Revalidation - JE Part B

The Patient Protection and Affordable Care Act established a requirement for all enrolled providers/suppliers to revalidate their Medicare enrollment information. According to the Program Integrity Manual (PIM), pursuant to 42 CFR §§ 424.515, 410.41(c), and 424.57(g), providers and suppliers use the CMS enrollment application process to periodically revalidate their Medicare enrollment record. Suppliers of durable medical equipment, prosthetics, orthotics, and supplies are required to revalidate every three years and all other providers and suppliers every five years.

Revalidation is the process of reviewing and confirming all information that is on file with Medicare is current and correct. Revalidation guidance can be found in CMS Internet Only Manual (IOM), Publication 100-08, Chapter 10, Section 10.1.2.

All actively enrolled providers/suppliers will be required to revalidate. Providers opted out of Medicare or enrolled solely to order, certify, and prescribe do not have to revalidate.

• Due Dates
• Revalidation Look-up Tool
• Failure to Revalidate
• Sole Owners
• Application Submission
• Resources

Due Dates

• CMS has established due dates for revalidation on last day of month (e.g. January 31, 2024, February 29, 2024).
• To avoid deactivation of Medicare billing privileges, submit revalidation application to appropriate Medicare Administrator Contractor (MAC) within seven months of due date
• If the revalidation application is submitted to the contractor more than seven months before the due date, it will be returned as unsolicited
• If a change of information (COI) application is received prior to the contractor mailing out the revalidation letter, the application is processed as a change.
• If the provider/supplier submits an application marked as a revalidation but only includes enough information to be considered a COI, the contractor will develop for a complete revalidation application and process as a revalidation.
• If a COI application is received after the contractor has mailed the revalidation notice, the contractor will develop for a complete revalidation and process it as a revalidation.

Look-up Tool

The Revalidation Look-up Tool is an online tool that can be used to verify if an enrollment must revalidate.

• View Medicare Revalidation List which includes all enrolled suppliers
• All providers/suppliers not due for revalidation will display a "TBD" (To Be Determined) in the due date field. Some providers/suppliers will have an Adjusted Due Date displaying. In that case, a revalidation application should be submitted.
  • If no results are displayed for a National Provider Identifier (NPI) search, be sure there is not a space after the NPI. Extra spaces can cause inaccurate information to display. If there is no space at end of the NPI, and no due date populates, then a revalidation is not due.
  • Once application has been completed, and notification letters have been sent, enrollment will not need to be revalidated again until requested
  • When looking up organization information in revalidation loop-up tool, select organization name. Here, names of providers who must revalidate, have revalidated, or have TBD will populate

  Notification

  • Each provider/organization will receive their own revalidation request letter
    • We will mail two revalidation letters. One to special payments address and one to correspondence address. If both of those addresses are same, a letter will be mailed to one of the practice locations the organization has on file to which the provider reassigns his/her benefits to
    • Revalidation notices for individual group members will list organization or organizations with whom individual provider reassign benefits
    • Organizations will have organization information that is requested to revalidate
    • Noridian will also send out a reminder email roughly four months before due date. If correspondence email address is valid, another email will be sent a month and a half before due date again. This will be a generic email stating that your enrollment is due for revalidation. It will not contain any identifying information within it

    Failure to Revalidate

    Pend Status

    • Organizations, sole proprietors and sole owners, will have their enrollment record placed into a pend status if a revalidation application isn't received by due date. Pend will be placed on group enrollment up to 25 days after due date
      • This means that it can be applied anywhere from 1-25 days after due date

      Deactivation

      • Provider or organization is at risk when revalidation application is received after due date
        • If no application has been submitted, enrollment is deactivated 60-75 days after due date

        Reactivation

        • What does reactivation mean for you? It means that you must re-enroll with Medicare. Noridian will process the application as if it were a new enrollment
          • If supporting documentation currently exists in provider's file, the provider or supplier is not required to submit that documentation again during enrollment process

          Gap in Billing (Lapse in Coverage)

          • Gap in billing (lapse in coverage) is where the enrollment is deactivated when either revalidation date has passed, or revalidation application is rejected
          • Once Noridian receives a new application, enrollment will be reactivated with a gap in billing (lapse in coverage) on the enrollment
            • Payment will not be made from Medicare for dates of service within this gap in billing (lapse in coverage) on the enrollment
            • Original effective date of Provider Transaction Access Number (PTAN) would be used
            • For example:
              • Provider deactivated 12/19/2023 for non-response to revalidation
              • Revalidation reactivation application received 12/19/2023
              • PTAN effective date can go back 30 days prior to 12/19/2023 which would be 11/19/2023
              • A lapse would not be applied
              • Original effective date of PTAN would be used

              Sole Owners

              • If you are a sole owner, meaning you have type 1 and a type 2 NPI, must revalidate BOTH enrollments at same time
                • This will apply even if one of enrollments has not been asked to revalidate
                • In PECOS it will show as an 855I for the individual and an 855B for the group enrollment. If only one is submitted, a development request will be sent asking for the additional application

                Application Submission

                • The fastest and most efficient way to submit revalidation information is via Internet-based PECOS Web. Applications can also be submitted via the paper CMS-855 forms.
                • After logging in, select My Associates, View Enrollments next to the enrollment the needs to Revalidate, select Revalidate in the Existing Enrollments Box. Go through application to ensure all information is correct
                • Complete all sections of CMS-855B, even if nothing has changed
                • List all current, active practice locations
                • Use boxes/fields to indicate change, add, delete, and list an effective date
                • Attach or upload all supporting documentation such as IRS document and/or voided check/bank letter
                • PECOS application
                • CMS-855I
                • CMS-588 EFT (If no revalidation has been completed in the past)
                • After logging in, select My Associates, View Enrollments next to the enrollment the needs to Revalidate, select Revalidate in the Existing Enrollments Box. Go through application to ensure all information is correct
                • Complete sections 1, 2, 3, 4A1, 4A2, 4B-E, 6, 8, 13, and 15 of CMS-855I, even if nothing has changed
                • List all current, active practice locations
                • Use boxes/fields to indicate change, add, delete, and list an effective date
                • Include a contracted or W-2 managing employee
                • Attach or upload all supporting documentation such as Diploma, Internal Revenue Service (IRS) document, Certification and/or voided check/bank letter
                • PECOS Application
                • CMS-855I
                • CMS-588 EFT (If no revalidation has been completed in the past)
                • After logging in, select My Associates, View Enrollments next to the enrollment the needs to Revalidate, select Revalidate in the Existing Enrollments Box. Go through application to ensure all information is correct
                • Complete sections 1, 2, 3, 4A3, 4B-E, 6, 8, 13, and 15 of CMS-855I, even if nothing has changed
                • List all reassignments, if applicable, including other Organizations, PTANs, and NPIs in which provider renders services
                • List all current, active practice locations
                • Use boxes/fields to indicate change, add, delete, and list an effective date
                • List all directors, board members, and contracted or W-2 managing employee
                • Attach all supporting documentation such as Diploma, IRS document (if billing with EIN), Certification and/or voided check/bank letter
                • PECOS application
                • CMS-855I
                • After logging in, select My Associates, View Enrollments next to the enrollment the needs to Revalidate, select Revalidate in the Existing Enrollments Box. Go through application to ensure all information is correct
                • Complete sections 1, 2, 3, 4F, 13, and 15 of CMS 855I, even if nothing has changed
                • Complete sections 1, 2, 2I, 13 and 15 of CMS 855I for Physician Assistants (PAs), even if nothing has changed
                • List all reassignments including other Organizations, PTANs, and NPIs in which provider renders services
                • Attach or upload all supporting documentation such as Diploma and Certification

                Resources

                • Electronic Code of Federal Regulations
                • CMS Revalidation Information
                Last Updated Dec 26 , 2023

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