Medicare Compliance & Reimbursement

Know the current revalidation requirements with this handy list of dos and don’ts.

With cycle two of the Medicare revalidation process in full swing since last spring, CMS now requires all enrolled providers and suppliers to validate their credentials and eligibility every five years under the Affordable Care Act (ACA), section 6401(a). The reasoning behind this important process is to ensure that the health care practices of the aforementioned providers and suppliers have followed the CMS-mandated rules, regulations, and laws during the five years between validation.

Moreover, missing your revalidation due date will likely cause your Medicare payments to stop. Consider this revalidation primer if your Medicare enrollment revalidation is up for renewal.

Do Utilize the PECOS System

If you still like to run your office old school with paper applications, those are still available for revalidation purposes. You have three form options, depending on your status as a provider. CMS-855I is for sole proprietors; CMS-855B is for group providers; and CMS-855A is for institutions like hospitals.

For those providers, who prefer a quicker turnaround imbibed with accurate information, Medicare’s Provider Enrollment, Chain, and Ownership System (PECOS) is the superior choice.

“PECOS provides a tailored application that is relative to your situation, so you don’t need to worry about forgetting something,” Susan Stafford COA, AMR, NGS representative said in a Sept. 7, 2016 webinar. Register at https://pecos.cms.hhs.gov/pecos/login.do#headingLv1 to see if your due date is coming up.

Don’t Submit Your Revalidation Unless Advised to Do So

The infamous yellow Medicare envelope means it’s revalidation time, but if you don’t get one and you know it’s due soon, Stafford recommended calling your MAC for clarification, and mentioned that “unsolicited revalidations will be returned,” so do not send one out in the mail without verification.

Special note. NGS also offers up the reminder that enrollment revalidation is different than updating enrollment changes. Providers must update their information on a continuing basis or risk disruption of their Medicare payments due to incomplete applications on file.

Do Include the Nitty Gritty

Revalidation is not a time to be vague about your credentials, so make sure you have all your ducks in a row before attempting the revalidation task. Providers should be prepared with their NPIs, MAC-assigned PTANs, all medical licenses, certifications and diplomas including those at the state and local level, Social Security and IRS details, addresses, group and business associations.

Unfortunately, many providers omit small, trivial things like their Social Security numbers or NPIs, but they also forget to add adverse legal actions or convictions, too. This may prevent the revalidation from being processed. When CMS says it wants a “full and complete” enrollment revalidation application, they mean that literally all information must be included and match what is in its system, suggests Stafford.

Don’t Miss Your Due Date

Since revalidation letters go out two to three months in advance of the day they’re due, providers have plenty of time to prepare. Tech savvy clinicians can easily look up their details on both the PECOS and the CMS revalidation webpages, so don’t expect your MAC to accept most excuses for a missed due date.

Bottom line. The onus is on you. “Failure to respond in a timely manner will result in impacts to claims processing,” the NGS webinar factsheet advised. The end game will be a hold on your payment for services you’ve already rendered and possible deactivation from the Medicare system. Check with your MAC for details that involve denied revalidations and how to proceed. 

For more information about the Medicare enrollment revalidation process, visit https://www.cms.gov/medicare/provider-enrollment-and-certification/medicareprovidersupenroll/revalidations.html.