Don’t Hesitate — Revalidate

Revalidation efforts are underway again, but this time for all providers and suppliers. When CMS revised the Medicare enrollment rules in June 2006, one change was to require each provider or supplier to revalidate its enrollment at least every 5 years. The initial revalidation efforts, which began in 2007, focused on providers and suppliers that had enrolled prior to 2003, when CMS had fully implemented the PECOS database for maintaining Medicare enrollment data. This article contains information on the revalidation process and tips for preparing revalidation forms.

The requirement to revalidate Medicare enrollment data was codified in federal law through Section 6401(a) of PPACA — the 2010 health care reform legislation.  Final regulations to implement this and other PPACA provisions related to provider and supplier enrollment were effective March 2011.  The new regulations also include requirements for Medicaid revalidations in addition to Medicare revalidations.  Refer to the Payment Matters article I drafted on these March 2011 enrollment changes, changes designed to combat fraud.

CMS has confirmed the mailing address/es to be used when sending a request for revalidation.  For a provider or supplier that still does not have an active enrollment in the PECOS database, the request will be sent to the special payments address on file or to the primary practice location address.  For providers or suppliers who have an enrollment record in PECOS, the revalidation request will be sent to boththe special payments and correspondence addresses unless these are the same in which case the request will additionally be sent to the primary practice location address.

Upon receipt of a request to revalidate, consider the following tips to facilitate the proper submission of the revalidation forms:

  • Unless currently set-up to utilize the Internet-based PECOS system, download the current version of the applicable CMS 855 form.
  • With the exception of individual practitioners and practitioner groups, all other providers and suppliers will need to pay the application fee as part of the revalidation process.  Refer to the Blog post related to application fees for more information about paying this fee.
  • Ensure that complete and accurate enrollment date is included on the revalidation form, particularly as it relates to information about the practice location.  This is particularly important for provider and supplier types subject to a site verification visit in conjunction with the revalidation.

In response to concerns from enrollees, CMS now posts a listing of providers and suppliers who have been sent a revalidation request.  The listing contains the name of the enrollee and the last four digits of the enrollee’s NPI number.  To view the listing, click on “Revalidation Phase 1 Listing” in the Downloads section of the Medicare Provider Supplier Enrollment Revalidation Page.  Any provider or supplier on the list who has no knowledge of receiving a revalidation request should immediately contact the Medicare Administrative Contractor regarding its revalidation.  Failure to promptly reply to a revalidation requests provides grounds for CMS to revoke Medicare billing privileges.