CMS Updates Healthcare Provider/Supplier Enrollment Chapter of Medicare Program Integrity Manual

On February 1, 2008, the Centers for Medicare and Medicaid Services (CMS) issued Transmittal 236, which updates various provisions in the Healthcare Provider/Supplier Enrollment Chapter of the Medicare Program Integrity Manual.[1]

Among the issues addressed in Transmittal 236 are: guidance to the Medicare contractors on the handling of CMS-855 change of information requests that cannot be processed to completion; elimination, in certain circumstances, of the need for contractors to make a recommendation for approval to the regional office; and the description of several addition supplier types to the chapter. Finally, this transmittal provides instructions on the accreditation of suppliers of durable medical equipment, prosthetics, orthotics and supplies. Each of these issues is described in greater detail below:

Guidance on handling CMS-855 change of information requests that cannot be processed to completion. Providers and suppliers are required to submit completed CMS-855 applications if they are requested a change of information or have not established enrollment records in the Provider Enrollment, Chain, and Ownership System (PECOS). Pursuant to the Transmittal, if a contractor receives a change request from a non-PECOS provider, the contractor need not return the application and change request to the entity but instead may treat the transaction as a request for additional information and the provider/supplier has sixty (60) calendar days from the date of the contractor's request to furnish the entire CMS-855 application.

Elimination of the need for contractors to make recommendations for approval to the regional office in certain situations. Certain change of information requests require (1) a recommendation for approval/denial, (2) a referral to the State/regional office (RO), and/or (3) a tie-in notice or other type of RO approval.

Transactions that require a recommendation and referral to the State/RO include (a) the addition of practice locations or subunits; (b) changes to the address of an existing practice location or subunit; (c) changes in hospital types not involving critical access hospitals; (d) large-scale stock transfers; and (e) changes in a provider's legal business name or Taxpayer Identification Number (TIN) that do not involve a change of ownership. By contrast, some changes are so minor that there is no need to refer the matter to the State/RO.

For those transactions that generally do not require recommendations and referrals to the State/RO, contractors can simply notify providers via letter, email, or telephone that the changes have been made, without sending concomitant notification to the State/RO. However, since each RO may have different preferences as to the types of changes it wishes to review and approve, contractors are strongly advised to contact ROs to confirm whether a given change request should be referred to the RO and whether the RO will issue a formal approval notice for such a change.

Guidance for certain supplier types regarding the existing provisions for carrier-enrolled organizational suppliers. The Transmittal adds new guidance for several supplier types: pharmacies, portable x-ray suppliers, radiation therapy centers, slide preparation facilities, and registered dietitians. The transmittal also revises existing guidance for several other supplier types, including CLIA laboratories, mammography screening centers, physicians, physician assistants, and psychologists practicing independently.

Instructions on the accreditation of suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). DMEPOS suppliers must be accredited prior to submitting applications to the National Supplier Clearinghouse (NSC) on or after March 1, 2008. The NSC need not approve any DMEPOS supplier's enrollment application if the enrollment package does not contain an approved accreditation upon receipt or in response to a developmental request. The NSC may reject an enrollment application if the DMEPOS supplier fails to provide supporting documentation which demonstrates that the supplier has an approved accreditation. For applications that were pending as of March 1, 2008, the contractor was entitled to develop for accreditation. DMEPOS suppliers that were enrolled for the first time with the NSC between January 1, 2008 and February 28, 2008 are required to obtain and submit approved accreditation to the NSC by January 1, 2009. DMEPOS suppliers that were enrolled in the Medicare program prior to January 1, 2008 are required to obtain and submit approved accreditation to the NSC by September 30, 2009. The NSC may revoke a DMEPOS supplier's billing privileges if the supplier fails to obtain and submit supporting documentation that the supplier has been accredited. Additionally, the NSC may enroll Indian Health Service (IHS) facilities as DMEPOS suppliers in accordance with the general enrollment procedures. Medicare recognizes two types of IHS facilities for enrollment purposes: (1) facilities that are wholly-owned and operated by the IHS, and (2) facilities that are owned by the IHS but are tribally operated or totally owned and operated by a tribe.


[1] Transmittal 236 may be downloaded on the CMS website, available athttp://www.cms.hhs.gov/transmittals/downloads/R236PI.pdf. This transmittal contains updates to Chapter 10 of the Medicare Program Integrity Manual.

The full Medicare Integrity Program Manual may be downloaded on the CMS website,available at http://www.cms.hhs.gov/Manuals/IOM/list.asp.