Posts Tagged ‘enrollment’

CMS Will Deny Enrollment Applications When Outstanding Overpayment Exists

In Uncategorized on August 23, 2013 at 7:16 pm

Effective October 1, 2013, any providers or owners of provider-entities having an existing or delinquent overpayment that has not been repaid in full at the time of the enrollment application or change of ownership filing may be denied that new enrollment or change of ownership until that overpayment has been addressed. 

Upon receipt of the CMS enrollment forms (855A, 855B or 855S application), the Medicare Contractor will determine – whether any of the owners listed in Section 5 or 6 of the application has an existing or delinquent Medicare overpayment.  Upon receipt of a CMS-855I application, the Medicare Contractor will determine whether the physician or non-physician practitioner has an existing or delinquent Medicare overpayment.

If an owner, physician, or non-physician practitioner has such an overpayment, the contractor shall deny the application, using 42 CFR 424.530(a)(6) as the basis. The denial shall be issued regardless of:

  • Whether the person or entity is on a Medicare-approved plan of repayment or payments are currently being offset:
    • Whether the overpayment is currently being appealed
    • The reason for the overpayment

For now this rule applies only to initial enrollments and new owners in a CHOW, not revalidations or updates to current enrollments.  Note also that if the Medicare Contractor determines that the overpayment existed at the time the application was filed, but the debt was paid in full by the time the contractor performed its review, the contractor will not deny the application because of that overpayment.


PECOS/Ordering & Referring Issue Redux

In Uncategorized on August 23, 2013 at 6:03 pm

As some of you may recall, there was a flurry of activity a couple of years ago regarding PECOS – CMS’s online provider enrollment system – and the need for all providers to be enrolled in PECOS.  CMS’s incentive (or, “stick”), if you will, for getting all providers on board was to deny any claims related to providers not enrolled in PECOS, and identified in the PECOS “ordering and referring” list.  That deadline for compliance, and the subsequent enforcement was slated to be May 1, 2013 – as of that date, any claim relating to an ordering/referring provider not enrolled in PECOS was going to be summarily denied.  However, just prior to that enforcement date, CMS announced that:

Due to technical issues, implementation of the Phase 2 ordering and referring denial edits is being delayed. These edits would have checked the following claims for an approved or validly opted-out physician or non-physician who is an eligible specialty type with a valid individual National Provider Identifier (NPI). If either of these were missing or incorrect, claims would deny.  

  • Medicare Part B claims from laboratories, imaging centers and Durable Medical Equipment, Orthotics, and Supplies (DMEPOS) that have an ordering or referring physician/non-physician provider; and
  • Part A Home Health Agency (HHA) claims that require an attending physician provider. 

CMS will advise you of the new implementation date in the near future. In the interim, informational messages will continue to be sent for those claims that would have been denied had the edits been in place.

You may be questioned by any facilities, labs, or DME providers to which you refer patients regarding your PECOS status….  This is what they are talking about, and the potential for their claims to be denied if you are not in PECOS is the root of their concern.

New Docs Can Apply To Medicare Earlier!

In Uncategorized on May 10, 2012 at 3:47 pm

CMS, after considerable pressure from many medical and billing advocacy groups and organizations, has announced a change in its provider enrollment process that will allow providers to enroll in Medicare up to 60 days prior to their start date. Until now, providers were prohibited from enrolling in Medicare more than 30 days prior to their start date.  This is great news, which will only enhance providers’ ability to recoup funds for services provided to patients.

 The announcement is included in a MedLearn Matters article released earlier today. The new policy is effective May 14th.

 The new policy does not apply to:

                         (a) providers and suppliers submitting a Form CMS-855A application, 
                        (b) Ambulatory Surgical Centers (ASCs), or 
                        (c) Portable X-ray Suppliers (PXRSs)

Please contact M.E.D.I.C., Inc. should you have any questions.

reprinted in substance with permission of HBMA

CMS’ Revalidation Effort Delayed

In Uncategorized on November 7, 2011 at 9:28 pm

Over the past few months, much has been discussed about CMS’s “revalidation” effort.  Essentially, all providers and suppliers enrolled in the Medicare program prior to March 25, 2011, will be required to submit their enrollment information so they can be revalidated under new risk screening criteria required by the Affordable Care Act (Section 6401a).  Providers/suppliers who enrolled on or after March 25, 2011, have already been subject to this screening and need not revalidate at this time.

CMS & MACs have advised providers and suppliers not to take any action intil they have received a “revlidation letter” from their MAC, for this is going to be a staged process in which all providers and suppliers would be revalidated over the course of the next two years (by March 23, 2013).  The followig link provides an example of what a validation letter would look like:$File/J11_Revalidation_Letter_Web_Example.pdf

Once your office receives such a notice, please notify M.E.D.I.C., Inc. ASAP, for at that point, you have only 60 days in which to complete the revalidation process.  Providers failing to respond to such a revalidation request run the risk of being deactivated from the Medicare program.

Just this past week, however, CMS announced that it would “delay” this revalidation effort in order to streamline the process by improving the PECOS online registration system prior to revalidating all Medicare providers.  According to the Medical Society of Virginia’s website (–.aspx):

In order to comply with the program integrity screening provisions of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) launched an effort to revalidate the enrollment of every provider and supplier by March 23, 2013. This effort has now been pushed back to 2015. Physicians will be among the last to revalidate.
In addition to pushing back the revalidation efforts, CMS made improvements to the online Medicare Provider Enrollment, Chain and Ownership (PECOS) system, which include:

  • E-signatures
  • Electronic document upload
  • Batch upload capability
  • Seamless password reset
  • Enhancements for authorized officials
  • Reassignment reports
  • New “my enrollments page” and “fast track view” screens
  • Fewer duplicative document submission requirements

CMS stated that the PECOS improvements will be implemented before most physicians are asked to revalidate.

CMS Delays PECOS Phase II Implementation Date

In Uncategorized on March 30, 2011 at 3:11 pm

CMS has recently issued a statement that it will NOT implement Phase 2 of PECOS on July 5th, as was originally published (point of reference:  during Phase I, which is currently underway, claims will have an appended warning when the ordering/referring proivider is not enrolled in PECOS; during Phase 2, which has yet to begin, all claims processed with an ordering/referring provider who is not enrolled in PECOS will be denied…  for more information on what PECOS is, see post published June 8, 2010):

“It has come to CMS’ attention that there was an editorial oversight in the OIG Compendium of Unimplemented Recommendations (March 2011 Edition). The OIG report states that the CMS will delay the implementation of Phase 2 of Change Request (CR) 6417 and CR until Tuesday, July 5, 2011.  This is incorrect. 

 CMS has not yet determined when it will begin to apply the ordering/referring provider claim edit to ordering/referring providers that do not have a record in the Provider Enrollment, Chain, and Ownership System (PECOS).  As previously stated, CMS will give providers ample notice before the ordering/referring provider claim edit is applied.  Recent revisions to CRs #6417 and #6421 require MACs to delay rejecting claims until receiving further direction from CMS.”  (emphasis added)

So, the net result is that parties to whom patients are ordered/refered will continue to receive EOB warnings regarding the PECOS status of the referring provider, but will be paid.  For now. 

When will this change?  I have no idea, so it would be advisable for all providers who have not enrolled in PECOS to date to do so as soon as practicable.  Anyone needing assistance in a) checking to see whether they are currently enrolled in PECOS, or b) enrolling in PECOS can contact M.E.D.I.C., Inc. ( — we are happy to assist!