provider is still appropriately licensed and/or certified (e.g., the contractor can check State Web sites).  

• Consistent with section 15.19.2.4 of this chapter, shall perform a site visit if the provider is in the moderate or high screening category. 

 • Process the changed information in accordance with the instructions in this chapter.  The entire RCP transaction (including the changed data) shall, however, be processed as a revalidation. 

The contractor need not prescreen the RCP. If the contractor determines that (1) the RCP complies with the requirements of this section 15.27.1.2.2(B), (2) remains appropriately licensed and/or certified, (3) none of the names in the provider or supplier’s enrollment record are excluded or debarred, (4) the provider (if in the moderate or high screening category) is operational per the site visit, (5) all of the changed information can be processed to approval, and (6) for HHAs, the provider has undergone a new State survey or accreditation, the contractor may reactivate the provider’s Medicare billing privileges in accordance with existing procedures.  

If the contractor determines that any of these criteria are not met, it shall deny the reactivation application in accordance with existing procedures.  (Rejection is appropriate, however, if the provider does not adequately respond to the contractor’s developmental request.)  If the contractor believes that a denial ground other than the aforementioned exists, it shall contact its (PEBFL) for guidance.  

C.  PECOS Web Printout  

If the provider or supplier cannot produce a printout of the applicable PECOS Web enrollment record (e.g., provider has no enrollment record in PECOS) or cannot otherwise submit a valid RCP, it must submit a complete Form CMS-855 application in order to reactivate its Medicare billing privileges.