Medicare Program Integrity Manual 
Chapter 10  Medicare Enrollment
  
Table of Contents 
(Rev. 12209, 08-17-23) 
 
 
 
Transmittals for Chapter 10 
 
 
10.1  Introduction to Medicare Provider Enrollment  
10.1.1  Definitions 
10.1.2  Enrolling to Receive Medicare Payment  
10.1.3 - General Summary of Process to Enroll in Medicare  
10.1.4 - General Overview of Medicare Enrollment Application Forms 
10.2  Provider and Supplier Types/Services 
10.2.1  Certified Providers and Certified Suppliers That Enroll Via the Form    CMS-    
855A 
  10.2.1.1 - Community Mental Health Centers (CMHCs) 
10.2.1.2 - Comprehensive Outpatient Rehabilitation Facilities (CORFs)  
10.2.1.3 - End-Stage Renal Disease Facilities (ESRDs)  
10.2.1.4 - Federally Qualified Health Centers (FQHCs) 
10.2.1.5 - Histocompatibility Laboratories 
10.2.1.6 - Home Health Agencies (HHAs) 
  10.2.1.6.1  HHA Ownership Changes 
        10.2.1.6.2  HHA Capitalization 
10.2.1.7 - Hospices 
10.2.1.8 - Hospitals and Hospital Units 
        10.2.1.8.1  Rural Emergency Hospitals (REHs) 
10.2.1.9 - Indian Health Services (IHS) Facilities 
10.2.1.10 - Organ Procurement Organizations (OPOs) 
10.2.1.11 - Outpatient Physical Therapy/Outpatient Speech Pathology 
10.2.1.12 - Religious Non-Medical Health Care Institutions (RNHCIs) 
10.2.1.13  Rural Health Clinics (RHCs)  
10.2.1.14 - Skilled Nursing Facilities (SNFs)  
 
10.2.2 - Suppliers That Enroll Via the Form CMS-855B 
                        10.2.2.1 - Ambulatory Surgical Centers (ASCs)  
10.2.2.2  Home Infusion Therapy Suppliers 
10.2.2.3 - Independent Clinical Laboratory Improvement Act (CLIA) Labs   
10.2.2.4 - Independent Diagnostic Testing Facilities (IDTFs) 
10.2.2.5 - Intensive Cardiac Rehabilitation (ICR) 
10.2.2.6 - Mammography Screening Centers (MSCs)    
10.2.2.7 - Pharmacies     
10.2.2.8 - Portable X-Ray Suppliers (PXRSs) 
10.2.2.9 - Radiation Therapy Centers (RTCs)  10.2.2.10 - Suppliers of Ambulance Services 
 10.2.3 - Individual Practitioners Who Enroll Via the Form CMS-855I 
10.2.3.1. Anesthesiology Assistants 
10.2.3.2. Audiologists 
10.2.3.3 - Certified Nurse-Midwives 
10.2.3.4 - Certified Registered Nurse Anesthetists  
10.2.3.5 - Clinical Nurse Specialists 
10.2.3.6 - Clinical Psychologists 
10.2.3.7 - Clinical Social Workers 
10.2.3.8 - Nurse Practitioners 
10.2.3.9 - Occupational Therapists in Private Practice 
10.2.3.10 - Physical Therapists in Private Practice 
10.2.3.11 - Physicians 
10.2.3.12 - Physician Assistants  
10.2.3.13 - Psychologists Practicing Independently 
10.2.3.14 - Registered Dietitians/Nutrition Professionals 
10.2.3.15 - Speech Language Pathologists in Private Practice 
10.2.3.16 - Manufacturers of Replacement Parts/Supplies for Prosthetic 
Implants or Implantable Durable Medical Equipment (DME) Surgically 
Inserted at an Ambulatory Surgical Center (ASC) 
10.2.4 - Other Medicare Part B Services 
10.2.5  Suppliers That Enroll Via the Form CMS-855S 
     10.2.5.1 - DMEPOS Supplier Accreditation 
10.2.5.2  Fraud Level Indicators for DMEPOS Suppliers - Development and Use 
                        10.2.5.3  Surety Bonds 
10.2.5.3.1  Basics of the Surety Bond Requirement 
10.2.5.3.2  Claims against Surety Bonds 
10.2.5.4  Indian Health Services (IHS) Facilities Enrollment as DMEPOS 
Suppliers 
  10.2.5.5  Pharmacy Enrollment as a DMEPOS Supplier  Accreditation 
10.2.6 - Medicare Diabetes Prevention Program (MDPP) Suppliers 
10.2.7 - Opioid Treatment Programs   
10.2.8 - Providers/Suppliers Not Eligible to Enroll 
10.3  Medicare Enrollment Forms  Information, Processing, and PECOS 2.0  
   10.3.1 - CMS-855 Series Enrollment Forms: Information and Processing 
10.3.1.1  Form CMS-855A  Medicare Enrollment Application for Institutional 
Providers  
10.3.1.1.1  Section 1 (Basic Information) - Form CMS-855A   
10.3.1.1.2 - Section 2 (Identifying Information) - Form CMS-855A 
10.3.1.1.3 - Section 3 (Final Adverse Legal Actions/Convictions) - Form 
CMS-855A 
10.3.1.1.4 - Section 4 (Practice Location Information) - Form CMS-855A 
10.3.1.1.5 - Sections 5 and 6 (Ownership Interest and/or Managing 
Control Information) - Form CMS-855A 
10.3.1.1.6 - Section 7 (Chain Home Office Information) - Form CMS-
855A 
10.3.1.1.7 - Section 8 (Billing Agency Information) - Form CMS-855A  10.3.1.1.8 - Section 12 (Special Requirements for Home Health Agencies) 
- Form CMS-855A 
10.3.1.1.9 - Sections 13 and 14 (Contact Person and Penalties for 
Falsifying Information) - Form CMS-855A 
10.3.1.1.10 - Certification Statement - Form CMS-855A 
10.3.1.1.11 - Section 15 (Authorized Officials) - Form CMS-855A 
10.3.1.1.12 - Section 16 (Delegated Officials) - Form CMS-855A 
10.3.1.1.13 - Additional Form CMS-855A Processing Information 
10.3.1.1.14 - Form CMS-855A Processing Alternatives 
10.3.1.2 - Form CMS-855B Medicare Enrollment Application for Clinics, Group 
Practices, and Certain Other Suppliers 
10.3.1.2.1 - Section 1 (Basic Information) - Form CMS-855B 
10.3.1.2.2 - Section 2 (Identifying Information) - Form CMS-855B 
10.3.1.2.3 - Section 3 (Final Adverse Legal Actions/Convictions) - Form 
CMS-855B 
10.3.1.2.4 - Section 4 (Practice Location Information)  Form CMS-855B 
10.3.1.2.5 - Sections 5 and 6 (Ownership Interest and/or Managing 
Control Information) - Form CMS-855B 
10.3.1.2.6 - Sections 8, 13, and 14 (Billing Agencies, Contact Persons, and 
Penalties for Falsifying Information) - Form CMS-855B 
10.3.1.2.7 - Certification Statement - Form CMS-855B 
10.3.1.2.8 - Section 15 (Authorized Officials) - Form CMS-855B 
10.3.1.2.9 - Section 16 (Delegated Officials) - Form CMS-855B 
10.3.1.2.10 - Additional Form CMS-855B Processing Information 
10.3.1.3 - Form CMS-855I  Medicare Enrollment Application for Physicians and 
Non-Physician Practitioners 
10.3.1.3.1 - Section 1 (Basic Information)  Form CMS-855I 
10.3.1.3.2 - Section 2 (Personal Identifying Information)  Form CMS-
855I 
10.3.1.3.3 - Section 3 (Final Adverse Legal Actions/Convictions) - Form 
CMS-855I 
10.3.1.3.4 - Section 4 (Business Information) - Form CMS-855I 
10.3.1.3.5 - Sections 6, 8, 12, 13, and 14 - Form CMS-855I 
10.3.1.3.6 - Section 15 (Certification Statement) - Form CMS-855I 
10.3.1.3.7/Additional Processing Information and Alternatives  Form 
CMS-855I 
10.3.1.4 - Medicare Enrollment Application for Reassignment of Medicare 
Benefits  Form CMS-855R   
                 10.3.1.4.1 - Sections 1 through 5 of the Form CMS-855R 
10.3.1.4.2 - Section 6 (Certification Statements and Signatures) - Form 
CMS-855R 
10.3.1.4.3 - Additional Form CMS-855R Policies and Processing 
Alternatives 
10.3.1.5 - Form CMS-855O  Medicare Enrollment Application for Eligible 
Ordering and Certifying Physicians, and other Eligible Professionals 
      10.3.1.5.1 - Sections 1 through 7 of the Form CMS-855O 
      10.3.1.5.2 - Section 8 (Certification Statement) - Form CMS-855O 
10.3.1.5.3 - Form CMS-855O Initial Applications and Change Requests  10.3.1.5.4 - Form CMS-855O Processing Alternatives and Miscellaneous 
Policies 
      10.3.1.5.5 - Form CMS-855O Revocations 
10.3.1.6 - Form CMS-855S  Medicare Enrollment Application for Durable 
Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers 
      10.3.1.6.1 - Sections 1 through 13  Form CMS-855S 
      10.3.1.6.2 - Authorized and Delegated Officials  Form CMS-855S 
10.3.1.6.3 - Additional Processing Information and Alternatives for Form 
CMS-855S 
10.3.2  CMS-20134  Enrollment Form: Information and Processing 
10.3.2.1  CMS-20134 (Section 1 - Basic Information)   
10.3.2.2  CMS-20134 (Section 2 - Identifying Information)   
10.3.2.3  CMS-20134 (Section 3 - Final Adverse Legal Actions/Convictions)   
10.3.2.4  CMS-20134 (Section 4 - MDPP Location Information)  
10.3.2.5  CMS-20134 (Sections 5 & 6 - Owning and Managing 
Organizations and Individuals)   
10.3.2.6  Reserved for Future Use   
10.3.2.7  CMS-20134 (Section 7 - Coach Roster)   
10.3.2.8  CMS-20134 (Section 8 - Billing Agency Information)   
10.3.2.9  CMS-20134 (Section 13 - Contact Person) 
10.3.2.10  CMS-20134 (Section 14 - Penalties for Falsifying Information)  
10.3.2.11  CMS-20134 (Section 15 - Certification Statement and 
Authorized Officials)  
10.3.2.12  CMS-20134 (Section 16 - Delegated Officials) 
10.3.2.13  CMS-20134 (Section 17 - Supporting Documents)  
10.3.2.14  Additional Form CMS-20134 Processing Information and 
Alternatives 
10.3.3  Other Enrollment Forms: Information and Processing  
10.3.3.1  Form CMS-588  Electronic Funds Transfer (EFT) Authorization 
Agreement  
10.3.3.2  Form CMS-460  Medicare Participating Physician or Supplier 
Agreement  
10.4  Medicare Enrollment: Contractor Processing Duties 
  10.4.1  General Processing Functions 
     10.4.1.1  Overview of the Process 
     10.4.1.2  Receipt of Application 
     10.4.1.3  Review of Application 
       10.4.1.3.1  Initial Steps of Review of Application 
       10.4.1.3.2  Data Verification 
10.4.1.3.3  Requesting Missing/Clarifying Data/Documentation 
(Development)  
10.4.1.3.4 - Receiving Missing/Clarifying Data/Documentation (Response 
to Development)  
10.4.1.3.5  Provider/Supplier Fails to Submit Requested 
Data/Documentation  
10.4.1.4  Application Disposition  
10.4.1.4.1  Approvals  
10.4.1.4.2 - Returns   10.4.1.4.3 - Rejections 
10.4.2 - Denials  
10.4.2.1 - Denials  General Principles 
10.4.2.2 - Denial Reasons 
10.4.2.3  Additional Denial Policies 
  10.4.2.3.4  Denial Based on Survey Failure 
10.4.3  Voluntary and Involuntary Terminations 
10.4.4  Changes of Information 
10.4.5  Revalidations 
10.4.5.1  Revalidation Solicitations 
10.4.5.2  Non-Responses to Revalidation and Extension Requests 
10.4.5.3  Receipt and Processing of Revalidation Applications 
10.4.6  Reactivations  
10.4.7  Revocations  
10.4.7.1  Revocations  Background and General Requirements  
10.4.7.2  Revocation Effective Dates and Miscellaneous Policies 
10.4.7.3  Revocation Reasons 
10.4.7.4  Reenrollment Bar  
10.4.7.5  Additional Revocation Policies  
10.4.8  Deactivations   
10.4.8.1  Deactivation Rebuttals 
10.5  Timeliness and Accuracy Standards 
10.6  Additional Topics Pertaining to Medicare Enrollment 
  10.6.1  Certified Providers/Certified Suppliers 
10.6.1.1  Changes of Ownership (CHOWs)  Transitioned  Certified Providers 
and Suppliers 
Nursing Facilities (SNFs) 
 10.6.1.1.1  General Background on CHOWs  
10.6.1.1.2  Examples of CHOW and Non-CHOW Situations 
10.6.1.1.3  Ascertaining Whether a CHOW Has Occurred  
10.6.1.1.3.1  Step 1 - Initial Review of the CHOW Application 
10.6.1.1.3.1.1  Special Processing Instructions and 
Considerations for the Initial Review Process 
10.6.1.1.3.2  Step 2  Post-Initial Review Actions and Scenarios 
10.6.1.1.3.3  Step 3  Post-State Review Actions and Scenarios 
10.6.1.1.4  Additional CHOW Processing Policies 
10.6.1.2 Changes of Information  Transitioned Certified 
Providers and Suppliers 
    10.6.1.3  Voluntary Terminations 
  10.6.2  Establishing Effective Dates 
  10.6.3  Legal Business Name 
  10.6.4  Provider and Supplier Business Structures 
  10.6.5  National Provider Identifier (NPI) 
  10.6.6  Final Adverse Actions 
  10.6.7  Owning and Managing Information 
    10.6.7.1  Organizational Owning and Managing Information 
10.6.7.2  Individual Owning and Managing Information 
10.6.7.3  Owning and Managing Information  Tax Identification Numbers  (TINs) 
  10.6.8  Billing Agencies 
  10.6.9  Contact Persons 
  10.6.10  Medicare Payment 
  10.6.11  Participation (Par) Agreements and the Acceptance of Assignment 
  10.6.12  Opting-Out of Medicare 
  10.6.13  Ordering/Certifying Suppliers 
  10.6.14  Application Fees 
  10.6.15  Risk-Based Screening 
  10.6.16  Temporary Moratoria 
  10.6.17  Deceased Practitioners 
10.6.18  Appeals Process 
10.6.19  Other Medicare Contractor Duties 
  10.6.20  Screening: On-Site Inspections and Site Verifications 
10.6.21  Miscellaneous Enrollment Topics  
10.6.21.1  Additional Miscellaneous Enrollment Topics 
   10.6.22  Non-Transitioned Certified Provider/Supplier Changes of Ownership 
10.6.22.1 - Non-Transitioned Certified Provider/Supplier Changes of Information  
 10.6.23  Special Instructions for Electronic Funds Transfer (EFT) Accounts and 
Special Payment Addresses 
10.7  Model Letters 
            10.7.1  Acknowledgement Letters 
10.7.2  Development Letters 
10.7.3  Approval Letters 
10.7.4  DME Approval Letter Templates 
10.7.5  Part A/B Certified Provider Approval Letter Templates 
10.7.5.1  Part A/B Certified Provider and Supplier Letter Templates  Post-         
Transition             
10.7.5.1.1  Additional Certified Provider and Certified Supplier Letters  
10.7.6  Part B Non-Certified Supplier Approval Letter Templates 
10.7.7  Application Return and Rejection Model Letters 
 
10.7.8 Denial Model Letters 
10.7.9  Revocation Letters 
10.7.10  Corrective Action Plan (CAP) Model Letters 
10.7.11  Reconsideration Request Model Letters 
10.7.12  Deactivation Model Letters 
10.7.13  Rebuttal Model Letters 
10.7.14  Model Opt-Out Letters 
10.7.15  Revalidation Notification Letters 
10.7.16  Model Letters for Claims Against Surety Bonds 
10.7.17  Model Identity Theft Prevention Letter 
10.7.18  Model Documentation Request Letter 
10.7.19  ESRD Approval Letters 
 
  10.1  Introduction to Medicare Provider Enrollment                           
(Rev. 11859; Issued: 02-16-23; Effective: 03-17-23; Implementation: 03-17-23) 
 
This chapter specifies the resources and procedures Medicare Administrative Contractors 
(MACs) must use to establish and maintain provider and supplier enrollment in the Medicare 
program.  These procedures apply to the MACs (hereafter occasionally referred to collectively as 
simply the contractor), unless contract specifications state otherwise. 
 
10.1.1  Definitions                                                                                   
(Rev. 11808; Issued: 01-24-23; Effective: 01-01-23; Implementation: 01-03-23) 
 
Below is a list of terms commonly used in the Medicare enrollment process: 
 
Accredited provider/supplier means a supplier that has been accredited by a CMS-designated 
accreditation organization. 
 
Add  For purposes of completing the Form CMS-855 or Form CMS-20134 enrollment 
applications, you are adding enrollment information to your existing enrollment record (e.g., 
practice locations). When adding a practice location, an application fee may be required for 
applicable institutions.  (For further information, see the term institutional provider as defined 
in 42 CFR  424.502, the application fee requirements in 42 CFR  424.514, and the application 
fee guidance in section 10.6.14 of this chapter.) 
 
Administrative location means a physical location associated with a Medicare Diabetes 
Prevention Program (MDPP) suppliers operations from where: (1) coaches are dispatched or 
based; and (2) MDPP services may or may not be furnished. 
 
Advanced diagnostic imaging service means any of the following diagnostic services: 
 
(i)  Magnetic Resonance Imaging (MRI) 
(ii)  Computed Tomography (CT) 
(iii) Nuclear Medicine 
(iv) Positron Emission Tomography (PET) 
 
Applicant means the individual (practitioner/supplier) or organization who is seeking enrollment 
into the Medicare program. 
 
Approve/Approval means the enrolling provider or supplier has been determined to be eligible 
under Medicare rules and regulations to: (1) receive a Medicare billing number and be granted 
Medicare billing privileges; or (2) enroll to solely order, certify, or refer the items or services 
described in 42 CFR  424.507. 
 
Authorized official (as defined by 42 CFR  424.502) means an appointed official (for example, 
chief executive officer, chief financial officer, general partner, chairman of the board, or direct 
owner) to whom the organization has granted the legal authority to enroll it in the Medicare 
program, to make changes or updates to the organization's status in the Medicare program, and to  commit the organization to fully abide by the statutes, regulations, and program instructions of 
the Medicare program. 
 
Billing agency means an entity that furnishes billing and collection services on behalf of a 
provider or supplier.  A billing agency is not enrolled in the Medicare program.  A billing agency 
submits claims to Medicare in the name and billing number of the provider or supplier that 
furnished the service or services.  In order to receive payment directly from Medicare on behalf 
of a provider or supplier, a billing agency must meet the conditions described in  1842(b)(6)(D) 
of the Social Security Act.  (For further information, see CMS Publication (Pub.) 100-04, Claims 
Processing Manual, chapter 1, section 30.2.4.) 
 
Change - For purposes of completing the Form CMS-855 or CMS-20134 enrollment 
applications, you are replacing existing information with new information (e.g. practice location, 
ownership) or updating existing information (e.g. change in suite #, telephone #).  If you are 
changing a practice location an application fee is not required. 
 
Change in majority ownership occurs when an individual or organization acquires more than a 
50 percent direct ownership interest in a home health agency (HHA) during the 36 months 
following the HHAs initial enrollment into the Medicare program or the 36 months following 
the HHAs most recent change in majority ownership (including asset sales, stock transfers, 
mergers, or consolidations). This includes an individual or organization that acquires majority 
ownership in an HHA through the cumulative effect of asset sales, stock transfers, 
consolidations, or mergers during the 36-month period after Medicare billing privileges are 
conveyed or the 36-month period following the HHAs most recent change in majority 
ownership.  (See 42 CFR  424.550(b) for more information on HHA changes of ownership.)  
 
Change of ownership (CHOW) is defined in 42 CFR  489.18(a) and generally means, in the 
case of a partnership, the removal, addition, or substitution of a partner, unless the partners 
expressly agree otherwise, as permitted by applicable State law. In the case of a corporation, the 
term generally means the merger of the provider corporation into another corporation, or the 
consolidation of two or more corporations, resulting in the creation of a new corporation. The 
transfer of corporate stock or the merger of another corporation into the provider corporation 
does not constitute a change of ownership. 
 
CMS-approved accreditation organization means an accreditation organization designated by 
CMS to perform the accreditation functions/deeming activities specified. (See 42 CFR  488.1 
and 488.5 for more information on accrediting organizations.) 
 
Coach means an individual who furnishes MDPP services on behalf of an MDPP supplier as an 
employee, contractor, or volunteer. 
 
Community setting means a location where the MDPP supplier furnishes MDPP services outside 
of its administrative locations in meeting locations open to the public. A community setting is a 
location not primarily associated with the supplier where many activities occur, including, but 
not limited to, MDPP services.  Community settings may include, for example, church 
basements or multipurpose rooms in recreation centers.   
  Deactivate means that the provider or suppliers billing privileges were stopped, but can be 
restored upon the submission of updated information. 
 
Delegated official (as defined by 42 CFR  424.502) means an individual who is delegated by 
the Authorized Official the authority to report changes and updates to the provider/suppliers 
enrollment record. The delegated official must be an individual with an ownership or control 
interest in (as that term is defined in section 1124(a)(3) of the Social Security Act), or be a W-2 
managing employee of, the provider or supplier. 
 
Delete/Remove  For purposes of completing the Form CMS-855 enrollment and Form CMS-
20134 applications, you are removing existing enrollment information.  If you are deleting or 
removing a practice location, an application fee is not required. 
 
Deny/Denial means the enrolling provider or supplier has been determined to be ineligible to: (1) 
receive Medicare billing privileges; or (2) enroll to solely order, certify, or refer the items or 
services described in 42 CFR  424.507. 
 
Director means a director of a corporation, regardless of whether the provider or supplier is a 
non-profit entity.  This includes any member of the corporations governing body irrespective of 
the precise title of either the board or the member; said body could be a board of directors, board 
of trustees, or similar body. 
 
Effective Date means the date on which a providers or suppliers eligibility was initially 
established for the purposes of submitting claims for Medicare-covered items and services and/or 
ordering or certifying Medicare-covered items and services. (This is not the same as a 
reactivation effective date.)   
 
Eligible coach means an individual who CMS has screened and determined can provide MDPP 
services on behalf of an MDPP supplier. 
 
Enroll/Enrollment means the process that Medicare uses to establish eligibility to submit claims 
for Medicare-covered items and services, and the process that Medicare uses to establish 
eligibility to order or certify Medicare-covered items and services.  
 
Enrollment application means a paper Form CMS-855 or Form CMS-20134 enrollment 
application or the equivalent electronic enrollment process approved by the Office of 
Management and Budget (OMB). 
 
Final adverse legal action means the following:   
 
For purposes of the definition of this term in  424.502, final adverse action means one or more 
of the following: 
(1) A Medicare-imposed revocation of any Medicare billing privileges; 
(2) Suspension or revocation of a license to provide health care by any state licensing authority;  (3) Revocation or suspension by an accreditation organization; 
(4) A conviction of a federal or state felony offense (as defined in  424.535(a)(3)(i)) within the 
last 10 years preceding enrollment, revalidation, or re-enrollment; or 
(5) An exclusion or debarment from participation in a federal or state health care program. 
For purposes of the reporting requirements on the Form CMS-855 or Form CMS-20134, final 
adverse action means one or more of the following: 
 
Convictions (as defined in 42 CFR 1001.2) within the preceding 10 years 
 
1.  Any federal or state felony conviction(s). 
2.  Any misdemeanor conviction, under federal or state law, related to: (a) the delivery of an 
item or service under Medicare or a state health care program, or (b) the abuse or neglect of a 
patient in connection with the delivery of a health care item or service. 
3.  Any misdemeanor conviction, under federal or state law, related to the theft, fraud, 
embezzlement, breach of fiduciary duty, or other financial misconduct in connection with the 
delivery of a health care item or service. 
4.  Any misdemeanor conviction, under federal or state law, related to the interference with or 
obstruction of any investigation into any criminal offence described in 42 C.F.R. section 
1001.101 or 1001.201. 
5.  Any misdemeanor conviction, under federal or state law, related to the unlawful 
manufacture, distribution, prescription, or dispensing of a controlled substance. 
  
Exclusions, Revocations, or Suspensions 
 
1.  Any current or past revocation, suspension, or voluntary surrender of a medical license in 
lieu of further disciplinary action. 
2.  Any current or past revocation or suspension of accreditation. 
3.  Any current or past suspension or exclusion imposed by the U.S. Department of Health and 
Human Services Office of Inspector General (OIG). 
4.  Any current or past debarment from participation in any Federal Executive Branch 
procurement or non- procurement program. 
5.  Any other current or past federal sanctions. 
6.  Any Medicaid exclusion, revocation, or termination of any billing number. 
 
Immediate family member or member of a physician's immediate family means  under 42 CFR 
 411.351 - a husband or wife; birth or adoptive parent, child, or sibling; stepparent, stepchild, 
stepbrother, or stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-
law, or sister-in-law; grandparent or grandchild; and spouse of a grandparent or grandchild. 
 
Ineligible coach means an individual whom CMS has screened and determined cannot provide 
MDPP services on behalf of an MDPP supplier. 
 
Institutional provider means  for purposes of the Medicare application fee only - any provider 
or supplier that submits a paper Medicare enrollment application using the Form CMS855A,  Form CMS855B (not including physician and non-physician practitioner organizations), Form 
CMS855S, or associated Internet-based Provider Enrollment, Chain and Ownership System 
(PECOS) enrollment application. 
Legal business name is the name that is reported to the Internal Revenue Service (IRS). 
 
Managing employee means a general manager, business manager, administrator, director, or 
other individual who exercises operational or managerial control over, or who directly or 
indirectly conducts, the day-to-day operation of the provider or supplier, either under contract or 
through some other arrangement, whether or not the individual is a W-2 employee of the 
provider or supplier. 
 
Managing organization means an entity that exercises operational or managerial control over, or 
who directly or indirectly conducts, the day-to-day operations of the provider or supplier, either 
under contract or through some other arrangement.   
 
Medicare identification number - For Part A providers, the Medicare identification number is the 
CMS Certification Number (CCN).  For Part B suppliers the Medicare identification number is 
the Provider Transaction Access Number (PTAN).   
 
National Provider Identifier is the standard unique health identifier for health care providers 
(including Medicare suppliers) and is assigned by the National Plan and Provider Enumeration 
System (NPPES). 
 
Officer means an officer of a corporation, regardless of whether the provider or supplier is a non-
profit entity. 
 
Operational  under 42 CFR  424.502  means that the provider or supplier has a qualified 
physical practice location; is open to the public for the purpose of providing health care related 
services; is prepared to submit valid Medicare claims; and is properly staffed, equipped, and 
stocked (as applicable, based on the type of facility or organization, provider or supplier 
specialty, or the services or items being rendered) to furnish these items or services. 
 
Other eligible professional  as defined in 1848(k)(3)(B) of the Social Security Act  means: (i) a 
physician; (ii) a practitioner described in section 1842(b)(18)(C); (iii) a physical or occupational 
therapist or a qualified speech-language pathologist; or (iv) a qualified audiologist (as defined in 
section 1861(ll)(3)(B)).  (For (ii), practitioner is defined in section 1842(b)(18)(C) as a 
physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse 
anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, or registered 
dietitian or nutrition professional.) 
 
Owner means any individual or entity that has any partnership interest in, or that has 5 percent or 
more direct or indirect ownership of, the provider or supplier as defined in sections 1124 and 
1124(A) of the Social Security Act. 
 
Ownership or investment interest  under 42 CFR  411.354(b)  means an ownership or 
investment interest in the entity that may be through equity, debt, or other means, and includes 
an interest in an entity that holds an ownership or investment interest in any entity that furnishes 
designated health services.   
Physician means a doctor of medicine or osteopathy, a doctor of dental surgery or dental 
medicine, a doctor of podiatric medicine, a doctor of optometry, or a chiropractor, as defined in 
section 1861(r) of the Social Security Act. 
 
Physician-owned hospital  under 42 CFR  489.3  means any participating hospital in which a 
physician, or an immediate family member of a physician, has a direct or indirect ownership or 
investment interest, regardless of the percentage of that interest. 
 
Physician owner or investor  under 42 CFR  411.362(a)  means a physician (or an immediate 
family member) with a direct or an indirect ownership or investment interest in the hospital. 
 
Prospective provider means any entity specified in the definition of provider in 42 CFR  
498.2 that seeks to be approved for coverage of its services by Medicare. 
 
Prospective supplier means any entity specified in the definition of supplier in 42 CFR  
405.802 that seeks to be approved for coverage of its services under Medicare. 
 
Provider is defined at 42 CFR  400.202 and generally means a hospital, critical access hospital, 
skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency or 
hospice, that has in effect an agreement to participate in Medicare; or a clinic, rehabilitation 
agency, or public health agency that has in effect a similar agreement but only to furnish 
outpatient physical therapy or speech pathology services; or a community mental health center 
that has in effect a similar agreement but only to furnish partial hospitalization services. 
 
Reassignment means that an individual physician, non-physician practitioner, or other supplier 
has granted a Medicare-enrolled provider or supplier the right to receive payment for the 
physicians, non-physician practitioners or other suppliers services.  (For further information, 
see  1842(b)(6) of the Social Security Act, the Medicare regulations at 42 CFR 424.70 - 
424.90, and CMS Pub. 100-04, chapter 1, sections 30.2  30.2.16.) 
 
Reject/Rejected means that the provider or suppliers enrollment application was not processed 
due to incomplete information or that additional information or corrected information was not 
received from the provider or supplier in a timely manner.  (See 42 CFR  424.525 for more 
information.) 
 
Retrospective Billing Privileges means that certain Part B suppliers can bill retrospectively for 
up to 30 or 90 days prior to their enrollment effective date as described in 42 CFR  424.520(d) 
and 424.521(a). 
 
Revoke/Revocation means that the providers or suppliers billing privileges are terminated. 
 
Supplier is defined in 42 CFR  400.202 and means a physician or other practitioner, or an entity 
other than a provider that furnishes health care services under Medicare. 
 
Tax identification number means the number (either the Social Security Number (SSN) or 
Employer Identification Number (EIN) that the individual or organization uses to report tax 
information to the IRS.   
10.1.2  Enrolling to Receive Medicare Payment  
(Rev. 10672; Issued: 03-18-21; Effective: 03-12-21; Implementation: 03-22-21) 
 
No provider or supplier shall receive payment for services furnished to a Medicare beneficiary 
unless the provider or supplier is enrolled in the Medicare program.  Further, it is essential that 
each provider and supplier enroll with the appropriate Medicare Administrative Contractor.  We 
use the term enrollment generally to include activities a provider or supplier undertakes to 
enroll in the Medicare program and maintain enrollment in good standing, which includes, but is 
not limited to, initially enrolling, revalidating enrollment, and reporting changes of information 
as described within this chapter.  
 
A. Initial Enrollment 
 
In general, a provider or supplier shall enroll as an initial applicant if it is:  
 
  Initially enrolling in the Medicare program or enrolling as a provider or supplier in a new 
geographic jurisdiction.  
 
  Seeking to reestablish itself in the Medicare program after a voluntary withdrawal from 
the Medicare program, or subsequent to a termination or revocation of enrollment based upon 
any CMS authority under Title 42 of the CFR.   
 
For additional information, refer to sections of this chapter concerning unique provider and 
supplier types, the applications that correspond to Medicare enrollment by provider/supplier type 
and purpose, and a general discussion of enrollment topics.  
 
B. Revalidation 
 
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 3 years and all other providers and suppliers every 5 years.   
 
C. Changes of Information 
 
Consistent with 42 CFR  424.516, providers and suppliers use the CMS enrollment application 
process to report changes of information as required to remain in compliance with the 
requirements to participate in Medicare.   
 
10.1.3 - General Summary of Process to Enroll in Medicare  
(Rev. 10672; Issued: 03-18-21; Effective: 03-12-21; Implementation: 03-22-21) 
 
Providers and suppliers, including physicians, may enroll or update their Medicare enrollment 
record using the: 
 
  Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or   
  Paper enrollment application process (e.g., Form CMS-855). 
 
The Medicare enrollment applications are issued by CMS and approved by the Office of 
Management and Budget.  
 
Paper applications can be accessed at the Web site https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/MedicareProviderSupEnroll/EnrollmentApplications.html. 
 
PECOS can be accessed at https://pecos.cms.hhs.gov/pecos/login.do. 
 
Web Sites 
 
The contractor must link to CMS provider/supplier enrollment Web site located at 
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/MedicareProviderSupEnroll/index.html?redirect=/MedicareProviderSupEnroll/. 
The link shall: (1) be available on the contractors existing provider outreach Web site (which 
should be an established sub-domain of the contractors current commercial Web site); and (2) 
comply with the guidelines stated in the Provider/Supplier Information and Education Web site 
section (Activity Code 14101) under the Provider Communications Budget and Performance 
Requirements.  Bulletins, newsletters, seminars/workshops and other information concerning 
provider enrollment issues shall also be made available on the existing provider outreach Web 
site.  All contractor Web sites must comply with section 508 of the Rehabilitation Act of 1973 in 
accordance with, 36 CFR 1194, and must comply with CMS Contractor Web site Standards 
and Guidelines posted on CMSs Web site. 
 
The CMS Provider/Supplier Enrollment Web site, https://www.cms.gov/Medicare/Provider-
Enrollment-and-
Certification/MedicareProviderSupEnroll/index?redirect=/MedicareProviderSupEnroll/, 
furnishes the user with access to provider/supplier enrollment forms, specific requirements for 
provider/supplier types, manual instructions, frequently asked questions (FAQs), contact 
information, hot topics, and other pertinent provider/supplier information.  The contractor shall 
not duplicate content already provided at the CMS provider/supplier enrollment Web site and 
shall not reproduce the forms or establish the contractors own links to forms.  It shall, however, 
have a link on its Web site that goes directly to the forms section of the CMS provider/supplier 
enrollment site. 
 
On a quarterly basis (specifically, no later than the 15th day of January, April, July, and October), 
each contractor shall review and provide updates regarding its contact information shown at 
URL: https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/MedicareProviderSupEnroll/Downloads/contact_list.pdf  
 
If the contractor services several states with a universal address and telephone number, the 
contractor shall report that information.  In situations where no actions are required, a response 
from the contractor is still required (i.e., the contact information is accurate).  In addition, only 
such information that pertains to provider enrollment activity for the contractors jurisdiction is  to be reported.  All updates shall be sent directly via e-mail to the contractors CMS Provider 
Enrollment & Oversight Group Business Function Lead. 
 
10.1.4 - General Overview of Medicare Enrollment Application Forms 
(Rev. 11859; Issued: 02-16-23; Effective: 03-17-23; Implementation: 03-17-23) 
 
The enrollment applications are available online as well as in paper form: 
 
A. General Overview of Form CMS-855 and CMS-20134 
 
Each Form CMS-855 application is used to enroll a specific provider or supplier type for a 
specific purpose. 
 
1.  CMS-855A  Medicare Enrollment Application for Institutional Providers 
 
This application should be completed by institutional providers (e.g., hospitals) that will furnish 
Medicare Part A services to beneficiaries. 
 
2.  CMS-855B Medicare Enrollment Application for Clinics, Group Practices, and Certain 
Other Suppliers 
 
This application should be completed by supplier organizations (e.g., ambulance companies) that 
will bill Medicare for Part B services furnished to Medicare beneficiaries. It is not used to enroll 
individuals. 
 
3.  CMS-855I - Medicare Enrollment Application for Physicians and Non-Physician 
Practitioners 
 
This application should be completed by physicians and non-physician practitioners who render 
Medicare Part B services to beneficiaries.  (This includes a physician or practitioner who is: (1) 
the sole owner of a professional corporation, professional association, or limited liability 
company and will bill Medicare through this business entity; or (2) a sole proprietor.) (See 
section 10.6.4 of this chapter for more information on the business types discussed in this 
paragraph.)  
 
4.  CMS-855R - Medicare Enrollment Application for Reassignment of Medicare Benefits 
 
An individual who renders Medicare Part B services and seeks to reassign his or her benefits to 
an eligible entity should complete this form for each entity eligible to receive reassigned 
benefits.  The individual must be enrolled in the Medicare program as an individual prior to 
reassigning his or her benefits. 
 
5.  CMS-855S  Medicare Enrollment Application for Durable Medical Equipment, 
Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers 
 
This application should be completed by DMEPOS suppliers.   
  6. CMS-855O  Medicare Enrollment Application for Eligible Ordering, Certifying 
Physicians, and other Eligible Professionals 
 
This form is used for physicians and other eligible professionals who wish to register in Medicare 
solely for the purpose of ordering and certifying the items and services described in 42 CFR  
424.507. These physicians and other eligible professionals do not and will not send claims to a 
MAC for any services they furnish. 
 
7. CMS-20134  Medicare Enrollment Application for Medicare Diabetes Prevention 
Program (MDPP) Suppliers  
 
This application should be completed by any supplier organizations that will furnish and bill 
Medicare Part B for the MDPP services furnished to Medicare beneficiaries.   
 
B. General Overview of Additional Enrollment Forms  
 
The following forms or form types are routinely submitted with an enrollment application: 
 
1.  CMS-588  Electronic Funds Transfer (EFT) Authorization Agreement  
 
The EFT Agreement authorizes CMS to deposit Medicare payments directly into a 
provider/suppliers bank account.   
 
For Form CMS-855S enrollments, CMS only requires collection of the Form CMS-588 with 
initial enrollment applications. 
 
2.   CMS-460  Medicare Participating Physician or Supplier Agreement 
 
This agreement establishes that the Medicare provider/supplier accepts assignment of the 
Medicare Part B payment for all services for which the participant is eligible to accept 
assignment under the Medicare law and regulations and which are furnished while the agreement 
is in effect. The contractor shall explain to the provider or supplier the purpose of the agreement 
and how it differs from the actual enrollment process.  (This only applies to suppliers that 
complete the Forms CMS-855B, CMS-855I and CMS-855S.)   
 
3.  CMS Standard Electronic Data Interchange (EDI) Enrollment Form 
 
See CMS Publication 100-04, Medicare Claims Processing Manual, chapter 24, sections 30 - 
30.5 for further information. 
 
4.  State-Specific Forms for Certified Providers/Certified Suppliers 
 
If the applicant is a certified supplier or certified provider, it will need to contact the state agency 
for any state-specific forms and to begin preparations for a state survey.  (This does not apply to 
those certified entities, such as federally qualified health centers, that do not receive a state 
survey.)   
  10.2  Provider and Supplier Types/Services                                                    
(Rev. 10672; Issued: 03-18-21; Effective: 03-12-21; Implementation: 03-22-21) 
 
The contractor shall consult other Medicare manuals for more information on how these 
providers and suppliers bill Medicare, their conditions of coverage, their conditions of 
participation, etc. 
 
Provider and supplier specialty codes can be found at CMS Publication 100-04, chapter 26, 
sections 10.8 through 10.8.3. 
 
10.2.1  Certified Providers and Certified Suppliers That Enroll Via the Form 
CMS-855A 
(Rev. 11139; Issued: 11-23-21; Effective: 10-15-21; Implementation: 01-03-22) 
 
(For purposes of sections 10.2.1.1 through 10.2.1.14, the term SOG Locations refers to CMS 
Survey & Operations Group (SOG) Locations (formerly CMS Regional Offices)). 
 
Sections 10.2.1.1 through 10.2.1.14 address the specific types of providers and suppliers that 
complete the Form CMS-855A.  While these sections mostly address the unique statutory and 
regulatory requirements for these types, some of them also contain detailed application 
processing instructions, which the contractor shall follow.   
 
10.2.1.1 - Community Mental Health Centers (CMHCs) 
(Rev. 11574; Issued: 08-25-22; Effective:  06-24-22; Implementation: 09-27-22) 
 
A.  General Background Information 
 
A CMHC is a facility that provides mental health services.  A CMHC must perform certain core 
services.  These are: 
 
1.   Outpatient services (This includes services for (a) children, (b) the elderly, (c) persons who 
are chronically mentally ill, and (d) certain persons who have been discharged from a mental 
health facility for inpatient treatment.) 
 
2.   24-hour-a-day emergency psychiatric services;  
 
3.   Day treatment or other partial hospitalization (PH) services, or psychosocial rehabilitation 
services; and 
 
4.   Screening for patients being considered for admission to state mental health facilities. 
 
NOTE:  Partial hospitalization is the only core service for which a CMHC can bill Medicare as a 
CMHC.  Thus, while a facility must furnish certain core services in order to qualify as a 
CMHC, it can only get reimbursed for one of them  partial hospitalization.  However, the 
facility may still be able to enroll in Medicare as a Part B clinic if it does not perform partial 
hospitalization services.   
In some instances, these core services can be furnished under arrangement.  This generally 
means that the facility can arrange for another facility to perform the service if, among other 
things, CMS determines that the following conditions are met: 
 
  The CMHC arranging for the particular service is authorized by State law to perform the         
service itself; 
 
  The arranging CMHC accepts full legal responsibility for the service; and 
 
  There is a written agreement between the two entities 
 
While the CMHC generally has the option to furnish services under arrangement, there is 
actually an instance where the facility must do so.  If the CMHC is located in a state that 
prohibits CMHCs from furnishing screening services (service (4) above), it must contract with 
another entity to have the latter perform the services.  Any such arrangement must be approved 
by the SOG Location. (See CMS Pub. 100-07, State Operations Manual, chapter 2, section 2250 
for additional information on core services and arrangements.) 
 
A CMHC must provide mental health services principally to individuals who reside in a defined 
geographic area (service area); that is, it must service a distinct and definable community.   
 
B.  Initial Enrollment and Certification 
 
1.   Introduction 
 
As of October 29, 2014, CMHCs are required to meet the conditions of participation outlined in 
42 CFR Part 485, subpart J.  CMHCs, like many other types of certified providers and certified 
suppliers, are therefore required to undergo a state survey as part of the certification and 
enrollment process.  The SOG Location no longer performs the site visit nor does the CMHC 
need to submit the previously-required attestation statement.  Except as otherwise noted in this 
chapter 10 or in another CMS directive, CMHC initial applications shall  on and after October 
29, 2014 - be processed in the same manner as those for all other certified providers.  
 
2.  Processing Instructions for CMHC Initial Form CMS-855A Applications 
 
In the past, the SOG Location had vital functions in reviewing CMHC requests for Medicare 
participation and finalizing CMS decision. With the transition of certain SOG activities to the 
state agencies, the contractors, and CMS PEOG, however, the operational process of reviewing 
CMHC requests for participation and enrollment now generally involves (and with exceptions) 
the following: 
 
  The contractor sends the enrollment application (and all supporting documentation) and its 
recommendation for approval to the state for review 
  The state notifies the contractor of its recommendation  
  A site visit is performed    The contractor notifies PEOG of the recommendation.  PEOG signs the provider agreement 
and performs other administrative functions pertaining to the enrollment  
  Once PEOG completes the required administrative actions, PEOG will notify the contractor 
thereof  
  The contractor completes processing and notifies the provider of the approval of the 
transaction using the appropriate model letter (sending a copy thereof to the state). 
 
(Thus, and except as otherwise stated, SOG Locations are no longer involved in the CMHC 
initial application process for Form CMS-855As.) 
 
Specific details on these steps are outlined in this section 10.2.1.1(B)(2).  Said instructions take 
precedence over any conflicting processing directives in this chapter.   
 
i.  Receipt of Application  
 
Upon receipt of a CMHC initial Form CMS-855A application, the contractor shall undertake the 
following (in whichever order the contractor prefers unless directed otherwise in this chapter): 
 
(A) Perform all data validations otherwise required per this chapter.    
 
(B) Ensure that the application(s) is complete consistent with the instructions in this chapter. 
 
(C) Ensure that the CMHC has submitted all documentation otherwise required per this chapter.  
For CMHC initial enrollment, this also includes the following: 
 
  Form CMS-1561 (Health Insurance Benefit Agreement, also known as a provider 
agreement)   
 
  Evidence of successful electronic submission of the Form HHS-690 through the Office of 
Civil Rights (OCR) portal, as applicable.  (Evidence should be either written or electronic 
documentation.) (See https://www.hhs.gov/sites/default/files/forms/hhs-690.pdf for more 
information.)   
 
(The CMHC must complete, sign, date, and include the Form CMS-1561, though the CMHC 
need not complete those sections of the form reserved for CMS.  For organizational CMHCs, an 
authorized official (as defined in  424.502) must sign the form; for sole proprietorships, the sole 
proprietor must sign.)   
 
Notwithstanding the foregoing, if the Form CMS-1561 or the Form HHS-690 evidence is 
missing, unsigned, undated, or otherwise incomplete, the contractor need not develop for the 
form(s) or the information thereon; the contractor shall instead notify the state in its 
recommendation letter which document(s) was/were missing or otherwise incomplete. For all 
other missing or incomplete required documentation, the contractor shall follow the normal 
development instructions in this chapter. 
 
ii.  Conclusion of Initial Contractor Review 
  (Nothing in this section 10.2.1.1(B)(2) prohibits the contractor from returning or rejecting the 
CMHC application if otherwise permitted to do so per this chapter.  When returning or rejecting 
the application, the contractor shall follow this chapters procedures for doing so.)     
 
(A) Approval Recommendation 
 
If, consistent with the instructions in section 10.2.1.1(B)(2) and this chapter, the contractor 
believes an approval recommendation is warranted, the contractor shall send the 
recommendation to the state pursuant to existing practice and this chapters instructions.  The 
contractor need not copy the SOG Location or PEOG on the recommendation.  Unless CMS 
directs otherwise, the contractor shall also send to the provider the notification letter in section 
10.7.5.1(E) of this chapter. 
 
The state will: (1) review the recommendation package for completeness; (2) review the 
contractors recommendation for approval; (3) perform any state-specific functions; and (4) 
contact the contractor with any questions.  The contractor shall respond to any state inquiry in 
Item (4) within 5 business days.  If the inquiry involves the need for the contractor to obtain 
additional data, documentation, or clarification from the CMHC, however, the timeframe is 15 
business days; if the provider fails to respond to the contractor within this timeframe, it shall 
notify the state thereof.  The contractor may always contact its PEOG BFL should it need the 
latters assistance with a particular state inquiry. 
 
(B)  Denial 
 
If the contractor determines that a denial is warranted, it shall follow the denial procedures 
outlined in this chapter.  This includes: (1) using the appropriate denial letter format in section 
10.7.8 of this chapter; and (2) if required under section 10.6.6 (or another CMS directive) of this 
chapter, referring the matter to PEOG for review prior to denying the application. 
 
iii.  Completion of State Review 
 
The state will notify the contractor once it has completed its review.  There are two potential 
outcomes: 
 
(A)  Approval Not Recommended 
 
If the state does not recommend approval, it will notify the contractor thereof.  (The contractor 
may accept any notification that is in writing (e-mail is fine).)  The site visit described in 
subsection (B)(3)(a) below need not be performed.  No later than 5 business days after receiving 
this notification, therefore, the contractor shall commence the actions described in section 
10.2.1.1(B)(2)(ii)(B) above.   
 
(B)  Approval Recommended 
 
If the state recommends approval, it will typically (though not always) do so via a Form CMS-
1539; the contractor may accept any documentation from the state signifying that the latter 
recommends approval.  (Note that the contractor will not receive a formal tie-in notice.) 
  No later than 5 business days after receipt of the recommendation from the state, the contractor 
shall order the site visit described in subsection (B)(3)(a) below. 
 
If the CMHC fails the site visit, the contractor shall follow the denial procedures addressed in 
subsection (B)(2)(ii)(B) above.  If the CMHC passes the site visit, the contractor shall (within 3 
business days of completing its review of the results) send an e-mail to 
MedicareProviderEnrollment@cms.hhs.gov with the following information and documents:  
 
  The Form CMS-855 application or PECOS Application Data Report and all application 
attachments 
  A copy of the Form CMS-1539 or similar documentation received from the state 
  A copy of the provider-signed Form CMS-1561 
  A copy of the draft approval letter, with the effective date shown on the Form CMS-1539 (or 
similar documentation) included in the draft letter.  (See section 10.7.5.1 for the model 
approval letter.)  
 
PEOG will countersign the provider agreement.  Based on the information received from the 
contractor, PEOG will also (1) assign an effective date, (2) assign a CCN, and (3) enter the 
applicable data into ASPEN, and (4) approve (with possible edits) the approval letter.   
 
Within 5 business days of receiving from PEOG the signed provider agreement, effective date, 
and CCN, the contractor shall: (1) send the approval letter and a copy of the CMS-countersigned 
provider agreement to the CMHC; (2) send a copy of both the approval letter and the provider 
agreement to the state and/or AO (as applicable)); and (3) switch the PECOS record from 
approval recommended to approved consistent with existing instructions. 
 
3.   Site Visits  
 
a.  Initial Enrollment 
 
The scope of the site visit will be consistent with sections 10.6.20(A) and 10.6.20(B) of this 
chapter; the National Site Visit Contractor (NSVC) will perform the site visit.  The contractor 
shall not convey Medicare billing privileges to the provider prior to the completion of the 
NSVCs site visit and the contractors review of the results. 
 
b.  Practice Locations 
 
Each CMHC location must separately and independently meet the CMHC conditions of 
participation in 42 CFR Part 485, subpart J.  Accordingly, a CMHC must separately enroll each 
of its practice locations.  It cannot have multiple locations on a single application.   
 
If a CMHC is changing its physical location, the contractor shall order a site visit of the 
new/changed location through PECOS no later than 5 business days after the contractor receives 
the approval recommendation from the state but before the contractor sends to PEOG the 
applicable e-mail described in section 10.6.1.2(A)(3) of this chapter.  (See the latter section for 
more information.)  This is to ensure that the new/changed location is in compliance with CMSs 
enrollment requirements.  The scope of the site visit will be consistent with sections 10.6.20(A)  and 10.6.20(B) of this chapter.  The NSVC will perform the site visit.  The contractor shall not 
switch the providers enrollment record to Approved prior to the completion of the NSVCs 
site visit and the contractors review of the results. 
 
c.  Revalidation Site Visits 
 
If the CMHC submits a Form CMS-855A revalidation application, the contractor shall order a 
site visit through PECOS.   This is to ensure that the provider is still in compliance with CMSs 
enrollment requirements.  The scope of the site visit will be consistent with section 10.6.20 of 
this chapter.  The NSVC will perform the site visit.  The contractor shall not make a final 
decision regarding the revalidation application prior to the completion of the NSVCs site visit 
and the contractors review of the results. 
 
C.  CMHC 40 Percent Rule 
 
Effective October 29, 2014, under  485.918(b)(1) a CMHC must provide at least 40 percent of 
its items and services to individuals who are not eligible for benefits under title XVIII of the 
Social Security Act; this is measured by the total number of CMHC clients treated by the CMHC 
for whom services are not paid for by Medicare, divided by the total number of clients treated by 
the CMHC in the applicable timeframe.  
 
Pursuant to this requirement, a CMHC is required to submit to CMS a certification statement 
provided by an independent entity (such as an accounting technician).  The document must 
certify that the entity has reviewed the CMHCs client care data for: 
 
  Initial enrollments: The CMHC meets the 40 percent requirement for the prior 3 months. 
 
  Revalidations: The CMHC meets the 40 percent requirement for each of the intervening 12-
month periods between initial enrollment and revalidation. 
 
The statement must be submitted as part of any initial enrollment or revalidation (including off-
cycle revalidations). 
 
When processing the application, the contractor shall abide by the following: 
 
1.  Contractor Does Not Receive the Certification 
 
If the contractor does not receive the certification with the Form CMS-855, the contractor shall 
develop for the certification as it would with any other form of required supporting 
documentation. If the CMHC fails to submit the certification within the applicable time period, 
the contractor shall follow the instructions in section 10.4.1.4.3 of this chapter. 
 
2.  Contractor Receives the Certification 
 
If the contractor receives the certification with the Form CMS-855 or timely receives the 
certification as part of a development request, the contractor shall review the certification to 
ensure that it complies with  485.918(b)(1) and the provisions of this section 10.2.1.1(C). If the  certification is compliant, the contractor shall continue processing the application; if the 
certification is not compliant, the contractor shall deny the application or, if it chooses, develop 
for a revised certification. 
 
Section 10.2.1.1(C) does not apply if the contractor determines that the Form CMS-855 can be 
returned under section 10.4.1.4.2 of this chapter. 
 
If the contractor exceeds applicable timeliness standards due to the instructions in this section 
10.2.1.1(C), the contractor shall accordingly document the provider file consistent with section 
10.6.19(H) of this chapter.  
 
3. Special Guidelines 
 
The following additional guidelines concerning certification apply:  
 
(i)  As previously indicated, an appropriate official of the certifying entity must sign the 
document.  (Notarization is not required unless CMS requests it.)  Such persons may include 
accounting technicians, CEOs, officers, directors, etc. 
 
(ii)  The certification should be on the certifying entitys letterhead or should otherwise indicate 
that the document is clearly from the entity. 
 
(iii) The contractor shall include the certification in the recommendation package it sends to the 
state agency.   
 
Unless CMS instructs the contractor otherwise, the appropriate denial bases for failing to comply 
with  485.918(b)(1) are  424.530(a)(1) and 485.918(b)(1).  The appropriate revocation bases 
are  424.535(a)(1) and 485.918(b)(1).  In cases involving the latter, CMS will determine the 
appropriate re-enrollment bar length under  424.535(c) and will notify the contractor thereof. 
 
D.  CHOWs and Changes of Information 
 
For CMHC CHOWs, the contractor shall follow the instructions in section 10.6.1.1 of this 
chapter.  For CMHC changes of information, the contractor shall follow the instructions in 
section 10.6.1.2 of this chapter. 
 
E.  Additional Information 
 
For more information on CMHCs, refer to: 
 
  Section 1861(ff) of the Social Security Act 
  42 CFR  410.2, 410.43, and 410.110  
  Pub. 100-07, chapter 2, sections 2250 - 2251F  
  42 CFR  489.18(b)(1) 
 
10.2.1.2 - Comprehensive Outpatient Rehabilitation Facilities (CORFs)  
(Rev. 11574; Issued: 08-25-22; Effective:  06-24-22; Implementation: 09-27-22)   
A. General Background Information 
 
A CORF is a facility established and operated at a single fixed location exclusively for the 
purpose of providing diagnostic, therapeutic, and restorative services to outpatients by or under 
the supervision of a physician.  Specific examples of such services include: 
 
  Physician services (*) 
  Physical therapy (*) 
  Occupational therapy 
  Respiratory therapy 
  Speech pathology 
  Social work or psychological services (*) 
  Prosthetic/orthotic devices 
  Lab services (must meet 42 CFR Part 493 requirements) 
 
(* Services that the CORF must provide) 
 
In addition: 
 
  If the state determines that sufficient functional and operational independence exists, a CORF 
may be able to share space with another Medicare provider.  However, the CORF may not 
operate in the same space at the same time with another Medicare provider.  (See Pub. 100-
07, chapter 2, sections 2364 - 2364C for more information.) 
 
  Like most certified providers, CORFs must be surveyed by the state agency and must sign a 
provider agreement. 
 
  On occasion, an outpatient physical therapy/speech language pathology location might 
convert to a CORF; prior to enrolling in Medicare, however, it must be surveyed to ensure 
that the CORF conditions of participation are met.  
 
B.  Processing Instructions for CORF Initial Form CMS-855A Applications 
 
1.  Receipt of Application 
 
Upon receipt of a CORF initial Form CMS-855A application, the contractor shall undertake the 
following (in whichever order the contractor prefers unless directed otherwise in this chapter): 
 
(A) Perform all data validations otherwise required per this chapter.    
 
(B) Ensure that the application(s) is complete consistent with the instructions in this chapter. 
 
(C) Ensure that the CORF has submitted all documentation otherwise required per this chapter.  
For CORF initial enrollment, this also includes the following:   
  Form CMS-1561 (Health Insurance Benefit Agreement, also known as a provider 
agreement)   
 
  Evidence of successful electronic submission of the Form HHS-690 through the Office of 
Civil Rights (OCR) portal, as applicable.  (Evidence should be either written or electronic 
documentation.) (See https://www.hhs.gov/sites/default/files/forms/hhs-690.pdf for more 
information.)   
 
(The CORF must complete, sign, date, and include the Form CMS-1561, though the CORF need 
not complete those sections of the form reserved for CMS.  For organizational CORFs, an 
authorized official (as defined in  424.502) must sign the form; for sole proprietorships, the sole 
proprietor must sign.)   
 
Notwithstanding the foregoing, if the Form CMS-1561 or the Form HHS-690 evidence is 
missing, unsigned, undated, or otherwise incomplete, the contractor need not develop for the 
form(s) or the information thereon; the contractor shall instead notify the state in its 
recommendation letter which document(s) was/were missing or otherwise incomplete.  For all 
other missing or incomplete required documentation, the contractor shall follow the normal 
development instructions in this chapter. 
 
2.  Conclusion of Initial Contractor Review 
 
(Nothing in this section 10.2.1.2(B) prohibits the contractor from returning or rejecting the 
CORF application if otherwise permitted to do so per this chapter.  When returning or rejecting 
the application, the contractor shall follow this chapters procedures for doing so.)     
 
(A) Approval Recommendation 
 
If, consistent with the instructions in section 10.2.1.2(B)(2) and this chapter, the contractor 
believes an approval recommendation is warranted, the contractor shall send the 
recommendation to the state pursuant to existing practice and this chapters instructions.  The 
contractor need not copy the SOG Location or PEOG on the recommendation.  Unless CMS 
directs otherwise, the contractor shall also send to the provider the notification letter in section 
10.7.5.1(E) of this chapter. 
 
The state will: (1) review the recommendation package for completeness; (2) review the 
contractors recommendation for approval; (3) perform any state-specific functions; and (4) 
contact the contractor with any questions.  The contractor shall respond to any state inquiry in 
Item (4) within 5 business days.  If the inquiry involves the need for the contractor to obtain 
additional data, documentation, or clarification from the CORF, however, the timeframe is 15 
business days; if the provider fails to respond to the contractor within this timeframe, it shall 
notify the state thereof.  The contractor may always contact its PEOG BFL should it need the 
latters assistance with a particular state inquiry. 
 
(B) Denial 
  If the contractor determines that a denial is warranted, it shall follow the denial procedures 
outlined in this chapter.  This includes: (1) using the appropriate denial letter format in section 
10.7.8 of this chapter; and (2) if required under section 10.6.6 (or another CMS directive) of this 
chapter, referring the matter to PEOG for review prior to denying the application. 
 
3.  Completion of State Review 
 
The state will notify the contractor once it has completed its review.  There are two potential 
outcomes: 
 
(A) Approval Not Recommended 
 
If the state does not recommend approval, it will notify the contractor thereof.  (The contractor 
may accept any notification that is in writing (e-mail is fine).)  The site visit described in 
subsection (D)(1) below need not be performed.  No later than 5 business days after receiving 
this notification, therefore, the contractor shall commence the actions described in section 
10.2.1.2(B)(2)(B) above.   
 
(B)  Approval Recommended 
 
If the state recommends approval, it will typically (though not always) do so via a Form CMS-
1539; the contractor may accept any documentation from the state signifying that the latter 
recommends approval.  (Note that the contractor will not receive a formal tie-in notice.) 
 
No later than 5 business days after receipt of the recommendation from the state, the contractor 
shall order the site visit described in subsection (D)(1) below. 
 
If the CORF fails the site visit, the contractor shall follow the denial procedures addressed in 
subsection (B)(2)(B) above.  If the CORF passes the site visit, the contractor (within 3 business 
days of completing its review of the results) shall send an e-mail to 
MedicareProviderEnrollment@cms.hhs.gov with the following information and documents:  
 
  The Form CMS-855 application (or PECOS Application Data Report) and all application 
attachments   
  A copy of the Form CMS-1539 or similar documentation received from the state 
  A copy of the provider-signed Form CMS-1561 
  A copy of the draft approval letter, with the effective date shown on the Form CMS-1539 (or 
similar documentation) included in the draft letter.  (See section 10.7.5.1 for the model 
approval letter.)    
 
PEOG will countersign the provider agreement.  Based on the information received from the 
contractor, PEOG will also (1) assign an effective date, (2) assign a CCN, and (3) enter the 
applicable data into ASPEN, and (4) approve (with possible edits) the approval letter.  Within 5 
business days of receiving from PEOG the signed provider agreement, effective date, and CCN, 
the contractor shall: (1) send the approval letter and a copy of the CMS-countersigned provider 
agreement to the CORF; (2) send a copy of both the approval letter and the provider agreement  to the state and/or AO (as applicable)); and (3) switch the PECOS record from approval 
recommended to approved consistent with existing instructions. 
 
C.  Offsite Locations  Initial Enrollment Applications 
 
Notwithstanding the single fixed location language cited in section 10.2.1.2(A) above, there 
may be isolated cases where CMS or the state permits a CORF to have an offsite location.  This 
typically arises if the CORF wants to provide physical therapy, occupational therapy, or speech 
language pathology services away from the primary location.  (This is permitted under 42 CFR  
485.58(e)(2)).  The offsite location would not necessarily be separately surveyed but would be 
listed as a practice location on the CORFs initial Form CMS-855A application. 
 
D.  Site Visits  
 
1.  Initial application - The scope of the site visit will be consistent with sections 10.6.20(A) and 
10.6.20(B) of this chapter.  The NSVC will perform the site visit.  The contractor shall not 
convey Medicare billing privileges to the provider prior to the completion of the NSVCs site 
visit and the contractors review of the results. 
 
2.  Revalidation  If a CORF submits a revalidation application, the contractor shall order a site 
visit through PECOS.  This is to ensure that the provider is still in compliance with CMSs 
enrollment requirements.  The scope of the site visit will be consistent with sections 10.6.20(A) 
and 10.6.20(B) of this chapter.  The NSVC will perform the site visit.  The contractor shall not 
make a final decision regarding the revalidation application prior to the completion of the 
NSVCs site visit and the contractors review of the results. 
 
3.  New/changed location - If a CORF is (1) adding a new location or (2) changing the physical 
location of an existing location, the contractor shall order a site visit of the new/changed location 
through PECOS new/changed location through PECOS no later than 5 business days after the 
contractor receives the approval recommendation from the state but before the contractor sends 
to PEOG the applicable e-mail described in section 10.6.1.2(A)(3) of this chapter.  (See the latter 
section for more information.)  This is to ensure that the new/changed location is in compliance 
with CMSs enrollment requirements.  The scope of the site visit will be consistent with sections 
10.6.20(A) and 10.6.20(B) of this chapter.  The NSVC will perform the site visit.  The contractor 
shall not make a final decision regarding the change of information application prior to the 
completion of the NSVCs site visit and the contractors review of the results. 
 
 
E.  CHOWs and Changes of Information 
 
For CORF CHOWs, the contractor shall follow the instructions in section 10.6.1.1 of this 
chapter.  For CORF changes of information, the contractor shall follow the instructions in section 
10.6.1.2 of this chapter. 
 
F.  Additional Information 
 
For more information on CORFs, refer to: 
    Section 1861(cc) of the Social Security Act 
  42 CFR Part 485, Subpart B 
  Pub. 100-07, chapter 2 
  Pub. 100-07, Appendix K  
  Pub. 100-02, Benefit Policy Manual, chapter 12  
 
10.2.1.3 - End-Stage Renal Disease Facilities (ESRDs)  
(Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
(In this section 10.2.1.3, the terms ESRD and ESRD facility have the same meaning and will 
be used interchangeably).   
 
A. General Background Information 
 
ESRD facilities are entities that provide renal services and related care for patients with 
irreversible and permanent kidney failure.  
 
The provider-based rules for ESRD facilities are outlined in 42 CFR  413.174 and are slightly 
different than those in the main provider-based regulation (42 CFR  413.65).  (For instance,  
413.174 uses the term hospital-based as opposed to provider-based.) 
 
The ESRD Network is a group of organizations under contract with CMS that serve as liaisons 
between the agency and ESRD providers.  The organizations oversee the care that ESRD patients 
receive, collect data, and furnish technical assistance to ESRD providers and patients. 
 
B. Types of ESRD Facilities 
 
Pub. 100-07, State Operations Manual, lists several classifications of ESRD facilities.  They are 
summarized as follows:  
 
1.  Hospital-Based ESRD Facility 
 
A hospital-based ESRD facility is a separately certified ESRD facility that (1) is an outpatient 
department of a hospital and (2) meets the ESRD conditions of coverage at 42 CFR Part 494.  A 
hospital-based ESRD facility is owned and administered by a hospital or critical access hospital 
and is physically located on the hospital campus.  If a hospital operates multiple separately 
certified hospital-based ESRD facilities, each separate ESRD facility must have its own CCN 
and be separately enrolled. 
 
A hospital-based ESRD facility is discussed at 42 CFR  413.174(c) and must meet the criteria 
listed therein (e.g., ESRD facility and hospital have a common governing body and are 
financially integrated). Hospital-based ESRD facilities are assigned CCNs from the 2300-2499 
series.  
2.  Satellite Renal Dialysis Facility (Hospital-Based) 
  A satellite renal dialysis facility is a hospital-owned and hospital-administered ESRD facility but 
is not located on the campus of the hospital.  A single hospital may have several satellite renal 
dialysis facilities.  Each satellite facility: (1) is separately certified and surveyed; (2) must 
independently meet the ESRD conditions of coverage; (3) is assigned its own CCN; and (4) be 
separately enrolled.  Satellite renal dialysis facilities (hospital-based) are assigned CCNs in the 
3500-3699 series. 
 
3.  Independent Renal Dialysis Facility 
 
An independent renal dialysis facility is any outpatient ESRD facility that does not meet the 
definition of a hospital-based renal dialysis facility or satellite renal dialysis facility as described 
in the paragraphs above.  An independent renal dialysis facility may be physically located on a 
hospital campus, but it is not owned and/or administered by the hospital.  Independent renal 
dialysis facilities are assigned CCNs in the 2500-2899 series and are individually enrolled. 
 
4.  Special Purpose Renal Dialysis Facility (SPRDF) ( 494.120) 
 
This type of renal disease facility is temporarily certified to furnish dialysis at special locations 
on a short-term basis (i.e., up to 8 months in any 12-month period) to a group of dialysis patients 
who would otherwise be unable to obtain treatment in the geographical area. The SOG Location 
must clearly specify the limited nature of the SPRDF certification, the time period covered by the 
certification, and the automatic termination of payment on the last day of the certification period 
in its notifications. The special locations for SPRDF fall into two categories: 
 
(A) Vacation Camps - Vacation camps serve dialysis patients temporarily residing there.  A 
vacation camp SPRDF would allow campers to receive hemodialysis at the camp site, avoiding 
interruption of the camping experience.  Vacation camps may be approved for the duration of the 
camp but up to a maximum of 8 months in any 12-month period.  
 
(B) Emergency Circumstance SPRDFs - These locations are set up to provide dialysis services to 
those ESRD patients who would otherwise be unable to obtain such services in their 
geographical area as a result of a natural or man-made disaster or a need for a greater capacity to 
dialyze patients who may have been evacuated from another location.  The CMS SOG Location 
may extend the time period in emergency SPRDF approvals, where necessary, beyond the 
standard eight-month period based upon the termination of the emergency condition.   
 
SPRDFs are assigned CCNs in the 3700-3799 series when owned and administered by a hospital 
and in the 2900-2999 series for independent facilities.  Although they are individually enrolled, 
they cannot convert to a permanent ESRD facility (i.e., to a non-SPRDF).  They must instead 
reapply as a brand new ESRD facility and receive an initial certification survey.   
 
C.  Processing Instructions for ESRD Initial Form CMS-855A Applications 
 
An ESRD facility is separately and individually certified and does not have any branch, multiple, 
or parent locations.  As such, each type of ESRD facility/location must independently and 
separately enroll as such via the Form CMS-855A; multiple sites cannot be listed on a single 
application.   
  Note that the instructions in this section 10.2.1.3(C) apply to all ESRD facility types except 
for SPRDFs.  This ESRD type is not transitioning as that term is described in this 
chapter.   Accordingly, the contractor shall continue to process initial applications from SPRDFs 
consistent with longstanding instructions rather than those described in this section 10.2.1.3(C) 
(e.g., receiving the final approval from the SOG location rather than the state; no need to send 
the application to PEOG after final SOG location approval).   
 
1.  Receipt of Application 
 
Upon receipt of an initial ESRD Form CMS-855A application, the contractor shall undertake the 
following (in whichever order the contractor prefers unless directed otherwise in this chapter): 
 
(A) Perform all data validations otherwise required per this chapter.    
 
(B) Ensure that the application(s) is complete consistent with the instructions in this section 
10.2.1.3 and this chapter. 
 
(C) Ensure that the ESRD facility has submitted all documentation otherwise required per this 
chapter.  For ESRD initial enrollment, this also includes the following: 
 
  Part I of the Form CMS-3427A (End Stage Renal Disease Application and Survey and 
Certification Report) (See Pub. 100-07, chapter 2, section 2247B for more information on this 
form.)   
 
  A certificate of need (CON) if required by state law (though SPRDFs need not submit a 
CON)    
 
(The ESRD must complete and submit Part I of the Form CMS-3427A, though the ESRD need 
not complete those sections of the form reserved for CMS.  For organizational ESRDs, an 
authorized official (as defined in  424.502) must sign the form; for sole proprietorships, the sole 
proprietor must sign.  Note that there is no provider agreement for ESRD facilities; the Form 
CMS-3427A is a survey and certification document, not a provider/supplier agreement.)    
 
Notwithstanding the foregoing, if Part I of the Form-CMS-3427A and/or CON evidence is 
missing, unsigned, undated, or otherwise incomplete, the contractor need not develop for the 
form(s) or the information thereon. (Nor need the contractor: (1) research individual state laws to 
ascertain whether the state requires a CON; or (2) review the data on the CON.)  The contractor 
shall instead notify the state in its recommendation letter which document(s) was/were missing 
or otherwise incomplete.  For all other missing or incomplete required documentation, the 
contractor shall follow the normal development instructions in this chapter. 
 
2.  Conclusion of Initial Contractor Review 
 
(Nothing in this section 10.2.1.3(C) prohibits the contractor from returning or rejecting the 
ESRD application if otherwise permitted to do so per this chapter.  When returning or rejecting 
the application, the contractor shall follow this chapters procedures for doing so.)     
  (A) Approval Recommendation 
 
If, consistent with the instructions in section 10.2.1.3(C) and this chapter, the contractor believes 
an approval recommendation is warranted, the contractor shall send the recommendation to the 
state pursuant to existing practice and this chapters instructions.  The contractor need not copy 
the SOG Location or PEOG on the recommendation.  Unless CMS directs otherwise, the 
contractor shall also send to the provider the notification letter in section 10.7.5.1(E) of this 
chapter. 
 
The state will: (1) review the recommendation package for completeness; (2) review the 
contractors recommendation for approval; (3) perform any state-specific functions; and (4) 
contact the contractor with any questions.  The contractor shall respond to any state inquiry in 
Item (4) within 5 business days.  If the inquiry involves the need for the contractor to obtain 
additional data, documentation, or clarification from the ESRD, however, the timeframe is 15 
business days; if the provider fails to respond to the contractor within this timeframe, it shall 
notify the state thereof.  The contractor may always contact its PEOG BFL should it need the 
latters assistance with a particular state inquiry. 
 
(B) Denial 
 
If the contractor determines that a denial is warranted, it shall follow the denial procedures 
outlined in this chapter.  This includes: (1) using the appropriate denial letter format in section 
10.7.5.1 of this chapter; and (2) if required under section 10.6.6 (or another CMS directive) of 
this chapter, referring the matter to PEOG for review prior to denying the application. 
 
3.  Completion of State Review 
 
The state will notify the contractor once it has completed its review.  There are two potential 
outcomes: 
 
(A)  Approval Not Recommended 
 
If the state does not recommend approval, it will notify the contractor thereof----typically via the 
Form CMS-1539, although the contractor may accept any notification that is in writing (e-mail is 
fine).  No later than 5 business days after receiving this notification, the contractor shall 
commence the actions described in section 10.2.1.3(C)(2)(B) above.   
 
(B)  Approval Recommended 
 
If the state recommends approval, it will typically do so via a Form CMS-1539; however, the 
contractor may accept any documentation from the state signifying that the latter recommends 
approval.  (Note that the contractor will not receive a formal tie-in notice.) 
 
No later than 5 business days after receipt of the recommendation from the state, the contractor 
shall send an e-mail to MedicareProviderEnrollment@cms.hhs.gov with the following 
information and documents:  
    The Form CMS-855 application (or PECOS Application Data Report) and all application 
attachments   
  A copy of the Form CMS-1539 from the state or similar documentation received from the 
AO 
  A copy of the draft approval letter, with the effective date shown on the Form CMS-1539 (or 
similar documentation) included in the draft letter.  (See section 10.7.5.1 for the model 
approval letter.)    
 
(As required per section 10.6.21 of this chapter, the e-mail subject line shall include the 
following: SUBJECT LINE: S&C: Facility Type; Application Type; Facility Name; National 
Provider Identifier; CCN; Application Receipt Date (MMDDYY*) (*Date the Contractor 
Received the Application from the Provider/Supplier).  (Note, however, that this data need not be 
duplicated in the e-mails body.)) 
 
PEOG will review the documentation. Based on the information received from the contractor, 
PEOG will also (1) assign an effective date, (2) assign a CCN, and (3) enter the relevant data into 
the applicable national database, and (4) approve (with possible edits) the approval letter.  Within 
5 business days of receiving from PEOG the effective date, and CCN the contractor shall: (1) 
send the approval letter to the ESRD provider, with a copy to the state and/or AO (as applicable); 
and (2) switch the PECOS record from approval recommended to approved consistent with 
existing instructions. 
 
D.  Additional/Changed Stations 
 
If an enrolled ESRD seeks to add/change services or stations (e.g., add ESRD services in SNFs, 
additional modalities), the ESRD need not submit a Form CMS-855A application to do so, for 
these services and stations do not constitute practice locations and cannot otherwise be reported 
on the application.  Instead, the ESRD contacts the state or accreditation organization (AO) to 
request these changes.  The ESRD must complete a Form CMS-3427 and submit it to the state or 
AO (as applicable).  A survey may be performed, and the state will update the applicable 
national database with any administrative changes.   
 
The state will also send a CMS-1539 or approval letter to the contractor as notification of the 
additional/change service(s) or station(s).  When the contractor receives such a notice, it shall 
abide by the following:  
  As applicable, and consistent with longstanding practice, the contractor shall enter all 
relevant data into PECOS.  No referral to or prior approval from PEOG is 
necessary.  However, the contractor may contact its PEOG BFL if it has questions 
regarding the Form CMS-1539 or the suppliers PECOS record.   
  For situations involving new/expanded/changed ESRD stations, the contractor shall send 
to the supplier the ESRD Service Station/Modality Changes letter identified in section 
10.7.19 of this chapter.  (The state and, as applicable, the AO shall be copied on said 
letter.) 
E.  ESRD Location Changes 
  An ESRD facility that is changing its location must submit either a Form CMS-855A change of 
information application or an initial enrollment application.  The specific transaction type 
involved (change request or initial) will depend on the particular situation.  These situations 
include the following, and they will generally trigger the termination of the ESRDs existing 
CCN and the issuance of a new one.   
 
(i)  A hospital-based ESRD facility is relocating to an off-campus location in the same state. 
 
In this situation, the ESRDs current CCN will be retired.   
 
If the off-campus location will still function under a common governing body, operate under the 
hospitals policies and practices, continue to serve the same community, and utilize the same 
staff at this new location, the new CCN will be that of a renal satellite facility.  The application 
can be processed as a change of information pursuant to the instructions in section 10.6.1.2(A). 
 
If the off-campus location will no longer be operationally, administratively, or financially 
integrated with the hospital, the new CCN will be that of an independent dialysis facility.  The 
hospital must voluntarily terminate this location from its enrollment, and the site must enroll as a 
new ESRD facility.    
 
If the contractor has any questions as to whether the relocated location will still be sufficiently 
integrated with the hospital to permit a change of information application rather than an initial 
enrollment, the contractor may contact the state for guidance.  The processing time clock stops 
while the contractor awaits the states guidance. 
 
(ii) An independent ESRD facility is relocating to become a hospital-based facility or a 
renal satellite facility of a hospital 
 
Since the ESRD facility will be serving a different community under different policies, etc., the 
facility must terminate its existing enrollment and enroll as a new ESRD facility. 
 
(iii) An independent ESRD facility is relocating to another location and will remain 
independent 
 
If the ESRD facility will be serving a different community, the facility must terminate its 
existing enrollment and enroll as a new/initial ESRD facility.  If it will serve the same 
community, the relocation can be processed as a change of information. 
 
(iv) ESRD facility relocating out-of-state 
 
If an ESRD facility of any type (e.g., independent, satellite) is relocating out-of-state --- and 
notwithstanding any other instruction to the contrary in this chapter ---- it must terminate its 
existing enrollment and enroll as an initial/new applicant. 
 
F.  CHOWs and Changes of Information 
  For ESRD CHOWs, the contractor shall follow the instructions in section 10.6.1.1 of this 
chapter.  For ESRD changes of information, the contractor shall follow the instructions in section 
10.6.1.2 of this chapter. 
 
G.  New ESRD Model Letters 
Notwithstanding any other instruction to the contrary in this chapter, the contractor shall use the 
applicable ESRD letters in section 10.7.19 of this chapter for initial enrollments and state-
approved changes of ownership. 
H.  Beds and Services 
 
A Form CMS-3427 from the state must be included with an initial or CHOW Form CMS-1539 
that identifies, as applicable, the services or number of beds at issue.  If, nonetheless, this data is 
not furnished by the state to the contractor for an initial or CHOW application, the contractor 
may secure it from the state (or, for CHOWs, and as applicable, the AO).   
 
I.  ESRD Survey and Certification 
 
The standard CMS survey and certification form used for ESRDs is the Form CMS-3427.  For 
more information on this form, see Pub. 100-07, chapter 2, section 2247B.   
 
For further information on ESRD facilities, refer to: 
 
  Section  1881 of the Social Security Act 
 
  42 CFR Part 405, Subpart U 
 
  Pub. 100-07, chapter 2, section 2270  2287B  
 
  Pub. 100-02, chapter 11  
 
  Pub. 100-04, Claims Processing Manual, chapter 8 
(Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
(In this section 10.2.1.3, the terms ESRD and ESRD facility have the same meaning and will 
be used interchangeably).   
 
A. General Background Information 
 
ESRD facilities are entities that provide renal services and related care for patients with 
irreversible and permanent kidney failure.  
 
The provider-based rules for ESRD facilities are outlined in 42 CFR  413.174 and are slightly 
different than those in the main provider-based regulation (42 CFR  413.65).  (For instance,  
413.174 uses the term hospital-based as opposed to provider-based.) 
  The ESRD Network is a group of organizations under contract with CMS that serve as liaisons 
between the agency and ESRD providers.  The organizations oversee the care that ESRD patients 
receive, collect data, and furnish technical assistance to ESRD providers and patients. 
 
B. Types of ESRD Facilities 
 
Pub. 100-07, State Operations Manual, lists several classifications of ESRD facilities.  They are 
summarized as follows:  
 
1.  Hospital-Based ESRD Facility 
 
A hospital-based ESRD facility is a separately certified ESRD facility that (1) is an outpatient 
department of a hospital and (2) meets the ESRD conditions of coverage at 42 CFR Part 494.  A 
hospital-based ESRD facility is owned and administered by a hospital or critical access hospital 
and is physically located on the hospital campus.  If a hospital operates multiple separately 
certified hospital-based ESRD facilities, each separate ESRD facility must have its own CCN 
and be separately enrolled. 
 
A hospital-based ESRD facility is discussed at 42 CFR  413.174(c) and must meet the criteria 
listed therein (e.g., ESRD facility and hospital have a common governing body and are 
financially integrated). Hospital-based ESRD facilities are assigned CCNs from the 2300-2499 
series.  
2.  Satellite Renal Dialysis Facility (Hospital-Based) 
 
A satellite renal dialysis facility is a hospital-owned and hospital-administered ESRD facility but 
is not located on the campus of the hospital.  A single hospital may have several satellite renal 
dialysis facilities.  Each satellite facility: (1) is separately certified and surveyed; (2) must 
independently meet the ESRD conditions of coverage; (3) is assigned its own CCN; and (4) be 
separately enrolled.  Satellite renal dialysis facilities (hospital-based) are assigned CCNs in the 
3500-3699 series. 
 
3.  Independent Renal Dialysis Facility 
 
An independent renal dialysis facility is any outpatient ESRD facility that does not meet the 
definition of a hospital-based renal dialysis facility or satellite renal dialysis facility as described 
in the paragraphs above.  An independent renal dialysis facility may be physically located on a 
hospital campus, but it is not owned and/or administered by the hospital.  Independent renal 
dialysis facilities are assigned CCNs in the 2500-2899 series and are individually enrolled. 
 
4.  Special Purpose Renal Dialysis Facility (SPRDF) ( 494.120) 
 
This type of renal disease facility is temporarily certified to furnish dialysis at special locations 
on a short-term basis (i.e., up to 8 months in any 12-month period) to a group of dialysis patients 
who would otherwise be unable to obtain treatment in the geographical area. The SOG Location 
must clearly specify the limited nature of the SPRDF certification, the time period covered by the 
certification, and the automatic termination of payment on the last day of the certification period 
in its notifications. The special locations for SPRDF fall into two categories:   
(A) Vacation Camps - Vacation camps serve dialysis patients temporarily residing there.  A 
vacation camp SPRDF would allow campers to receive hemodialysis at the camp site, avoiding 
interruption of the camping experience.  Vacation camps may be approved for the duration of the 
camp but up to a maximum of 8 months in any 12-month period.  
 
(B) Emergency Circumstance SPRDFs - These locations are set up to provide dialysis services to 
those ESRD patients who would otherwise be unable to obtain such services in their 
geographical area as a result of a natural or man-made disaster or a need for a greater capacity to 
dialyze patients who may have been evacuated from another location.  The CMS SOG Location 
may extend the time period in emergency SPRDF approvals, where necessary, beyond the 
standard eight-month period based upon the termination of the emergency condition.   
 
SPRDFs are assigned CCNs in the 3700-3799 series when owned and administered by a hospital 
and in the 2900-2999 series for independent facilities.  Although they are individually enrolled, 
they cannot convert to a permanent ESRD facility (i.e., to a non-SPRDF).  They must instead 
reapply as a brand new ESRD facility and receive an initial certification survey.   
 
C.  Processing Instructions for ESRD Initial Form CMS-855A Applications 
 
An ESRD facility is separately and individually certified and does not have any branch, multiple, 
or parent locations.  As such, each type of ESRD facility/location must independently and 
separately enroll as such via the Form CMS-855A; multiple sites cannot be listed on a single 
application.   
 
Note that the instructions in this section 10.2.1.3(C) apply to all ESRD facility types except 
for SPRDFs.  This ESRD type is not transitioning as that term is described in this 
chapter.   Accordingly, the contractor shall continue to process initial applications from SPRDFs 
consistent with longstanding instructions rather than those described in this section 10.2.1.3(C) 
(e.g., receiving the final approval from the SOG location rather than the state; no need to send 
the application to PEOG after final SOG location approval).   
 
1.  Receipt of Application 
 
Upon receipt of an initial ESRD Form CMS-855A application, the contractor shall undertake the 
following (in whichever order the contractor prefers unless directed otherwise in this chapter): 
 
(A) Perform all data validations otherwise required per this chapter.    
 
(B) Ensure that the application(s) is complete consistent with the instructions in this section 
10.2.1.3 and this chapter. 
 
(C) Ensure that the ESRD facility has submitted all documentation otherwise required per this 
chapter.  For ESRD initial enrollment, this also includes the following: 
    Part I of the Form CMS-3427A (End Stage Renal Disease Application and Survey and 
Certification Report) (See Pub. 100-07, chapter 2, section 2247B for more information on this 
form.)   
 
  A certificate of need (CON) if required by state law (though SPRDFs need not submit a 
CON)    
 
(The ESRD must complete and submit Part I of the Form CMS-3427A, though the ESRD need 
not complete those sections of the form reserved for CMS.  For organizational ESRDs, an 
authorized official (as defined in  424.502) must sign the form; for sole proprietorships, the sole 
proprietor must sign.  Note that there is no provider agreement for ESRD facilities; the Form 
CMS-3427A is a survey and certification document, not a provider/supplier agreement.)    
 
Notwithstanding the foregoing, if Part I of the Form-CMS-3427A and/or CON evidence is 
missing, unsigned, undated, or otherwise incomplete, the contractor need not develop for the 
form(s) or the information thereon. (Nor need the contractor: (1) research individual state laws to 
ascertain whether the state requires a CON; or (2) review the data on the CON.)  The contractor 
shall instead notify the state in its recommendation letter which document(s) was/were missing 
or otherwise incomplete.  For all other missing or incomplete required documentation, the 
contractor shall follow the normal development instructions in this chapter. 
 
2.  Conclusion of Initial Contractor Review 
 
(Nothing in this section 10.2.1.3(C) prohibits the contractor from returning or rejecting the 
ESRD application if otherwise permitted to do so per this chapter.  When returning or rejecting 
the application, the contractor shall follow this chapters procedures for doing so.)     
 
(A) Approval Recommendation 
 
If, consistent with the instructions in section 10.2.1.3(C) and this chapter, the contractor believes 
an approval recommendation is warranted, the contractor shall send the recommendation to the 
state pursuant to existing practice and this chapters instructions.  The contractor need not copy 
the SOG Location or PEOG on the recommendation.  Unless CMS directs otherwise, the 
contractor shall also send to the provider the notification letter in section 10.7.5.1(E) of this 
chapter. 
 
The state will: (1) review the recommendation package for completeness; (2) review the 
contractors recommendation for approval; (3) perform any state-specific functions; and (4) 
contact the contractor with any questions.  The contractor shall respond to any state inquiry in 
Item (4) within 5 business days.  If the inquiry involves the need for the contractor to obtain 
additional data, documentation, or clarification from the ESRD, however, the timeframe is 15 
business days; if the provider fails to respond to the contractor within this timeframe, it shall 
notify the state thereof.  The contractor may always contact its PEOG BFL should it need the 
latters assistance with a particular state inquiry. 
 
(B) Denial 
  If the contractor determines that a denial is warranted, it shall follow the denial procedures 
outlined in this chapter.  This includes: (1) using the appropriate denial letter format in section 
10.7.5.1 of this chapter; and (2) if required under section 10.6.6 (or another CMS directive) of 
this chapter, referring the matter to PEOG for review prior to denying the application. 
 
3.  Completion of State Review 
 
The state will notify the contractor once it has completed its review.  There are two potential 
outcomes: 
 
(A)  Approval Not Recommended 
 
If the state does not recommend approval, it will notify the contractor thereof----typically via the 
Form CMS-1539, although the contractor may accept any notification that is in writing (e-mail is 
fine).  No later than 5 business days after receiving this notification, the contractor shall 
commence the actions described in section 10.2.1.3(C)(2)(B) above.   
 
(B)  Approval Recommended 
 
If the state recommends approval, it will typically do so via a Form CMS-1539; however, the 
contractor may accept any documentation from the state signifying that the latter recommends 
approval.  (Note that the contractor will not receive a formal tie-in notice.) 
 
No later than 5 business days after receipt of the recommendation from the state, the contractor 
shall send an e-mail to MedicareProviderEnrollment@cms.hhs.gov with the following 
information and documents:  
 
  The Form CMS-855 application (or PECOS Application Data Report) and all application 
attachments   
  A copy of the Form CMS-1539 from the state or similar documentation received from the 
AO 
  A copy of the draft approval letter, with the effective date shown on the Form CMS-1539 (or 
similar documentation) included in the draft letter.  (See section 10.7.5.1 for the model 
approval letter.)    
 
(As required per section 10.6.21 of this chapter, the e-mail subject line shall include the 
following: SUBJECT LINE: S&C: Facility Type; Application Type; Facility Name; National 
Provider Identifier; CCN; Application Receipt Date (MMDDYY*) (*Date the Contractor 
Received the Application from the Provider/Supplier).  (Note, however, that this data need not be 
duplicated in the e-mails body.)) 
 
PEOG will review the documentation. Based on the information received from the contractor, 
PEOG will also (1) assign an effective date, (2) assign a CCN, and (3) enter the relevant data into 
the applicable national database, and (4) approve (with possible edits) the approval letter.  Within 
5 business days of receiving from PEOG the effective date, and CCN the contractor shall: (1) 
send the approval letter to the ESRD provider, with a copy to the state and/or AO (as applicable);  and (2) switch the PECOS record from approval recommended to approved consistent with 
existing instructions. 
 
D.  Additional/Changed Stations 
 
If an enrolled ESRD seeks to add/change services or stations (e.g., add ESRD services in SNFs, 
additional modalities), the ESRD need not submit a Form CMS-855A application to do so, for 
these services and stations do not constitute practice locations and cannot otherwise be reported 
on the application.  Instead, the ESRD contacts the state or accreditation organization (AO) to 
request these changes.  The ESRD must complete a Form CMS-3427 and submit it to the state or 
AO (as applicable).  A survey may be performed, and the state will update the applicable 
national database with any administrative changes.   
 
The state will also send a CMS-1539 or approval letter to the contractor as notification of the 
additional/change service(s) or station(s).  When the contractor receives such a notice, it shall 
abide by the following:  
  As applicable, and consistent with longstanding practice, the contractor shall enter all 
relevant data into PECOS.  No referral to or prior approval from PEOG is 
necessary.  However, the contractor may contact its PEOG BFL if it has questions 
regarding the Form CMS-1539 or the suppliers PECOS record.   
  For situations involving new/expanded/changed ESRD stations, the contractor shall send 
to the supplier the ESRD Service Station/Modality Changes letter identified in section 
10.7.19 of this chapter.  (The state and, as applicable, the AO shall be copied on said 
letter.) 
E.  ESRD Location Changes 
 
An ESRD facility that is changing its location must submit either a Form CMS-855A change of 
information application or an initial enrollment application.  The specific transaction type 
involved (change request or initial) will depend on the particular situation.  These situations 
include the following, and they will generally trigger the termination of the ESRDs existing 
CCN and the issuance of a new one.   
 
(iii)A hospital-based ESRD facility is relocating to an off-campus location in the same state. 
 
In this situation, the ESRDs current CCN will be retired.   
 
If the off-campus location will still function under a common governing body, operate under the 
hospitals policies and practices, continue to serve the same community, and utilize the same 
staff at this new location, the new CCN will be that of a renal satellite facility.  The application 
can be processed as a change of information pursuant to the instructions in section 10.6.1.2(A). 
 
If the off-campus location will no longer be operationally, administratively, or financially 
integrated with the hospital, the new CCN will be that of an independent dialysis facility.  The 
hospital must voluntarily terminate this location from its enrollment, and the site must enroll as a 
new ESRD facility.      
If the contractor has any questions as to whether the relocated location will still be sufficiently 
integrated with the hospital to permit a change of information application rather than an initial 
enrollment, the contractor may contact the state for guidance.  The processing time clock stops 
while the contractor awaits the states guidance. 
 
(iv) An independent ESRD facility is relocating to become a hospital-based facility or a 
renal satellite facility of a hospital 
 
Since the ESRD facility will be serving a different community under different policies, etc., the 
facility must terminate its existing enrollment and enroll as a new ESRD facility. 
 
(iii) An independent ESRD facility is relocating to another location and will remain 
independent 
 
If the ESRD facility will be serving a different community, the facility must terminate its 
existing enrollment and enroll as a new/initial ESRD facility.  If it will serve the same 
community, the relocation can be processed as a change of information. 
 
(iv) ESRD facility relocating out-of-state 
 
If an ESRD facility of any type (e.g., independent, satellite) is relocating out-of-state --- and 
notwithstanding any other instruction to the contrary in this chapter ---- it must terminate its 
existing enrollment and enroll as an initial/new applicant. 
 
F.  CHOWs and Changes of Information 
 
For ESRD CHOWs, the contractor shall follow the instructions in section 10.6.1.1 of this 
chapter.  For ESRD changes of information, the contractor shall follow the instructions in section 
10.6.1.2 of this chapter. 
 
G.  New ESRD Model Letters 
Notwithstanding any other instruction to the contrary in this chapter, the contractor shall use the 
applicable ESRD letters in section 10.7.19 of this chapter for initial enrollments and state-
approved changes of ownership. 
H.  Beds and Services 
 
A Form CMS-3427 from the state must be included with an initial or CHOW Form CMS-1539 
that identifies, as applicable, the services or number of beds at issue.  If, nonetheless, this data is 
not furnished by the state to the contractor for an initial or CHOW application, the contractor 
may secure it from the state (or, for CHOWs, and as applicable, the AO).   
 
I.  ESRD Survey and Certification 
 
The standard CMS survey and certification form used for ESRDs is the Form CMS-3427.  For 
more information on this form, see Pub. 100-07, chapter 2, section 2247B.     
For further information on ESRD facilities, refer to: 
 
  Section  1881 of the Social Security Act 
 
  42 CFR Part 405, Subpart U 
 
  Pub. 100-07, chapter 2, section 2270  2287B  
 
  Pub. 100-02, chapter 11  
 
  Pub. 100-04, Claims Processing Manual, chapter 8 
 
10.2.1.4 - Federally Qualified Health Centers (FQHCs) 
(Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
A.  Statutory Background 
 
Section 4161(a)(2) of OBRA 90 (P.L. 101-508) amended 1861(aa) of the Act and established 
FQHC services as a benefit under the Medicare program effective October 1, 1991.  The 
statutory requirements that entities must meet to be considered an FQHC for Medicare purposes 
are at 1861(aa)(4) of the Act.  Regulations establishing the FQHC benefit and outlining the 
Conditions for Coverage for FQHCs were published on June 12, 1992, in the Federal Register 
(57 FR 24961) and became effective on the date of publication.  These regulations were amended 
on April 3, 1996 (61 FR 14640).  Section 13556 of OBRA 1993 (P.L. 103-66) amended 
1861(aa) of the Act by adding outpatient health programs or facilities operated by a tribe or 
tribal organization under the Indian Self-Determination Act or by an urban Indian organization 
receiving funds under title V of the Indian Health Care Improvement Act, as entities eligible to 
participate in Medicare as FQHCs. 
 
B.  Requirements  
 
FQHCs furnish services such as those performed by physicians, nurse practitioners, physician 
assistants, clinical psychologists, certified nurse-midwives, and clinical social workers.  This also 
includes certain preventive services like prenatal services, immunizations, blood pressure checks, 
hearing screenings and cholesterol screenings. (See Pub. 100-02, chapter 13 for more 
information).  To participate in the Medicare program, applicants seeking initial enrollment as an 
FQHC must submit a Form CMS-855A application to the appropriate Medicare Administrative 
Contractor (MAC).  Even though they complete the Form CMS-855A application, FQHCs are 
considered Part B certified suppliers and are paid Part B benefits for FQHC services.   
 
FQHCs are not required to obtain a state survey.  However, FQHCs still must meet all applicable 
state and local requirements and submit all applicable licenses.  Typically, the Health Resources 
and Services Administration (HRSA) will verify such state/local compliance by asking the 
FQHC to attest that it meets all state/local laws. 
  FQHCs can be located in a rural or urban area that is designated as either a health professional 
shortage area or an area that has a medically underserved population.   
 
For purposes of Medicare enrollment, an FQHC is defined as an entity that has entered into an 
agreement with CMS to meet Medicare program requirements under 42 CFR  405.2434(a), and 
(as outlined in Pub. 100-07, chapter 9, exhibit 179):   
 
  Is receiving a grant under  330 of the Public Health Service (PHS) Act; 
  Is receiving funding under a contract with the recipient of a  330 grant, and meets the 
requirements to receive a grant under  330 of the PHS Act; 
  Is an FQHC Look-Alike (i.e., HRSA), has notified it that it meets the requirements for 
receiving a  330 grant, even though it is not actually receiving such a grant); 
  Was treated by CMS as a comprehensive federally funded health center as of January 1, 
1990; or 
  Is an outpatient health program or facility operated by a tribe or tribal organization under the 
Indian Self-Determination Act or by an Urban Indian organization receiving funds under 
Title V of the Indian Health Care Improvement Act. 
 
C.  Initial FQHC Applications 
 
1.   Contractor Review and Required Documents 
 
In contrast to both past practice and the process that is normally followed with other certified 
provider/certified supplier types, the contractor does not make a recommendation for approval to 
the state/SOG Location for FQHC applications.  Instead, the contractor will either approve or 
deny the application at the contractor level pursuant to the instructions in this section.   
 
The following documents must be included with the FQHCs completed Form CMS-855A 
application: 
 
  One signed and dated copy of the attestation statement (Exhibit 177).  In order to attest to 
being in compliance, the facility must be open and operating when the attestation is signed.  
Since FQHCs must sign an agreement stipulating that they will comply with  1861(aa)(4) of 
the Act and specific FQHC regulations, this statement serves as the Medicare FQHC benefit 
(or provider/supplier) agreement when it is also signed and dated by PEOG.  (See Pub. 100-
07, chapter 2, section 2826B.)   
  HRSA Notice of Grant Award (NOA) or FQHC Look-Alike Designation that includes an 
address for the site of the applicant which matches the practice location reported on the Form 
CMS-855A.  A Notice of Grant Award by HRSA verifies that the applicant qualifies as a 
FQHC grant recipient; the FQHC Look-Alike Designation Memo from HRSA verifies look-
alike status.  
  Form CMS-588; Electronic Funds Transfer (EFT) Authorization Agreement. 
  Clinical Laboratory Improvement Act (CLIA) Certificate (if applicable).  Facilities that 
examine human specimens for the diagnosis, prevention, or treatment of any disease or 
impairment of, or the assessment of the health of, human beings is considered a laboratory 
and must meet CLIA requirements.  These facilities must apply and obtain a certificate from 
the CLIA program that corresponds to the complexity of tests performed.  Certain types of  laboratories and laboratory tests are NOT subject to meeting CLIA requirements.  One 
example would be facilities which serve only as collection stations.  A collection station 
receives specimens to be forwarded to a laboratory performing diagnostics test.  Pub. 100-07, 
chapter 6, section 6002 provides additional details regarding laboratories and laboratory tests 
NOT subject to CLIA requirements.  It is the FQHCs responsibility to review the CLIA 
requirements and obtain a CLIA certificate if needed.  Neither the contractor nor CMS 
determines whether the FQHC needs to obtain and submit a CLIA certificate. 
  Copy of state license (if applicable). 
 
2.   General Processing Concepts 
 
(A)  Practice Locations - An FQHC cannot have multiple sites or practice locations.  Each 
location must be separately enrolled and will receive its own CCN.  
 
(B)  Date on the NOA - The project period (Item 6 of the NOA) must be valid through the date 
on which the FQHCs application was complete (as determined by the contractor).  The 
contractor shall develop for a correct NOA date(s) if the project period and/or budget period do 
not meet the aforementioned requirement.  (In developing for this data, the contractor may (but is 
not required to) send the Reminder and Assistance for Health Centers for CMS FQHC Site 
Enrollment guidance to the FQHC.)  
 
(C)  Name on Exhibit 177 - The contractor shall ensure that Exhibit 177 contains the same legal 
business name and address as that which the FQHC provided in Section 2 and Section 4, 
respectively, of the Form CMS-855A.  If the attestation contains a different name, the contractor 
shall develop for the correct name.   
 
(D)  Date on Exhibit 177 - The contractor shall ensure that the date on which the Exhibit 177 was 
signed is on or after the date the FQHC listed as its effective date on the Form CMS-855A 
application.  If the Exhibit 177 was signed prior to the listed effective date, the contractor shall 
(using the development procedures outlined in this chapter) develop for an Exhibit 177 signed on 
or after the FQHCs listed effective date; the FQHC should be providing services in order to 
meet the regulations noted in Exhibit 177. 
 
(E)  Date Application Complete - When reviewing an initial FQHC application, the contractor 
shall determine the date on which the FQHCs application was complete.  To illustrate, assume 
that the FQHC submitted an initial application on March 1.  Two data elements were missing, so 
the contractor requested additional information.  The two elements were submitted on March 30.  
The contractor shall therefore indicate the March 30 date in its approval letter as the effective 
date of the FQHC.  
 
(F)  Contractor Jurisdiction - Except for tribal and Urban Indian FQHCs, a freestanding FQHC 
that is initially enrolling is assigned to the Medicare Administrative Contractor (MAC) that 
covers the state in which the FQHC is located.  An initially enrolling tribal or Urban Indian 
FQHC is assigned to the Jurisdiction H MAC. 
 
(G)  Tribal/Urban Indian Organizations  Certain outpatient health programs or facilities may be 
operated by a tribe or tribal organization or by an Urban Indian organization receiving funds  under title V of the Indian Health Care Improvement Act.  The contractor shall confirm the 
applicants attestation and tribal/urban Indian status if the FQHC indicates on the application that 
it has such status; several means are available:   
 
  The applicable Indian Health Service (IHS) web link at https://www.ihs.gov/locations/. The 
contractor can search for the facility by clicking on the Find Health Care sub-link 
https://www.ihs.gov/findhealthcare/?CFID=15011511&CFTOKEN=36378825 or 
downloading the Excel complete listing of HIS facilities.  (These are the highly 
recommended means of verification.) 
 
  Contacting (1) the IHS directly, (2) contacting the applicable SOG Location, or (3) the 
contractors PEOG BFL. 
 
(H)  Potential RHC Relationship  On occasion, a rural health clinic (RHC) may seek to convert 
to an FQHC.  (A facility cannot be both an RHC and an FQHC.)  Accordingly, in its review of 
an initial FQHC application, the contractor shall check PECOS to determine whether an RHC is 
enrolled at the same location.  If one is, the contractor shall refer the matter to 
MedicareProviderEnrollment@cms.hhs.gov. In doing so, the contractor shall furnish to PEOG 
(1) the names, NPIs, and shared address of the RHC and FQHC, and (2) a copy of all 
information submitted with the FQHC application; the e-mails subject line shall state: RHC & 
FQHC shared address. 
 
3.  Determination 
 
a.  Approval 
 
The contractor shall contact PEOG via email at MedicareProviderEnrollment@cms.hhs.gov if it 
believes that the FQHCs initial application should be approved. The contractor shall provide to 
PEOG: (1) a copy of the draft approval letter (see section 10.7.5.1(N) of this chapter for a model 
FQHC approval letter); (2) the Form CMS-855A application or PECOS Application Data Report 
(ADR) and all supporting documentation; (3) a copy of the FQHCs HRSA documentation; and 
(4) Exhibit 177.   
 
While awaiting PEOGs final determination---and beginning on the date following the sending of 
the aforementioned e-mail---the application processing time clock is stopped.  It resumes on the 
date on which the contractor receives PEOGs decision.  Communication between the contractor 
and PEOG during this waiting period (e.g., PEOG request for additional information from the 
contractor) does not restart the clock.  
 
b.  Denial 
 
If the contractor believes that the FQHCs application should be denied, the contractor shall 
notify the applicant of the denial using the appropriate model letter guidance in section 10.7.8 of 
this chapter.  If the contractor is uncertain as to whether a denial is warranted or what the 
appropriate denial ground under 42 CFR 424.530(a) should be, it may contact its PEOG BFL for 
guidance.   
  4.  Post-PEOG Review and Response to Contractor 
 
If PEOG determines (based on the information the contractor furnished) that the FQHCs 
application should be approved, PEOG will: 
 
  Assign the CCN, which will be part of the 1800-1989 series 
 
  Assign the effective date, which will be the date the FQHC application was considered 
complete by the contractor  
 
  Make any necessary revisions to the draft approval letter 
 
  Sign and date the attestation using the completion date, which is also the effective date 
(Exhibit 177) 
 
  E-mail all of the foregoing documents and data to the contractor, at which point the 
aforementioned processing time clock resumes. 
 
5.  Post-Approval Contractor Action 
 
If PEOG notifies the contractor that the FQHCs application should be approved, the contractor 
shall send the approval letter to the FQHC with a copy of the signed Exhibit 177.   
 
D.  Changes of Information 
 
1.   Location Changes 
 
a.  Verification 
 
If an FQHC is changing the physical location of an existing site, the FQHC must submit the 
following documentation (as applicable to that FQHC) to the contractor:  
 
  For 330 grantees, a Notice of Grant Award approving the physical location change and the 
new address; or 
  For look-alikes, an updated letter from HRSA approving the physical location change and 
listing the new address.  
 
(Consistent with the instructions in this chapter, the contractor shall develop for this 
documentation with the FQHC if the latter fails to submit it.)   
 
For tribal/Urban Indian organizations, the contractor may confirm the new location via the IHS 
website or by contacting IHS.  (See section 10.2.1.4(C)(2)(G) above for the web link.) 
 
In all cases, the new address listed on the notice of grant award (NOA), IHS website, etc., must 
match that listed on the Form CMS-855A change request.  If it does not, the contractor shall 
develop with the FQHC for clarification consistent with the instructions in this chapter.      In addition, both the budget date and the project date on the NOA must be valid through the date 
on which the FQHCs change request application was complete (as determined by the 
contractor).   The contractor shall develop for a correct NOA date(s) if the project period and/or 
budget period do not meet the aforementioned requirement.   
 
b.  Approval  
 
If approving the location change or updating the contact information (as described in section 
10.6.1.2 of this chapter), the contractor does not issue a recommendation of approval to the SOG 
Location, notwithstanding any instruction to the contrary in this chapter; rather, the contractor 
shall approve the location change in PECOS and issue an approval letter to the FQHC (with an e-
mailed copy to PEOG at MedicareProviderEnrollment@cms.hhs.gov (Subject line: FQHC 
COIAddress Change/Contact Change/Other).  PEOG will update ASPEN accordingly.).  
Beginning on March 15, 2021, tie-in notices will not be issued for address changes. 
 
c.  Denial 
 
If the contractor does not approve the location change (i.e., the FQHC is no longer located in a 
shortage area, the FQHC fails to submit the applicable HRSA supporting documentation after 
contractor development (discussed above), or another reason is implicated), the contractor shall 
refer the matter to PEOG at ProviderEnrollmentRevocations@cms.hhs.gov consistent with all 
applicable instructions in this chapter and other CMS directives.  (The referral shall include, at a 
minimum, the FQHCs LBN and NPI as well as a brief explanation of the situation and the 
reason for referral.)  PEOG will review the matter and instruct the contractor on how to proceed.   
 
2.  LBN, TIN, or DBA Name Changes Not Involving a CHOW 
 
The contractor shall process LBN, TIN, or DBA name changes not involving a CHOW 
consistent with the instructions in sections 10.6.1.2(B)(1) and (3) of this chapter.  No notification 
to the state or SOG Location regarding the change is needed. 
 
3.  All Other Change Requests 
 
For all change requests not described in subsections (D)(1) and (2) above, the contractor shall 
follow the instructions in sections 10.6.1.2(C)(1) and (2) of this chapter. 
 
E.  Changes of Ownership (CHOWs) 
 
This section 10.2.1.4(E) addresses procedures for processing FQHC CHOWs.  Except as noted 
otherwise, these instructions take precedence over those in section 10.6.1.1.3 et seq. of this 
chapter. 
 
For background information on CHOWs (which, for purposes of section 10.2.1.4(E), includes 
acquisitions/mergers and consolidations) and potential CHOW situations, see sections 10.6.1.1.1 
and 10.6.1.1.2 of this chapter.  The contractor shall, as needed, refer to these instructions in 
examining whether a CHOW has occurred.  In reviewing said sections, the contractor shall note 
the following: 
    The provider agreement for FQHCs is the Exhibit 177. 
  No recommendations to the state or SOG Location are involved.  The contractor and PEOG 
alone will handle the transaction.  In particular, the contractor---in lieu of making a 
recommendation to the state/SOG Location---will send its final analysis to PEOG.  PEOG 
will then: (i) review the transaction; (ii) determine whether the CHOW should be approved; 
(iii) as needed, update ASPEN and perform any other related tasks; and (iv) notify the 
contractor of the results of its review and provide any required direction.  The 
aforementioned process, in effect, combines a recommendation to the state/SOG Location 
and the contractors post-recommendation e-mail to PEOG (described in section 
10.6.1.1.3.3(B)) into a single step.  For purposes of this section 10.2.1.4(E), the term final 
analysis (in the context of FQHC CHOWs) is roughly the equivalent of a recommendation 
to the state.  Accordingly, when sending its final analysis to PEOG as described above, the 
contractor maybut is not required tochange the applications status in PECOS to 
approval recommended.   
 
In addition---and except as otherwise stated---the contractor shall adhere to the following 
subsections and instructions in sections 10.6.1.1.3 et seq. and 10.6.1.1.4: 
 
(i) Section 10.6.1.1.3.1(A) (This does not include the list of documents in section 
10.6.1.1.3.1(A)(iii), although all other instructions in section 10.6.1.1.3.1(A)(iii) shall be 
followed (e.g., development for missing/deficient documents).  The required FQHC CHOW 
documents are identified in this section 10.2.1.4(E).) 
 
(ii) Section 10.6.1.1.3.1(B) (Regarding section 10.6.1.1.3.1(B)(4), the contractor shall make this 
referral to PEOG before (and separate from) sending its final analysis to PEOG.)  
 
(iii) Sections 10.6.1.1.3.1.1(A)(1), (A)(2), (A)(3), (B)(1), (B)(2), (B)(3)(a) and (c), (F), and (G).  
(The contractor can disregard references to state recommendations in these sections.)  The 
remaining topics/instructions in section 10.6.1.1.3.1.1 are either inapplicable to FQHC CHOWs 
or addressed in this section 10.2.1.4(E). 
 
(iv) Sections 10.6.1.1.4(A), (B), (C), (D), (E), (F), (G), and (H) (With respect to the application 
of 10.6.1.1.4(C) to FQHC CHOWs, receipt of an approval recommendation from the state (as 
described in 10.6.1.1.4(C)) is the equivalent of the contractor sending its final analysis to 
PEOG.) 
 
The following instructions address FQHC-specific CHOW processing activities that the 
contractor shall follow in addition to the procedures contained in the section 10.6.1.1 et seq. 
subsections outlined in (i) through (iv) above.  If any inconsistency exists between these two sets 
of instructions (i.e., recommending approval to the state as described in 10.6.1.1 et seq. versus 
making a final analysis to PEOG as described below), the latter takes precedence. 
  
1.   Special Processing Steps 
 
a.  Required Documents  The contractor shall ensure that the FQHC submits all documentation 
otherwise required per this chapter.  For FQHC CHOW purposes, this also includes: 
    Legal Documentation of CHOW - The legal documents that governed the transaction, such as 
a sales agreement, bill of sale, or transfer agreement.  (See section 10.6.1.1.3.1.1(B) for more 
information on such documents.)  
 
  Evidence of state licensure of the new entity, if applicable.  (This can be furnished consistent 
with existing instructions in this chapter concerning submission of evidence of state 
licensure.) 
 
  Exhibit 177 containing the new owners information.  
 
  HRSA NOA or FQHC Look-Alike Designation containing the new owners information.  
(NOTE: Both the budget date and the project date on the NOA must be valid through the date 
on which the FQHCs CHOW application was complete (as determined by the contractor).  
The contractor shall develop for a correct NOA date(s) if the project period and/or budget 
period do not meet the aforementioned requirement.)   
 
b.  Old and New Owner Applications 
 
i.  Order of Receipt - To the maximum extent practicable, FQHC CHOW applications from the 
previous and new owners should be processed as they arrive. 
 
ii.  Non-Receipt of Previous Owners Application  Although the contractor shall attempt to 
collect the old owners application, it may make its final analysis without it. 
 
c.  Relocation of Entity - A new owner may seek to relocate the FQHC concurrent with a 
CHOW.  In such cases, the contractor shall ensure that the FQHC submits (along with the 
documents in (E)(1)(a) above): 
 
  For  330 grantees, a Notice of Grant Award approving the physical location change and the 
new address; or 
  For look-alikes, an updated letter from HRSA approving the physical location change and 
listing the new address.  
 
For tribal/Urban Indian organizations, the contractor may confirm the new location via the IHS 
website or by contacting IHS.  (See section 10.2.1.4(C)(2)(H) above for the web link.) 
 
The new address listed on the notice of grant award, IHS website, etc., must match that on the 
Form CMS-855A CHOW application.  If it does not, the contractor shall develop with the FQHC 
for clarification consistent with the instructions in this chapter.     
 
Notwithstanding the foregoing, the entire transaction shall be processed as a CHOW rather than 
a COI. 
 
d.  Intervening Change of Ownership  
  In situations where the FQHC (1) submits a Form CMS-855 initial application or CHOW 
application and (2) subsequently submits a Form CMS-855 CHOW application, the contractor 
shall adhere to the following: 
 
Situation 1  The FQHC submitted an initial application followed by a CHOW application, and 
the contractor has not yet sent its final analysis to PEOG: The contractor shall return both 
applications and require the FQHC to re-submit an initial application with the new owners 
information. 
 
Situation 2 - The FQHC submitted a CHOW application followed by another CHOW 
application, and the contractor has not yet sent its final analysis to PEOG regarding the first 
application: The contractor shall process both applications, preferably in the order they were 
received.  When sending its final analysis to PEOG, the contractor shall explain the dual CHOW 
application submission.   
 
Situation 3 - The FQHC submitted an initial application followed by a CHOW application, and 
the contactor has sent its final analysis of the initial application to PEOG but before it has 
notified the FQHC of the approval of the initial application: The contractor shall: 
 
  Return the CHOW application. 
 
  Notify PEOG via e-mail that a change of ownership has occurred (the new owner should be 
identified) and that the contractor will require the FQHC to resubmit a new initial application 
containing the new owners information. 
 
  Request via letter that the FQHC submit a new initial Form CMS-855 application containing 
the new owners information within 30 days of the date of the letter.  If the FQHC fails to do so, 
the contractor shall return the originally submitted initial application and notify the FQHC 
accordingly.  If the FQHC submits the requested application, the contractor shall process it 
consistent with the instructions in this chapter; the originally submitted initial application 
becomes moot.  If the newly submitted/second initial application is denied, however, the first 
submitted application is denied as well; the contractor shall notify the FQHC accordingly. 
 
Situation 4 - The FQHC submitted a CHOW application followed by another CHOW 
application, and the contactor has sent its final analysis of the first CHOW application to PEOG 
but before it has notified the FQHC of the approval thereof - The contractor shall: 
 
  Notify PEOG via e-mail that (1) a subsequent change of ownership has occurred (the new 
owner should be identified) and (2) the contractor will require the FQHC to resubmit a new 
CHOW application containing the subsequent/second new owners information. 
 
  Process the new/second CHOW application as normal.  If a final analysis to PEOG is made 
for this application, the contractor shall explain this situation in its e-mail; the first CHOW 
application becomes moot.  If the newly submitted/second CHOW application is returned or 
rejected per the instructions in this chapter, the first application should, too, be returned or 
rejected (as applicable).  The contractor shall notify the provider and PEOG accordingly. 
  2.  Post-Initial Review Actions and Scenarios 
 
After the contractor completes the tasks described in the above-referenced sections, several 
results are possible.  These are discussed below.  Should the contractor encounter a scenario not 
addressed herein, it may contact its PEOG BFL for guidance prior to its final analysis.  As a 
reminder, nothing in this section 10.2.1.4(E)(2) prohibits the contractor from returning or 
rejecting the application if otherwise permitted to do so per this chapter.    
 
a.   The contractor ascertains that the transaction falls within the scope of  489.18 and that the 
new owner has accepted assignment  If there are no apparent grounds for denying the CHOW 
application, the contractor shall send its final analysis to PEOG via e-mail at  
MedicareProviderEnrollment@cms.hhs.gov with the following information and documents: (1) 
the Form CMS-855 application or PECOS Application Data Report; (2) a copy of the final 
sales/transfer agreement; (3) a copy of the provider-signed Exhibit 177; and (4) NOA.  PEOG 
will countersign the Exhibit 177 and assign an effective date of the CHOW based on the date the 
application was complete (as determined by the contractor).  Within 5 business days of receiving 
from PEOG the signed Exhibit 177 and effective date, the contractor shall: (1) send the CHOW 
approval letter and a copy of the CMS-countersigned Exhibit 177 to the FQHC; and (2) switch 
the PECOS record to approved consistent with existing instructions. 
 
If a denial ground exists, however, the contractor shall refer the matter to its PEOG BFL for 
guidance notwithstanding any other instruction in this chapter to the contrary. The contractor 
should include an explanation of the ground(s) it believes exists for the denial (including the 
regulatory citation); the e-mail referral shall state in the subject line FQHC Guidance 
Required.  
 
b.  The contractor ascertains that the transaction falls within the scope of  489.18 but the new 
owner has not accepted assignment  The contractor shall: (a) return the application; and (b) 
notify the new owner in the return letter that it must submit the following within 30 days from 
the date of the return letter: (1) an initial Form CMS-855 application to enroll as a new FQHC; 
and (2) a voluntary termination application for the existing FQHC.  If the new owner fails to do 
so within 30 days of the request, the contractor shall contact its PEOG BFL via e-mail with this 
information notwithstanding any other instruction to the contrary in this chapter.  PEOG will 
review the matter and respond to the contractor. 
 
c.  The contractor ascertains that the transaction does not fall within the scope of  489.18 (e.g., 
stock transfer), regardless of whether the new owner accepted assignment - This qualifies as an 
ownership change under 42 CFR  424.516 rather than a CHOW under  489.18.  The contractor 
shall: (A) return the application; and (B) notify the FQHC in the return letter that it must submit 
a Form CMS-855 application to report the ownership change within 30 days of the return letter 
and provide all supporting documentation (including a revised NOA and agreement).  If the 
provider fails to do so, the contractor shall contact its PEOG BFL via e-mail with this 
information notwithstanding any other instruction to the contrary in this chapter. 
 
F.  Timeframes and Alternatives 
 
While awaiting PEOGs final determination (and beginning on the date following the sending of 
the aforementioned e-mail) for the applications described in subsections (C), (D), and (E), the  application processing time clock is stopped.  It resumes on the date on which the contractor 
receives PEOGs decision.  Communication between the contractor and PEOG during this 
waiting period (e.g., PEOG request for additional information from the contractor) does not 
restart the clock.   In addition, nothing in this section 10.2.1.4 negates other processing 
alternatives outlined in this chapter that can apply to the processing of FQHC applications. 
 
G.  Supporting Documentation 
1.  Revalidations 
Upon revalidation of an FQHC site, the FQHC must submit --- along with any other supporting 
documentation required per this chapter --- either an NOA (for awardees) or notice of look-alike 
designation (NLD, for look-alikes) approving the site.  If an NOA or NLD is unavailable for the 
site, a copy of the FQHC's "Form 5B: Service Sites" list downloaded from HRSAs Electronic 
Handbooks documenting all of the providers approved FQHC program sites is 
acceptable.  However, any NOA, NLD, or Form 5B must include the physical address of the site 
in question that matches the physical address on file with CMS and the address submitted on the 
Form CMS-855A application.  If the addresses do not match, the contractor shall develop for 
additional information. 
2.  Initial Applications, CHOWs, and Location Changes 
The contractor cannot accept a copy of the Form 5B as supporting documentation for initial 
applications, CHOWs, and new/changed FQHC locations.  As explained previously, only a valid, 
in effect NOA or NLD, as applicable, is acceptable. 
 
H.  Revocations and Other Transactions 
 
Except as otherwise stated or required by CMS, the contractor shall continue to adhere to the 
applicable instructions in this chapter and all other CMS directives regarding: 
 
  Potential FQHC revocations and referrals (including sending the referral/information to the 
appropriate PEOG mailbox) 
  Changes of ownership  
  Changes of information  
  Revalidations 
  Reactivations  
 
I.  Complaint Investigations 
 
CMS SOG Locations investigate complaints that raise credible allegations of an FQHCs 
noncompliance with health and safety standards found at 42 CFR 405 Subpart X, and 42 CFR 
491 Subpart A (except for 42 CFR  491.3). The contractor shall refer such complaints to the 
SOG Location that has jurisdiction over the FQHC.  
 
J.  FQHC DPV Errors 
  (This only applies to initial applications (subsection (C)(1) above) and location changes 
(subsection (D)(1).) 
 
A site visit for FQHCs is generally not required.  However, the contractor shall order a site visit 
if there is a DPV error.  The site visit shall be ordered before the contractor sends the applicable 
e-mail described in subsections (C)(3)(a) and (D)(1)(b) above.  If the site visit finds that the 
facility is not open and operational, the contractor shall deny the application.  If the facility is 
open and operational, the contractor can proceed as normal.   
 
K.  Additional Data 
 
For additional general information on FQHCs, refer to: 
 
  Section 1861(aa)(3-4) of the Social Security Act 
  42 CFR Part 491 and 42 CFR Part 405, subpart X 
  Pub. 100-07, chapter 2, sections 2825  2826H  
  Pub. 100-07, chapter 9, exhibits 177 and 179 
  Admin Info 21 06-ALL  Transitioning FQHC Certification Enrollment Performed by the 
CMS SOG (Standard Operating Procedures attached) 
  Pub. 100-04, chapter 9  
  Pub. 100-02, chapter 13  
 
For additional information on the appropriate contractor jurisdictions for incoming FQHC 
enrollment applications, see Pub. 100-04, chapter 1, section 20 as well as Pub. 100-07, chapter 9, 
exhibit 179. 
 
 
10.2.1.5 - Histocompatibility Laboratories 
(Rev. 10868; Issued: 07-14-21; Effective: 08-13-21; Implementation: 08-13-21) 
 
A histocompatibility laboratory does matching tests in preparation for procedures such as 
kidney transplants, bone marrow transplants, and blood platelet transfusions.  It is the only 
type of laboratory that must submit a Form CMS-855A application.  Each histocompatibility 
lab must meet all applicable requirements in 42 CFR Part 493 (see 42 CFR  493.1 in 
particular) and undergo a state survey. 
For information on the appropriate contractor jurisdiction for incoming histocompatibility lab 
applications, see Pub. 100-04, chapter 1, section 20. 
 
10.2.1.6 - Home Health Agencies (HHAs) 
(Rev. 11574; Issued: 08-25-22; Effective: 06-24-22; Implementation: 09-27-22) 
 
A. Background  
 
1.  General Information 
 
An HHA is an entity that provides skilled nursing services and at least one of the following 
therapeutic services: speech therapy, physical therapy, occupational therapy, home health aide  services, and medical social services.  The services must be furnished in a place of residence 
used as the patients home. 
 
Like most certified providers, HHAs receive a state survey (or a survey from an approved 
accrediting organization) to determine compliance with federal, state, and local laws) and must 
sign a provider agreement.   
 
There are two potential components of an HHA organization: 
 
Parent  The parent HHA is the entity that maintains overall administrative control of its 
location(s). 
 
Branch  A branch office is a location or site from which an HHA provides services within a 
portion of the total geographic area served by the parent agency. The branch office is part of the 
HHA and is located sufficiently close to the parent agency so that it shares administration, 
supervision, and services with the parent agency on a daily basis. The branch office is not 
required to independently meet the conditions of participation as an HHA; the branch can thus be 
listed as practice locations on the main providers Form CMS-855A.  Though the branch 
receives a 10-digit CCN identifier, it bills under the parent HHAs CCN.   
 
See Pub. 100-07, chapter 2 for more information on branches. 
 
2.  Out-of-State HHA Operations 
 
Pub. 100-07, chapter 2, section 2184 states that when an HHA provides services across state 
lines: 
 
  It must be certified by the state in which its CCN is based.   
 
  The involved states must have a written reciprocal agreement permitting the HHA to provide 
services in this manner.  In those states that have a reciprocal agreement, HHAs are not 
required to be separately approved in each state; consequently, they would not have to obtain 
a separate Medicare provider agreement/number in each state.  HHAs residing in a state that 
does not have a written reciprocal survey agreement with a contiguous state are precluded 
from providing services across state lines; the HHA must establish a separate parent agency 
in the state in which it wishes to provide services.   
 
  A CMS approved branch office may be physically located in a neighboring state if the state 
agencies responsible for certification in each state approve the operation. 
 
See section 10.3.1(A)(1)(d)(iii) of this chapter for additional information regarding the 
enrollment of out-of-state HHA locations. 
 
B.  Processing Instructions for HHA Initial Form CMS-855A Applications 
 
1.  Receipt of Application 
  Upon receipt of an HHA initial Form CMS-855A application, the contractor shall undertake the 
following (in whichever order the contractor prefers unless directed otherwise in this chapter): 
 
(A) Perform all data validations otherwise required per this chapter    
 
(B) Ensure that the application(s) is complete consistent with the instructions in this chapter 
 
(C) Ensure that the HHA has submitted all documentation otherwise required per this chapter.  
For HHA initial enrollment, this also includes the following: 
 
  Form CMS-1561 (Health Insurance Benefit Agreement, also known as a provider 
agreement)   
 
  Evidence of successful electronic submission of the Form HHS-690 through the Office of 
Civil Rights (OCR) portal, as applicable.  (Evidence should be either written or electronic 
documentation.) (See https://www.hhs.gov/sites/default/files/forms/hhs-690.pdf for more 
information.)   
 
(The HHA must complete, sign, date, and include the Form CMS-1561, though the HHA need 
not complete those sections of the form reserved for CMS.  For organizational HHAs, an 
authorized official (as defined in  424.502) must sign the form; for sole proprietorships, the sole 
proprietor must sign.)   
 
Notwithstanding the foregoing, if the Form CMS-1561 or the Form HHS-690 evidence is 
missing, unsigned, undated, or otherwise incomplete, the contractor need not develop for the 
form(s) or the information thereon; the contractor shall instead notify the state in its 
recommendation letter which document(s) was/were missing or otherwise incomplete. For all 
other missing or incomplete required documentation, the contractor shall follow the normal 
development instructions in this chapter. 
 
2.  Conclusion of Initial Contractor Review 
 
(Nothing in this section 10.2.1.6(B) prohibits the contractor from returning or rejecting the HHA 
application if otherwise permitted to do so per this chapter.  When returning or rejecting the 
application, the contractor shall follow this chapters procedures for doing so.)     
 
(A) Approval Recommendation 
 
If, consistent with the instructions in section 10.2.1.6(B) and this chapter, the contractor believes 
an approval recommendation is warranted, the contractor shall send the recommendation to the 
state pursuant to existing practice and this chapters instructions.  The contractor need not copy 
the SOG Location or PEOG on the recommendation.  Unless CMS directs otherwise, the 
contractor shall also send to the provider the notification letter in section 10.7.5.1(E) of this 
chapter. 
 
The state will: (1) review the recommendation package for completeness; (2) review the 
contractors recommendation for approval; (3) perform any state-specific functions; and (4)  contact the contractor with any questions.  The contractor shall respond to any state inquiry in 
Item (4) within 5 business days.  If the inquiry involves the need for the contractor to obtain 
additional data, documentation, or clarification from the HHA, however, the timeframe is 15 
business days; if the provider fails to respond to the contractor within this timeframe, it shall 
notify the state thereof.  The contractor may always contact its PEOG BFL should it need the 
latters assistance with a particular state inquiry. 
 
(B) Denial 
 
If the contractor determines that a denial is warranted, it shall follow the denial procedures 
outlined in this chapter.  This includes: (1) using the appropriate denial letter format in section 
10.7.8 of this chapter; and (2) if required under section 10.6.6 (or another CMS directive) of this 
chapter, referring the matter to PEOG for review prior to denying the application. 
 
3.  Completion of State Review 
 
The state will notify the contractor once it has completed its review.  There are two potential 
outcomes: 
   
(A)  Approval Not Recommended 
 
If the state does not recommend approval, it will notify the contractor thereof.  (The contractor 
may accept any notification that is in writing (e-mail is fine).)  A site visit need not be 
performed.  No later than 5 business days after receiving this notification, therefore, the 
contractor shall commence the actions described in section 10.2.1.6(B)(2)(B) above.   
 
(B)  Approval Recommended 
 
If the state recommends approval, it will typically (though not always) do so via a Form CMS-
1539; the contractor may accept any documentation from the state signifying that the latter 
recommends approval.  (Note that the contractor will not receive a formal tie-in notice.) 
No later than 5 business days after receiving the states recommendation, the contractor shall 
commence the following activities: 
 
(i) Order a site visit 
(ii) Undertake the 3rd capitalization review discussed in section 10.6.1.2.2 of this chapter.  
 
(iii) Ensure that each entity and individual listed in Sections 2, 5 and 6 of the HHAs Form CMS-
855A application is again reviewed against the Medicare Exclusion Database (MED) and the 
System for Award Management (SAM).  (This activity applies: (1) regardless of whether the 
HHA is provider-based or freestanding; and (2) only to initial enrollments).) 
 
If:  
 
a.  The HHA is still in compliance (e.g., no owners or managing employees are 
excluded/debarred; capitalization is met; site visit is passed): No later than 3 business days after 
all of these activities are complete (i.e., the 3-day period begins when the last of the three  activities has been completed), the contractor shall send an e-mail to 
MedicareProviderEnrollment@cms.hhs.gov with the following information and documents:  
 
  The Form CMS-855 application (or PECOS Application Data Report) and all applicable 
documents  
  A copy of the Form CMS-1539 or similar documentation received from the state 
  A copy of the provider-signed Form CMS-1561 
  A copy of the draft approval letter, with the effective date shown on the Form CMS-1539 (or 
similar documentation) included in the draft letter.  (See section 10.7.5.1 for the model 
approval letter.) 
 
PEOG will countersign the provider agreement.  Based on the information received from the 
contractor, PEOG will also (1) assign an effective date, (2) assign a CCN, and (3) enter the 
applicable data into ASPEN, and (4) approve (with possible edits) the approval letter.   
 
Within 5 business days of receiving from PEOG the signed provider agreement, effective date, 
and CCN, the contractor shall: (1) send the approval letter and a copy of the CMS-countersigned 
provider agreement to the HHA; (2) send a copy of both the approval letter and the provider 
agreement to the state and/or AO (as applicable)); and (3) switch the PECOS record from 
approval recommended to approved consistent with existing instructions. 
 
b.   The HHA is not in compliance (e.g., the HHA does not meet one of the requirements):   
The contractor shall deny the application in accordance with the instructions in this chapter.   
 
C.  Site Visits  
 
1.  Initial application The scope of the site visit will be consistent with sections 10.6.20(A) and 
10.6.20(B) of this chapter.  The NSVC will perform the site visit.  The contractor shall not 
convey Medicare billing privileges to the provider prior to the completion of the NSVCs site 
visit and the contractors review of the results. 
 
2.  Revalidation  If an HHA submits a revalidation application, the contractor shall order a site 
visit through PECOS.  This is to ensure that the provider is still in compliance with CMSs 
enrollment requirements.  The scope of the site visit will be consistent with sections 10.6.20(A) 
and 10.6.20(B) of this chapter.  The NSVC will perform the site visit.  The contractor shall not 
make a final decision regarding the revalidation application prior to the completion of the 
NSVCs site visit and the contractors review of the results. 
 
3.  New/changed location - If an HHA is (1) adding a new location or (2) changing the physical 
location of an existing location, the contractor shall order a site visit of the new/changed location 
through PECOS no later than 5 business days after the contractor receives the approval 
recommendation from the state but before the contractor sends to PEOG the applicable e-mail 
described in section 10.6.1.2(A)(3) of this chapter.  (See the latter section for more information.)  
This is to ensure that the new/changed location complies with CMSs enrollment requirements.  
The scope of the site visit will be consistent with sections 10.6.20(A) and 10.6.20(B) of this 
chapter.  The NSVC will perform the site visit.  The contractor shall not make a final decision  regarding the change of information application prior to the completion of the NSVCs site visit 
and the contractors review of the results. 
 
 
D.  Nursing Registries 
 
If the HHA checks Yes in Section 12B of the Form CMS-855A, the contractor shall ensure 
that the information furnished about the HHA nursing registry is accurate.  (A nursing registry is 
akin to a staffing agency, whereby a private company furnishes nursing personnel to hospitals, 
clinics, and other medical providers.) 
 
E.  Recommendation before New HHA Location Established 
   
If an HHA is adding a branch or changing the location of its main location or an existing branch, 
the contractor may make a recommendation for approval to the state prior to the establishment of 
the new/changed location (notwithstanding any other instruction in this chapter to the contrary). 
If the contractor opts to make such a recommendation prior to the establishment of the 
new/changed location, it shall note in its recommendation letter that the HHA location has not 
yet moved or been established. 
 
F.  CHOWs and Changes of Information 
 
HHA changes of ownership shall be processed in accordance with, as applicable, section 
10.2.1.6.1 or section 10.6.1.1.  HHA changes of information shall be processed in accordance 
with section 10.6.1.2. 
 
G.  Additional Information 
 
For more information on HHAs, refer to: 
  Sections 1861(o) and 1891 of the Social Security Act 
  42 CFR Part 484 
  42 CFR  489.28 (capitalization) 
  Pub. 100-07, chapter 2  
  Pub. 100-04, chapter 10  
  Pub. 100-02, chapter 7  
10.2.1.6.1  HHA Ownership Changes 
(Rev. 11574; Issued: 08-25-22; Effective: 06-24-22; Implementation: 09-27-22) 
 
A.   Background  36-Month Rule 
 
1.   General Principles  
 
Effective January 1, 2011, and in accordance with 42 CFR  424.550(b)(1), if there is a change 
in majority ownership of an HHA by sale (including asset sales, stock transfers, mergers, and 
consolidations) within 36 months after the effective date of the HHAs initial enrollment in 
Medicare or within 36 months after the HHAs most recent change in majority ownership, the  provider agreement and Medicare billing privileges do not convey to the new owner. The 
prospective provider/owner of the HHA must instead: 
 
  Enroll in the Medicare program as a new (initial) HHA under the provisions of  424.510, 
and 
 
  Obtain a state survey or an accreditation from an approved accreditation organization. 
 
For purposes of  424.550(b)(1), a change in majority ownership (as defined in 42 CFR  
424.502) occurs when an individual or organization acquires more than a 50 percent direct 
ownership interest in an HHA during the 36 months following the HHAs initial enrollment into 
the Medicare program or the 36 months following the HHAs most recent change in majority 
ownership (including asset sales, stock transfers, mergers, or consolidations).  This includes an 
individual or organization that acquires majority ownership in an HHA through the cumulative 
effect of asset sales, stock transfers, consolidations, or mergers during the 36-month period after 
Medicare billing privileges are conveyed or the 36-month period following the HHAs most 
recent change in majority ownership. 
 
2.  Exceptions 
 
There are several exceptions to  424.550(b)(1).  Specifically, the requirements of  
424.550(b)(1) do not apply if: 
 
  The HHA has submitted 2 consecutive years of full cost reports since initial enrollment or the 
last change in majority ownership, whichever is later. (For purposes of this exception, low 
utilization or no utilization cost reports do not quality as full cost reports.) 
 
  The HHAs parent company is undergoing an internal corporate restructuring, such as a 
merger or consolidation. 
 
  The HHA is changing its existing business structure  such as from a corporation, a 
partnership (general or limited), or a limited liability company (LLC) to a corporation, a 
partnership (general or limited) or an LLC - and the owners remain the same. 
 
  An individual owner of the HHA dies. 
 
In addition,  424.550(b)(1) does not apply to indirect ownership changes. 
 
3.  Timing of 36-Month Period 
 
As indicated earlier, the provisions of 42 CFR  424.550(b)(1) and (2) (as enacted in CMS-
6010-F, Medicare Program; Home Health Prospective Payment System Rate Update for 
Calendar Year 2011; Changes in Certification Requirements for Home Health Agencies and 
Hospices; Final Rule) became effective January 1, 2011.  This means these provisions impact 
only those HHA ownership transactions whose effective date is on or after January 1, 2011.  
However, the provisions can apply irrespective of when the HHA first enrolled in Medicare.  
Consider the following illustrations:   
  Example 1  Smith HHA initially enrolled in Medicare effective July 1, 2009.  Smith 
underwent a change in majority ownership effective September 1, 2011.  The provisions of  
424.550(b)(1) applied to Smith because it underwent a change in majority ownership within 
36 months of its initial enrollment. 
 
  Example 2  Jones HHA initially enrolled in Medicare effective July 1, 2007.  Jones 
underwent a change in majority ownership effective February 1, 2019.  Section 
424.550(b)(1) did not apply to this transaction because it occurred more than 36 months after 
Joness initial enrollment.  Suppose, however, that Jones underwent another change in 
majority ownership effective February 1, 2020.  Section 424.550(b)(1) applied to this 
transaction because it took place within 36 months after Joness most recent change in 
majority ownership (i.e., on February 1, 2019). 
 
  Example 3  Davis HHA initially enrolled in Medicare effective July 1, 2012.  It underwent 
its first change in majority ownership effective December 1, 2015.  This change was not 
affected by 424.550(b)(1) because it occurred more than 36 months after Daviss initial 
enrollment.  Davis underwent another change in majority ownership effective July 1, 2019.  
This change, too, was unaffected by  424.550(b)(1), for it occurred more than 36 months 
after the HHAs most recent change in majority ownership (i.e., on December 1, 2015).  
Davis underwent another majority ownership change on July 1, 2020.  This change was 
impacted by  424.550(b)(1), since it occurred within 36 months of the HHAs most recent 
change in majority ownership (i.e., on July 1, 2019). 
 
B.  Determining the 36-Month Rules Applicability 
 
If the contractor receives a Form CMS-855A application reporting an HHA ownership change 
(and unless a CMS instruction or directive states otherwise), it shall undertake the following 
steps: 
 
Step 1  Change in Majority Ownership 
 
The contractor shall determine whether a change in direct majority ownership has occurred.  
Through its review of the transfer agreement, sales agreement, bill of sale, etc., the contractor 
shall verify whether: 
 
  The ownership change was a direct ownership change and not a mere indirect ownership 
change, and 
 
  The change involves a party assuming a greater than 50 percent ownership interest in the 
HHA. 
 
Assumption of a greater than 50 percent direct ownership interest can generally occur in one of 
three ways.  First, an outside party that is currently not an owner can purchase more than 50 
percent of the business in a single transaction.  Second, an existing owner can purchase an 
additional interest that brings its total ownership stake in the business to greater than 50 percent.  
For instance, if a 40 percent owner purchased an additional 15 percent share of the HHA, this  would constitute a change in majority ownership.  This is consistent with the verbiage in the 
aforementioned definition of change in majority ownership regarding the cumulative effect 
of asset sales, transfers, etc.  Another example of a change in majority ownership would be if a 
50 percent owner obtains any additional amount of ownership (regardless of the percentage) and 
hence becomes a majority owner; thus, for instance, if a 50 percent owner were to acquire an 
additional .001 percent ownership stake, he or she becomes a majority owner and the transaction 
involves a change in majority ownership. 
 
If the transfer does not qualify as a change in majority ownership, the contractor can process the 
application normally (which will typically be as a change of information under 42 CFR  
424.516(e)).  If it does qualify, the contractor shall proceed to Step 2: 
 
Step 2  36-Month Period 
 
The contractor shall determine whether the effective date of the transfer is within 36 months after 
the effective date of the HHAs (1) initial enrollment in Medicare or (2) most recent change in 
majority ownership.  The contractor shall verify the effective date of the reported transfer by 
reviewing a copy of the transfer agreement, sales agreement, bill of sale, etc., rather than relying 
upon the date of the sale as listed on the application. It shall also review its records  and, if 
necessary, request additional information from the HHA  regarding the effective date of the 
HHAs most recent change in majority ownership, if applicable. 
 
If the effective date of the transfer does not fall within either of the aforementioned 36-month 
periods, the contractor may process the application normally; specifically, the contractor shall, as 
applicable and depending upon the facts of the case, process the application as a change of 
information under 42 CFR  424.516(e) or as a potential change of ownership under 42 CFR  
489.18.  
 
If the transfers effective date falls within one of these 36-month timeframes, the contractor shall 
proceed to Step 3. 
 
Step 3  Applicability of Exceptions 
 
If the contractor determines that a change in majority ownership has occurred within either of the 
above-mentioned 36-month periods, the contractor shall determine whether any of the exceptions 
in  424.550(b)(2) apply.  As alluded to earlier, the exceptions are as follows: 
 
i.  The HHA has submitted 2 consecutive years of full cost reports. 
 
(A) For purposes of this exception, low utilization or no utilization cost reports do not qualify as 
full cost reports. (See 42 CFR  413.24(h) for a definition of low Medicare utilization.) 
 
(B) The cost reports must have been: (1) consecutive, meaning that they were submitted in each 
of the 2 years preceding the effective date of the transfer; and (2) accepted by the contractor. 
 
ii.  The HHAs parent company is undergoing an internal corporate restructuring, such as a 
merger or consolidation. 
  iii. The HHA is changing its existing business structure  such as from a corporation, a 
partnership (general or limited), or an LLC to a corporation, a partnership (general or limited) or 
an LLC - and the owners remain the same. 
 
(A) If the HHA is undergoing a change in business structure other than those which are 
specifically mentioned in this exemption (e.g., corporation to an LLC), the contractor shall 
contact its PEOG Business Function Lead (BFL) for guidance. 
 
(B) For the exemption to apply, the owners must remain the same. 
 
iv. An individual owner of the HHA dies  regardless of the percentage of ownership the person 
had in the HHA. 
 
Step 4 - Determination 
 
If the contractor concludes that one of the aforementioned exceptions applies (and unless a CMS 
instruction or directive states otherwise), it may process the application normally; specifically, 
the contractor shall, as applicable and depending upon the facts of the case, process the 
application as a change of information under 42 CFR  424.516(e) (via the instructions in section 
10.6.1.2 of this chapter) or as a potential change of ownership under 42 CFR  489.18 (via the 
instructions in section 10.6.1.1 of this chapter).  
 
If no exception applies, the contractor shall refer the case to its PEOG BFL for review.  Under no 
circumstances shall the contractor apply the 36-month rule to the HHA and require an initial 
enrollment based thereon without the prior approval of PEOG.  If PEOG agrees with the 
contractors determination:  
 
(1) PEOG will terminate the seller in ASPEN. 
  
(2) The contractor shall identify the voluntary termination action in PECOS as a deactivation ---- 
and hence shall deactivate the HHAs billing privileges pursuant to  424.540(a)(8) --- with a 
status reason of Voluntarily Withdrawal from the Medicare Program.  Per  
424.540(d)(1)(ii)(E), the effective date of the deactivation shall be the date of the sale.   
 
(3) The contractor shall send to the HHA the 36-Month Rule Voluntary Termination Letter in 
section 10.7.5.1.  This letter will include, among other things, rebuttal rights regarding the 
deactivation as well as language stating that, as a result of  424.550(b)(1), the HHA must: 
 
  Enroll as an initial applicant; and 
 
  Obtain a new state survey or accreditation survey after it has submitted its initial enrollment 
application and the contractor has made a recommendation for approval to the state. 
 
(4) The HHA need not submit a Form CMS-855A voluntary termination application.  
  Providers and/or their representatives (e.g., attorneys, consultants) shall contact their local MAC 
with any questions concerning (1) the 36-month rule in general and (2) whether the rule and/or 
its exceptions apply in a particular providers case.   
 
C.  Additional Notes 
 
The contractor is advised of the following: 
 
1.    If the contractor learns of an HHA ownership change by means other than the submission of 
a Form CMS-855A application, it shall notify its PEOG BFL immediately. 
 
2.   If the contractor determines, under Step 3 above, that one of the  424.550(b)(2) exceptions 
applies, the ownership transfer still qualifies as a change in majority ownership for purposes of 
the 36-month clock.  To illustrate, assume that an HHA initially enrolled in Medicare effective 
July 1, 2010.  It underwent a change in majority ownership effective February 1, 2012.  The 
contractor determined that the transaction was exempt from  424.550(b)(1) because the HHA 
submitted full cost reports in the previous 2 years.  On February 1, 2014, the HHA underwent 
another change in majority ownership that did not qualify for an exception.  The HHA thus had 
to enroll as a new HHA under  424.550(b)(1) because the transaction occurred within 36 
months of the HHAs most recent change in majority ownership - even though the February 
2012 change was exempt from  424.550(b)(1). 
 
10.2.1.6.2  HHA Capitalization 
(Rev. 11682; Issued: 11-04-2022; Effective: 12-05-2022; Implementation: 12-05-2022) 
 
A.  Background 
 
Effective January 1, 2011, and pursuant to 42 CFR  489.28(a) and 424.510(d)(9), an HHA 
entering the Medicare program - including a new HHA resulting from a change of ownership if 
the change of ownership results in a new provider number being issued - must have available 
sufficient funds (known as initial reserve operating funds) at (1) the time of application 
submission and (2) all times during the enrollment process, to operate the HHA for the three-
month period after the Medicare contractor conveys billing privileges (exclusive of actual or 
projected accounts receivable from Medicare).  This means that the HHA must also have 
available sufficient initial reserve operating funds during the 3-month period following the 
conveyance of Medicare billing privileges.  
 
B.  Points of Review 
 
At a minimum, the contractor shall verify that the HHA meets the required amount of 
capitalization at the following times: 
 
  1st Review - Prior to making its recommendation for approval to the state 
 
  2nd Review  Between 30 and 35 calendar days after making its recommendation to the 
state.  (Only the request for proof of capitalization need be initiated between 30 and 35 
calendar days.  The verification need not be completed within or by this timeframe.)    
  3rd Review - After the contractor receives the state recommendation but before it sends to 
PEOG the e-mail described in section 10.2.1.6(B)(3)(B)  
 
  4th Review - During the 3-month period after the contractor conveys Medicare billing 
privileges to the HHA 
 
For initial applications, the contractor shall verify that the HHA meets all of the capitalization 
requirements addressed in 42 CFR 489.28.  (Note that capitalization need not be reviewed for 
revalidation, reactivation applications, and changes of ownership that do not require a new/initial 
enrollment under 424.550(b).)  The contractor may request from the HHA any and all 
documentation deemed necessary to perform this task. 
 
The HHA must submit proof of capitalization within 30 calendar days of the contractors request 
to do so.  Should the HHA fail to furnish said proof and billing privileges have not yet been 
conveyed, the contractor shall deny the HHAs application pursuant to 424.530(a)(8)(i) or (ii), 
as applicable.  If billing privileges have been conveyed, the contractor shall revoke the HHAs 
billing privileges per 424.535(a)(11). 
 
Should the contractor deem it necessary to verify the HHAs level of capitalization more than 
once within a given period (e.g., more than once between the time a recommendation is made 
and the completion of the state review process), the contractor shall seek approval from its 
PEOG BFL.  
 
C.  Determining Initial Reserve Operating Funds 
 
Initial reserve operating funds are sufficient to meet the requirement of 42 CFR 489.28(a) if the 
total amount of such funds is equal to or greater than the product of the actual average cost per 
visit of three or more similarly situated HHAs in their first year of operation (selected by CMS 
for comparative purposes) multiplied by the number of visits projected by the HHA for its first 3 
months of operation--or 22.5 percent (one fourth of 90 percent) of the average number of visits 
reported by the comparison HHAs--whichever is greater. 
 
The contractor shall determine the amount of the initial reserve operating funds by using reported 
cost and visit data from submitted cost reports for the first full year of operation from at least 
three HHAs that the contractor serves that are comparable to the HHA seeking to enter the 
Medicare program.  Factors to be used in making this determination shall include: 
 
  Geographic location and urban/rural status; 
  Number of visits;  
  Provider-based versus free-standing status; and  
  Proprietary versus non-proprietary status. 
 
The adequacy of the required initial reserve operating funds is based on the average cost per visit 
of the comparable HHAs, by dividing the sum of total reported costs of the HHAs in their first 
year of operation by the sum of the HHAs' total reported visits. The resulting average cost per 
visit is then multiplied by the projected visits for the first 3 months of operation of the HHA  seeking to enter the program, but not less than 90 percent of average visits for a 3-month period 
for the HHAs used in determining the average cost per visit. 
 
D.  Proof of Operating Funds 
 
As described further in section 10.2.1.6.2(E) and (G) below, the HHA must provide CMS with 
adequate proof of the availability of initial reserve operating funds.  In some cases, an HHA may 
have all or part of the initial reserve operating funds in cash equivalents. For purposes of the 
capitalization requirement, cash equivalents are short-term, highly liquid investments that are 
readily convertible to known amounts of cash and that present insignificant risk of changes in 
value.  A cash equivalent that is not readily convertible to a known amount of cash as needed 
during the initial 3-month period for which the initial reserve operating funds are required does 
not qualify as meeting the initial reserve operating funds requirement.  Examples of cash 
equivalents for purposes of the capitalization requirement are Treasury bills, commercial paper, 
and money market funds. 
 
As with funds in a checking, savings, or other account, the HHA also must be able to document 
the availability of any cash equivalents. CMS may later require the HHA to furnish: (1) another 
attestation from the financial institution that the funds remain available; and/or (2) 
documentation from the HHA that any cash equivalents remain available until a date when the 
HHA will have been surveyed by the state agency or by an approved accrediting organization. 
The officer of the HHA who will be certifying the accuracy of the information on the HHA's cost 
report must certify what portion of the required initial reserve operating funds constitutes non-
borrowed funds, including funds invested in the business by the owner.  That amount must be at 
least 50 percent of the required initial reserve operating funds.  The remainder of the reserve 
operating funds may be secured through borrowing or line of credit from an unrelated lender. 
 
E.  Borrowed Funds  
 
1.  General Information 
 
If borrowed funds are not in the same account(s) as the HHA's own non-borrowed funds, the 
HHA also must provide proof that the borrowed funds are available for use in operating the 
HHA.  As part of this, and except as stated in section 10.2.1.6.2(E)(2) and (H) below, the HHA 
must (at a minimum) furnish: (1) a copy of the statement(s) of the HHA's savings, checking, or 
other account(s) containing the borrowed funds; and (2) an attestation from an officer of the bank 
or other financial institution that the funds are in the account(s) and are immediately available to 
the HHA. As with the HHA's own (that is, non-borrowed) funds, CMS later may require the 
HHA to establish the current availability of such borrowed funds; this could include furnishing 
an attestation from a financial institution or other source (as may be appropriate) to establish that 
such funds will remain available until a date when the HHA will have been surveyed by the state 
agency or by an approved accrediting organization. 
 
2.  Inability to Obtain Attestation Statements 
 
Several national bank chains are no longer providing the attestation statements referenced in 42 
CFR  489.28(d) and  489.28(e) (e.g., to verify the existence of capitalization funds for HHAs). 
Accordingly, the contractor may accept a current bank statement unaccompanied by an  attestation from an officer of the bank or other financial institution if the HHA cannot secure the 
attestation. (See the phrase (if the financial institution offers such attestations) in revised  
489.28(d) and (e).)  All efforts must be exhausted, however, to obtain the attestation of funds 
statement before the contractor can forgo this requirement. In no circumstances shall the 
contractor instruct the HHA to obtain a different bank that will provide an attestation statement. 
All other documents listed in section 10.2.1.6(G) must be obtained if required. 
 
F.  Line of Credit 
 
If the HHA chooses to support the availability of a portion of the initial reserve operating funds 
with a line of credit, it must provide CMS with a letter of credit from the lender. CMS later may 
require the HHA to furnish an attestation from the lender that the HHA, upon its certification 
into the Medicare program, continues to be approved to borrow the amount specified in the letter 
of credit. 
 
G.  Documents 
 
As part of ensuring the prospective HHAs compliance with the capitalization requirements, the 
contractor shall obtain the following from the HHA: 
 
  A document outlining the HHAs projected budget  preferably, a full years budget broken 
out by month 
 
  A document outlining the number of anticipated visits - preferably a full year broken out by 
month 
 
  An attestation statement from an officer of the HHA defining the source of funds 
 
  Copies of bank statements, certificates of deposits, etc., supporting that cash is available 
(must be current) 
 
  Except as stated in section 10.2.1.6.2(E)(2) above, a letter from an officer of the bank 
attesting that funds are available 
 
  If available, audited financial statements 
 
The contractor shall also ensure that the capitalization information in Section 12 of the Form 
CMS-855A is provided. 
 
10.2.1.7 - Hospices 
(Rev. 10868; Issued: 07-14-21; Effective: 08-13-21; Implementation: 08-13-21) 
 
A. General Background Information 
 
A hospice is a public agency or private organization or subdivision of either of these that is 
primarily engaged in providing a comprehensive set of services such as the assessment and 
management of pain. Typically, the need for services is identified and coordinated by an  interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional 
needs of a terminally ill patient and/or family members, as delineated in a specific patient 
plan of care.  
 
B. Enrollment Information 
 
1. Multiple Practice locations 
 
Hospices are not precluded from having multiple practice locations if permitted by the SOG 
Location.  If the SOG Location disapproves an additional practice location, the location must 
seek Medicare approval as a separate hospice with its own enrollment and provider 
agreement.  (See Pub. 100-07, chapter 2, section 2088 for the policies regarding multiple 
hospice locations.) 
 
2. Site Visits 
 
a. Initial application  If a hospice submits an initial application, the contractor shall order a 
site visit through PECOS after the contractor receives the tie-in notice (or approval letter) 
from the SOG Location but before the contractor conveys Medicare billing privileges to the 
hospice.  This is to ensure that the provider is still in compliance with CMSs enrollment 
requirements.  The scope of the site visit will be consistent with section 10.6.20(A) and 
10.6.20(B) of this chapter.  The NSVC will perform the site visit.  The contractor shall not 
convey Medicare billing privileges to the provider prior to the completion of the NSVCs site 
visit and the contractors review of the results. 
 
b. Revalidation  If a hospice submits a revalidation application, the contractor shall order a 
site visit through PECOS.  This is to ensure that the provider is still in compliance with 
CMSs enrollment requirements.  The scope of the site visit will be consistent with sections 
10.6.20(A) and 10.6.20(B) of this chapter.  The NSVC will perform the site visit.  The 
contractor shall not make a final decision regarding the revalidation application prior to the 
completion of the NSVCs site visit and the contractors review of the results. 
 
c. New/changed location - If a hospice is (1) adding a new location or (2) changing the 
physical location of an existing location, the contractor shall order a site visit of the 
new/changed location through PECOS after the contractor receives notice of approval from 
the SOG Location but before the contractor switches the providers enrollment record to 
Approved.  This is to ensure that the new/changed location is in compliance with CMSs 
enrollment requirements.  The scope of the site visit will be consistent with sections 
10.6.20(A) and 10.6.20(B) of this chapter.  The NSVC will perform the site visit.  The 
contractor shall not switch the providers enrollment record to Approved prior to the 
completion of the NSVCs site visit and the contractors review of the results. 
 
C.  Additional Information: 
 
For more information on hospices, refer to: 
 
  Sections 1861(u) and 1861(dd) of the Social Security Act    42 CFR Part 418 
  Pub. 100-07, chapter 2, sections 2080  2089  
  Pub. 100-04, chapter 11  
  Pub. 100-02, chapter 9  
 
10.2.1.8 - Hospitals and Hospital Units 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
(This section 10.2.1.8 applies to standard hospitals (as the term hospital is defined in  
1861(e)(1)), psychiatric hospitals, hospital units, and transplant programs.  It does not apply to 
critical access hospitals, which are a separate provider type and are not transitioning.) 
 
A. General Background Information 
 
Hospitals and hospital units are a provider type that enrolls via the Form CMS-855A.  An 
exception to this is when the hospital is requesting enrollment to bill for practitioner services for 
hospital departments, outpatient departments, outpatient locations, and/or hospital clinics; in this 
circumstance, a new Form CMS-855B enrollment application is required.  
 
B.  Processing Instructions for Hospital Initial Form CMS-855A Applications 
 
1.  Receipt of Application 
 
Upon receipt of a hospital initial Form CMS-855A application, the contractor shall undertake the 
following (in whichever order the contractor prefers unless directed otherwise in this chapter): 
 
(A)  Perform all data validations otherwise required per this chapter.    
 
(B) Ensure that the application(s) is complete consistent with the instructions in this chapter. 
 
(C) Ensure that the hospital has submitted all documentation otherwise required per this chapter.  
For hospital initial enrollment, this also includes the following: 
 
  Form CMS-1561 (Health Insurance Benefit Agreement, also known as a provider 
agreement)   
 
  Evidence of successful electronic submission of the Form HHS-690 through the Office of 
Civil Rights (OCR) portal, as applicable.  (Evidence should be either written or electronic 
documentation.) (See https://www.hhs.gov/sites/default/files/forms/hhs-690.pdf for more 
information.)   
 
(An authorized official (as defined in  424.502) must complete, sign, date, and include the Form 
CMS-1561, though the hospital need not complete those sections of the form reserved for CMS.)   
 
Notwithstanding the foregoing, if the Form CMS-1561 or the Form HHS-690 evidence is 
missing, unsigned, undated, or otherwise incomplete, the contractor need not develop for the 
form(s) or the information thereon; the contractor shall instead notify the state in its  recommendation letter which document(s) was/were missing or otherwise incomplete.  For all 
other missing or incomplete required documentation, the contractor shall follow the normal 
development instructions in this chapter. 
 
2.  Conclusion of Initial Contractor Review 
 
(Nothing in this section 10.2.1.8(B) prohibits the contractor from returning or rejecting the 
hospital application if otherwise permitted to do so per this chapter.  When returning or rejecting 
the application, the contractor shall follow this chapters procedures for doing so.)     
 
(A) Approval Recommendation 
 
If, consistent with the instructions in section 10.2.1.8(B)(2) and this chapter, the contractor 
believes an approval recommendation is warranted, the contractor shall send the 
recommendation to the state pursuant to existing practice and this chapters instructions.  The 
contractor need not copy the SOG Location or PEOG on the recommendation.  Unless CMS 
directs otherwise, the contractor shall also send to the provider the notification letter in section 
10.7.5.1(E) of this chapter. 
 
The state will: (1) review the recommendation package for completeness; (2) review the 
contractors recommendation for approval; (3) perform any state-specific functions; and (4) 
contact the contractor with any questions.  The contractor shall respond to any state inquiry in 
Item (4) within 5 business days.  If the inquiry involves the need for the contractor to obtain 
additional data, documentation, or clarification from the hospital, however, the timeframe is 15 
business days; if the provider fails to respond to the contractor within this timeframe, it shall 
notify the state thereof.  The contractor may always contact its PEOG BFL should it need the 
latters assistance with a particular state inquiry. 
 
(B) Denial 
 
If the contractor determines that a denial is warranted, it shall follow the denial procedures 
outlined in this chapter.  This includes: (1) using the appropriate denial letter format in section 
10.7.5.1 of this chapter; and (2) if required under section 10.6.6 (or another CMS directive) of 
this chapter, referring the matter to PEOG for review prior to denying the application. 
 
3.  Completion of State Review 
 
The state will notify the contractor once it has completed its review.  There are two potential 
outcomes: 
 
(A)  Approval Not Recommended 
 
If the state does not recommend approval, it will notify the contractor thereof.  (The contractor 
may accept any notification that is in writing (e-mail is fine).)  The site visit described in 
subsection (D)(1) below need not be performed.  No later than 5 business days after receiving 
this notification, the contractor shall commence the actions described in section 
10.2.1.8(B)(2)(B) above.   
  (B)  Approval Recommended 
 
If the state recommends approval, it will typically (though not always) do so via a Form CMS-
1539; the contractor may accept any documentation from the state signifying that the latter 
recommends approval.  (Note that the contractor will not receive a formal tie-in notice.) 
 
No later than 5 business days after receipt of the recommendation from the state, the contractor 
shall send an e-mail to MedicareProviderEnrollment@cms.hhs.gov with the following 
information and documents:  
 
  The Form CMS-855 application (or PECOS Application Data Report) and all application 
attachments   
  A copy of the Form CMS-1539 from the state or similar documentation received from the 
accrediting organization 
  A copy of the provider-signed Form CMS-1561 
  A copy of the draft approval letter, with the effective date shown on the Form CMS-1539 (or 
similar documentation) included in the draft letter.  (See section 10.7.5.1 for the model approval 
letter.)    
 
PEOG will countersign the provider agreement.  Based on the information received from the 
contractor, PEOG will also (1) assign an effective date, (2) assign a CCN, and (3) enter the 
applicable data into the applicable national database, and (4) approve (with possible edits) the 
approval letter.  Within 5 business days of receiving from PEOG the signed provider agreement, 
effective date, and CCN, the contractor shall: (1) send the approval letter and a copy of the CMS-
countersigned provider agreement to the hospital; (2) send a copy of both the approval letter and 
the provider agreement to the state and/or accrediting organization (as applicable); and (3) switch 
the PECOS record from approval recommended to approved consistent with existing 
instructions. 
 
C.  Additional Enrollment Information 
 
1.  Swing-Bed Designation  
 
A swing-bed hospital is one that is approved by CMS to furnish post-hospital skilled nursing 
facility (SNF) services. That is, hospital (or critical access hospital (CAH)) patients beds can 
swing from furnishing hospital services to providing SNF care without the patient necessarily 
being moved to another part of the building.  It receives a separate survey and certification from 
that of the hospital.  Thus, if swing-bed designation is terminated, the hospital still maintains its 
certification.  In addition, the hospital is given an additional CCN to bill for swing-bed services.  
(The third digit of the CCN will be the letter U, W, Y or Z.) 
 
In general, and as stated in 42 CFR  482.58, in order to obtain swing-bed status the hospital 
must, among other things: (1) have a Medicare provider agreement; (2) be located in a rural area; 
and (3) have fewer than 100 non-newborn or intensive care beds.  Swing-bed hospitals, 
therefore, are generally small hospitals in rural areas where there may not be enough SNFs, and 
the hospital is thus used to furnish SNF services. 
  A separate provider agreement and enrollment for the swing-bed unit is not required.  (The 
hospitals provider agreement incorporates the swing-bed services.)  The hospital can add the 
swing-bed unit as a practice location via the Form CMS-855A. 
 
Additional data on swing-bed units can be found in Pub. 100-07, chapter 2, sections 2036  
2040.  
 
2.  Psychiatric and Rehabilitation Units  
 
Though these units receive a state survey, a separate provider agreement and enrollment is not 
required.  (The hospitals provider agreement incorporates these units.)  The hospital can add the 
unit as a practice location to the Form CMS-855A. 
 
3.  Multi-Campus Hospitals  
 
A multi-campus hospital (MCH) has two or more hospital campuses operating under one CCN.  
The MCH would report its various units/campuses as practice locations on the Form CMS-855A.  
For additional information on multi-campus hospitals, see Pub. 100-07, chapter 2, section 2024. 
 
4.  Physician-Owned Hospitals 
 
As defined in 42 CFR  489.3, a physician-owned hospital (POH) means any participating 
hospital (as defined in 42 CFR 489.24) in which a physician or an immediate family member of 
a physician has an ownership or investment interest in the hospital.  The ownership or investment 
interest may be through equity, debt, or other means, and includes an interest in an entity that 
holds an ownership or investment interest in the hospital.  (This definition does not include a 
hospital with physician ownership or investment interests that satisfy the requirements at 42 CFR 
 411.356(a) or (b).) 
 
Section 2(A)(4) of the Form CMS-855A asks the applicant to identify whether it is a physician-
owned hospital.  If the applicant indicates in Section 2(A)(2) that it is a hospital, it must 
complete Section 2(A)(4).  Applicants that are not hospitals need not complete Section 2(A)(4). 
 
At this time, POHs are not required to submit a completed Form CMS-855POH or a completed 
Attachment 1 of the Form CMS-855A. As stated in the March 12, 2015 announcement in MLN 
Connects Provider eNews, CMS has extended the deadline for the POH Initial Annual 
Ownership/Investment Report due to concerns about the accuracy of the data collected in the 
report. Future instruction regarding the reporting of POH ownership and investment will be 
provided on the CMS physician self-referral website.  
 
5.  Critical Access Hospitals 
 
Critical access hospitals (CAHs) are not considered to be a hospital sub-type for enrollment 
purposes.  CAHs instead must be enrolled as a separate, distinct provider type. Thus, if an 
existing hospital wishes to convert to a CAH, it must submit a Form CMS-855A as an initial 
enrollment. 
 
6.  Hospital Addition of Practice Location    
In situations where a hospital is adding a practice location, the contractor shall notify the 
provider in writing that its recommendation for approval does not constitute approval of the 
facility or group as provider-based under 42 CFR  413.65.  
 
If the contractor makes a recommendation for approval of the providers request to add a hospital 
unit, the contractor shall forward the package to the state agency as described in this chapter. 
 
7.  Transplant Programs 
 
A transplant program is a component within a transplant hospital that provides transplantation of 
a particular type of organ to include: heart, lung, liver, kidney, pancreas, or intestine.  All organ 
transplant programs must be located in a hospital that has a Medicare provider agreement.  The 
transplant program will receive a CCN that is separate and distinct from the hospital. 
 
For purposes of Medicare enrollment, a hospital transplant program is treated similarly to a 
hospital sub-unit.  If the hospital wishes to add a transplant program, it must check the other 
box in Section 2A2 of the Form CMS-855A, write transplant program (and the type(s) thereof, 
such as liver transplant program, kidney transplant program, etc.) on the space provided, and 
follow the standard instructions for adding a hospital sub-unit.  (If multiple types of transplant 
programs are listed, the contractor shall (a) treat each as a separate sub-unit for enrollment 
purposes and (b) process the application in the same fashion it would a hospital application that 
is reporting/adding multiple sub-units.)  No separate enrollment in PECOS need or will be 
created for the transplant center. 
 
 
 
 
D.  Section 4 of the Form CMS-855A 
 
Regarding Section 4 of the Form CMS-855A, the hospital must list all addresses where it - and 
not a separately enrolled provider or supplier it owns or operates, such as a nursing home - 
furnishes services.  The hospitals primary practice location should be the first location identified 
in Section 4A and the contractor shall treat it as such  unless there is evidence indicating 
otherwise.  NOTE: Hospital departments located at the same address as the main facility need 
not be listed as practice locations on the Form CMS-855A. 
 
If an enrolled hospital seeks to add or delete a rehabilitation, psychiatric, or swing-bed unit, it 
should submit a Form CMS-855 change of information request and not, respectively, an initial 
enrollment application or a voluntary termination application. 
 
E.  Non-Participating Emergency Hospitals, Veterans Administration (VA) Hospitals, and 
Department of Defense (DOD) Hospitals 
 
Non-participating emergency hospitals, VA hospitals and DOD hospitals no longer need to 
complete a Form CMS-855A enrollment application in order to bill Medicare. 
 
F.  Form CMS-855B Applications Submitted by Hospitals   
1.  Group Practices 
 
If an entity is enrolling via the Form CMS-855B as a hospital-owned clinic/physician practice, 
the contractor shall contact the applicant to determine whether the latter will be billing any of the 
listed locations as provider-based.  If the applicant will not be billing as provider-based, the 
contractor shall process the application normally.  If, however, the applicant will bill as provider-
based, the contractor shall notify the applicant that the hospital must report any changed practice 
locations to its contractor via the Form CMS-855A. 
 
If the supplier is enrolling as a hospital department (under the Clinic/Group Practice category 
on the Form CMS-855B) or an existing hospital department is undergoing a change of ownership 
(CHOW), the contractor shall only issue the necessary billing numbers upon notification that a 
provider agreement has been issued  or, in the case of a CHOW, the provider agreement has 
been transferred to the new owner.  If, however, the supplier is enrolling as a group practice that 
is merely owned by a hospital (as opposed to being a hospital department), the contractor need 
not wait until the provider agreement is issued before conveying billing privileges to the group. 
 
2. Individual Billings 
 
Assume an individual physician works for a hospital and will bill for services as an individual 
(i.e., not as part of the hospital service/payment).  However, he/she wants to reassign these 
benefits to the hospital.  The hospital will need to enroll with the contractor via the Form CMS-
855B (e.g., as a hospital department, outpatient location). 
 
10.2.1.8.1  Rural Emergency Hospitals (REHs) 
(Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
Section 125 of Division CC of the Consolidated Appropriations Act, 2021 added a new section 
1861(kkk) to the Social Security Act (the Act) to establish REHs as a new Medicare provider 
type to address the growing concern over closures of rural hospitals.  In accordance with section 
1861(kkk), a facility is eligible to convert to an REH if it was a CAH or rural hospital with not 
more than 50 beds as of December 27, 2020.  REHs must provide emergency services and 
observation care and are prohibited by the statute from providing inpatient services.   
 
The CY 2023 OPPS/ASC final rule (CMS-1772-F) established, among other things, 
requirements that REHs must meet in order to bill Medicare.  These included enrollment 
requirements, addressed in part in new 42 CFR  424.575.  In short, the rule specified the 
following: 
 
  A CAH or rural hospital wishing to convert to an REH must submit a Form CMS-855A 
change of information application, rather than an initial application 
  No application fee need be paid 
  REHs will be in the limited screening category under 42 CFR  424.518 
  REHs fall within 42 CFR  424.520(a) in terms of establishing an effective date of billing 
privileges. 
  This section 10.2.1.8.1 instructs contractors on the processing of REH enrollment applications.  
Note that REHs (like CAHs) are not transitioning as that term is used in this chapter with 
respect to the survey and certification process. 
 
A.  Initial Process 
 
(CMS will notify the contractors and the public as to when prospective REHs may begin to 
submit applications.) 
 
1.  Submission 
 
In submitting a Form CMS-855A change of information (COI) application to convert to an REH, 
the facility must: 
 
(a) Check the You are changing your Medicare information box in Section 1(A)  
 
(b) Check the Other box in Section 2(A)(2) and write Rural emergency hospital or REH in 
the line next thereto 
 
(c) Complete Sections 2(B) (with REH information), 3, and 15 and/or 16 (as applicable) 
 
(d) Report any additions/deletions/changes to its current enrollment information (that is, its 
current CAH or rural hospital enrollment) that will stem from its conversion to an REH (e.g., 
new billing agency, adding/deleting two managing employees, deleting a 10 percent owner) 
 
(e) Submit all required state licenses/certifications for operation as an REH (if available to the 
provider at the time) 
 
(CMS will conduct outreach to the prospective REH community regarding the above 
requirements.)   
 
However, the facility need not submit with its application: 
 
  An application fee 
 
  Any documentation related to its existing enrollment as a CAH or rural hospital (e.g., CAH 
licensure) except if a new adverse legal action is also being reported, in which case the 
contractor shall follow the instructions in section 10.6.6 of this chapter concerning 
documentation acquisition. 
 
  Any other documentation that: (1) is specific to the survey and certification process; and (2) a 
non-transitioned, certified provider/supplier typically submits directly to the state or SOG 
Location pursuant to this process (e.g., a signed provider agreement).  The state or SOG Location 
will, as applicable, collect this information.  If the provider nonetheless submits these materials 
with its application, the contractor shall include them in any recommendation package it sends to 
the state; however, the contractor need not review them for compliance, signatures, etc.   
  2.  Initial Contractor Review 
 
In reviewing the application, the contractor shall adhere to the following: 
 
(i)  Eligibility - The contractor need not check PECOS to see whether the REH was enrolled as a 
CAH or a rural hospital as of December 27, 2020.  CMS and the state agency will determine 
whether the facility meets the REH statutory and regulatory requirements.  So long as the 
hospital indicates in Section 2 that it is an REH, the contractor can process the application 
normally (and consistent with the instructions in this section 10.2.1.8.1).   
 
(ii) Submission of New/Initial Enrollment  In the highly unlikely event that the facility submits 
a full, initial REH enrollment application rather than a COI, the contractor shall nonetheless 
process the application.  No fee is required.  (See subsection (A)(3) below for more information.)  
 
(iii) Application Fee  If the facility submits an application fee and/or hardship waiver, the 
contractor shall refund/return it consistent with the instructions in this chapter.  However, if the 
facility seeks to add a new location pursuant to its application, the contractor in all cases shall 
contact its PEOG BFL for guidance.   
 
(iv) Returns  If the contractor determines that a basis exists for returning the application under 
42 CFR  424.526 and section 10.4.1.4.2 of this chapter, the contractor shall contact its PEOG 
BFL for guidance.   
 
(v) Authorized/Delegated Officials  The facility is not required to assign and utilize new 
authorized and delegated officials pursuant to the conversion.  It may continue to use the officials 
who are part of its existing CAH or rural hospital enrollment.  However, as with any other 
change of information stemming from the conversion, the facility must report any changes to its 
current authorized/delegated officials; this could occur, for example, if the facility will be under 
new leadership or management.    
 
(vi) Voluntary Termination  The facility is not required to submit a voluntary termination 
application to terminate its existing CAH or rural hospital enrollment.  Any termination will be 
effectuated upon the approval of the REHs enrollment.  (See subsection (B) below.)  
 
3.  Processing and PECOS 
 
Subject to the provisions in subsections 10.2.1.8.1(A)(1) and (2) above, the contractor shall 
process the COI consistent with the COI processing instructions in this chapter.  This includes, 
but is not limited to, performing all required verifications (e.g., a new managing employee and/or 
delegated official is reported), developing for any missing or incomplete data, etc.  It does not 
include, however, making determinations normally reserved to the state or SOG Location.  For 
REHs, this includes, but is not limited to: (1) the number of beds; (2) whether emergency 
services, observation care, and inpatient services will be performed; (3) whether the facility is 
indeed in a rural area; and (4) whether CoPs are met. 
 
Absent clear evidence to the contrary, the contractor can assume that any Form CMS-855A data 
that is not reported as changing per subsection (A)(1)(d) above is remaining intact.  For instance,  suppose the provider does not report any changes in Section 4 of the COI.  The contractor can 
assume that the providers practice location data will remain as is. 
 
During the aforementioned process, the contractor shall create a new enrollment record in 
PECOS for the REH.  The record shall include: (1) the data submitted on the COI; and (2) data 
that is currently part of the CAHs or rural hospitals enrollment record but is not changing on 
the COI.  To illustrate, assume a CAH submits a COI to convert to an REH.  Sections 6, 7, and 8 
are blank, but Section 2(B) contains new REH licensure data.  The new REH enrollment record 
shall include the Section 2(B) REH licensure information as well as the Section 6, 7, and 8 data 
that is in the CAHs current enrollment record.  The CAHs enrollment record shall remain 
active and intact at this point. 
 
For submitted initial applications: 
 
  The contractor shall process the application consistent with this chapters instructions for 
processing initial applications involving non-transitioning certified providers/suppliers. 
 
  While the contractor shall create a new PECOS enrollment record for the REH, it need not 
(unlike with a COI) populate it with data from the facilitys existing CAH or rural hospital 
record.  It can simply use the data on the initial application; the application shall be designated as 
an initial application in PECOS.)   
 
4.  Recommendation/Disposition 
 
i.  Approval Recommended  If the contractor believes that a recommendation for approval is 
warranted, it shall forward its recommendation to the state consistent with the instructions for 
processing non-transitioned certified provider/supplier applications.  The state will review the 
matter and thereafter refer it to the SOG Location for final review. 
 
ii.  Rejection or Denial  If the contractor believes the application should be rejected or denied, 
it shall send an e-mail to its PEOG BFL that: (1) identifies the provider (e.g., LBN); (2) explains 
the basis for the contractors position; and (3) if a potential denial is involved, includes a copy of 
the draft denial letter for non-transitioned certified providers/suppliers.  PEOG will review the 
matter.  If PEOG approves the rejection or denial, the contractor shall --- within 3 business days 
of receiving said approval --- follow existing procedures for rejecting or denying an application; 
the state and SOG shall be copied on any denial letter. 
 
B.  Post-SOG Location Procedures 
 
1.  Denial 
 
If the SOG Location denies the REHs request for participation, it will notify the contractor 
thereof.  The contractor shall accordingly follow the procedures in this chapter for denying non-
transitioned certified provider/supplier applications.  (No prior PEOG approval of the denial is 
needed.)  The facilitys CAH or rural hospital enrollment, however, remains as is.  
 
2.  Approval   
If the SOG Location notifies the contractor of its approval of the REHs request for participation, 
the contractor shall follow the procedures in this chapter for approving non-transitioned certified 
provider/supplier applications.  As part of this, the contractor shall: (a) switch the REHs PECOS 
record to Approved (using the participation effective date on the SOG Location approval 
notice); and (b) deactivate the facilitys CAH or rural hospital enrollment (with a status of 
voluntary withdrawal), as well as any CAH reassignments, effective the day before the REHs 
approval effective date.   
 
C.  Additional Considerations 
 
1.  Letters 
 
  Denial  Any denial letter sent pursuant to this section 10.2.1.8.1 shall include the following 
language: Your existing enrollment as a [insert critical access hospital or other hospital type, as 
applicable] is not affected by this determination.   
 
The contractor shall use the denial letter applicable to the type of application submitted (e.g., a 
COI denial letter for a COI application). 
 
  Approval  The approval letter shall include the following language: With your enrollment 
as a rural emergency hospital, your existing enrollment as a [insert critical access hospital or 
other hospital type, as applicable] has been deactivated effective [insert date].  You will no 
longer be able to bill for [insert critical access hospital or other hospital type, as applicable] 
services under this enrollment.  (No separate voluntary termination letter is required.) 
 
The contractor shall use the approval letter applicable to the type of application submitted (e.g., 
an initial approval letter for an initial application). 
 
The exact placement of the aforementioned language in the letters lies within the contractors 
discretion. 
 
2.  Processing Alternatives and Clock Stoppages  Except as otherwise indicated in this section 
10.2.1.8.1, all processing alternatives and clock stoppages described in this chapter apply to REH 
enrollment applications. 
 
D.  Enrolled REHs 
 
Once enrolled, the REH, like all providers and suppliers, must maintain compliance with the 
enrollment requirements in 42 CFR Part 424, subpart P.  This includes, but is not limited to, 
reporting changes to its enrollment information, undergoing revalidation (and submitting the 
required fee with this application), etc.  The contractor need not undertake any special actions 
unique to enrolled REHs that are different from those applicable to all other provider/supplier 
types. 
 
It is possible that an enrolled REH may seek to return to its former status as a CAH or rural 
hospital.  To do so---and consistent with 42 CFR Part 424, subpart P and this chapter---it must  submit an initial enrollment application and, for the REH enrollment, a voluntary termination 
application.  It cannot do so via a change of information.    
 
10.2.1.9 - Indian Health Services (IHS) Facilities 
(Rev. 10868; Issued: 07-14-21; Effective: 08-13-21; Implementation: 08-13-21) 
 
A.  General Background Information 
 
For purposes of provider enrollment only, there are several types of IHS facilities: (1) those 
that are wholly owned and operated by the IHS; (2) facilities owned by the IHS but tribally 
operated; and (3) facilities wholly owned and operated by a tribe, though under the general 
IHS umbrella.  When an IHS facility wishes to enroll with the Part A contractor, it may 
check in Section 2A of the Form CMS-855A either (a) Indian Health Services Facility or 
(b) the specific provider type it is.  For instance, if an IHS hospital is involved, the provider 
may check Indian Health Services Facility or Hospital on the application - or perhaps 
both.  Even if it only checked Hospital, the LBN or DBA Name will typically contain some 
type of reference to Indian Health Services.  The contractor will therefore know that an IHS 
facility is involved. 
 
The overwhelming majority of IHS facilities on the Part A side are either hospitals, SNFs, 
CAHs, or ESRD facilities.  The contractor processes IHS applications in the same manner 
(and via the same procedures) as it would with a hospital, SNF, etc.  (This also applies to 
procedures for PECOS entry.) 
 
As for CCNs, the IHS facility uses the same series that its concomitant provider type does.  
That is, an IHS hospital uses the same CCN series as a regular hospital, an IHS CAH 
utilizes the same series as a regular CAH, and so forth. 
 
B.  Enrollment Information 
 
IHS facilities and tribal providers may use Internet-based PECOS or the paper Form 
CMS-855 enrollment application for their enrollment transactions.  The designated 
Medicare contractor for IHS facilities and tribal providers is Novitas Solutions 
(Novitas). 
 
If the IHS facility or tribal provider mails its Form CMS-855 to a Medicare contractor 
other than Novitas, that contractor shall forward the application directly to Novitas at 
the following address: 
 
Novitas Solutions, Inc. 
P.O. Box 3115 
Mechanicsburg, PA 17055-1858 
 
C. Licensure Requirements for Physicians and Practitioners Enrolling to Work in or Reassign 
Benefits to an Indian Tribe or Tribal Organization 
  The Affordable Care Act (Pub. L 111-148) amended Section 221 of the Indian Health Care 
Improvement Act such that licensed health professionals employed by a tribal health program are, 
if licensed in any state, exempt from the licensing requirements of the state in which the tribal 
program performs the services described in the contract or compact of the tribal health program 
under the Indian Self-Determination and Education Assistance Act (ISDEAA) (25 U.S.C. 450, et 
seq.).  Pursuant to this statutory provision, therefore, any physician or practitioner need only be 
licensed in one state  regardless of whether that state is the one in which the practitioner practices 
 if he or she is employed by a tribal health program performing services as permitted under the 
ISDEAA (see Pub. 100-04, chapter 19, section 10 for definitions). 
 
The contractor shall apply this policy when processing applications from these individuals.  In 
terms of the effective date of Medicare billing privileges, the contractor shall continue to apply the 
provisions of 42 CFR  424.520(d) and 424.521(a) and section 10.6.2 of this chapter. 
 
D. Additional Information 
 
For additional general information on IHS facilities, see Pub. 100-04, chapter 19. 
 
10.2.1.10 - Organ Procurement Organizations (OPOs) 
(Rev. 10868; Issued: 07-14-21; Effective: 08-13-21; Implementation: 08-13-21) 
 
A. General Background Information 
 
An OPO is an organization that performs or coordinates the procurement, preservation, and 
transport of organs and maintains a system for locating prospective recipients for available 
organs.  An OPO must have been certified as a qualified OPO by CMS under 42 U.S.C. 
273(b) and  486.303 to be eligible for designation.  In order to be certified as a qualified 
OPO, an OPO must have received a grant under 42 U.S.C. 273(a) or have been certified or 
re-certified by the Secretary within the previous four years as being a qualified OPO.  Under 
the statute, no new OPOs can enroll into the Medicare program   
 
B. Re-Certification 
 
An OPO is designated for a 4-year agreement cycle.  The period may be shorter, for example, 
if an OPO has voluntarily terminated its agreement with CMS and CMS selects a successor 
OPO for the balance of the 4-year agreement cycle.  Re-certification must occur not more 
frequently than once every 4 years.  The SOG Location is responsible for conducting the re-
certification surveys every 4 years; the OPO must sign a new provider agreement (Form 
CMS-576A) and participate in the Organ Procurement and Transplantation Network.  (See 
CMS Pub. 100-07, chapter 2, sections 2810 and 2811.)    
 
C. Change in Control/Ownership or Service Area 
  
OPOs can undergo a change in control or ownership or service area ( 486.310).  The merger 
of one OPO into another or the consolidation of one OPO with another is considered a 
change in control or ownership.  The OPO must notify CMS before implementing a change 
in ownership or control or a change in its service area.  The OPO must provide the SOG  Location with information that is specific to the board structure of the new organization, as 
well as operating budgets, financial information and other documentation that the SOG 
Location determines to be necessary.  The OPO must also submit a revised Form CMS-855 
to the MAC for review and a recommendation of approval from the SOG Location.  When 
the SOG Location receives notification of a prospective change in control or ownership for a 
designated OPO, the SOG Location must determine (based upon the documents and 
information submitted) that the operation of the OPO will continue uninterrupted during and 
following the change.  For any change of ownership or control, a new CMS Form-576 must 
be signed.   
 
The instructions in the previous paragraph are in addition to, and not in lieu of, those 
pertaining to changes of ownership and referrals to SOG Locations in sections 10.6 and 
10.6.1 et seq. of this chapter. 
 
D. Additional Information 
 
For more information on OPOs, refer to: 
 
  Section 1138 of the Social Security Act 
 
  42 CFR  486.301 -  486.360 
 
  Pub. 100-07, chapter 2, sections 2810  2821  
 
For guidance on the appropriate contractor jurisdiction for incoming OPO applications, see 
CMS Pub. 100-04, chapter 1, section 20.  Note that a hospital-based OPO must enroll 
separately, be separately certified, and sign its own provider agreement.   
 
 
10.2.1.11 - Outpatient Physical Therapy/Outpatient Speech Pathology 
Services (OPT/OSP) 
(Rev. 11574; Issued: 08-25-22; Effective: 06-24-22; Implementation: 09-27-22) 
 
A.  General Background Information 
 
Physical therapists and speech pathologists provide therapy targeting a persons ability to move 
and perform functional activities in their daily lives typically inhibited by illness or injury. Care 
is typically coordinated by therapists in conjunction with a physician and is based on an agreed 
upon plan of care.  
 
As explained in Pub. 100-07, chapter 2 section 2292, there are three types of organizations that 
may qualify as providers of OPT and OSP services under 42 CFR Part 485, Subpart H: clinics, 
public health clinics, and rehabilitation agencies.  However, rehabilitation agencies are the only 
organizations that are currently enrolled as a Medicare provider with a CCN.  The primary 
purpose of a rehabilitation agency is to improve or rehabilitate an injury or disability and to tailor 
a rehabilitation program to meet the specific rehabilitation needs of each patient referred to the 
agency.  A rehabilitation agency must provide, at a minimum, physical therapy and/or speech  language pathology services to address those needs of the patients.  Social/vocational services 
are no longer a requirement. 
 
Note that: 
 
  If an OPT/OSP provider elects to convert to a CORF, it must meet the CORF conditions of 
coverage and participation.  An initial Form CMS-855A enrollment application, state survey, 
and CMS program approval are also required. 
 
  Only those OTP/OSP providers covered under 42 CFR Part 485, Subpart H that furnish 
OPT/OSP services (as listed above) have provider agreements under 42 CFR  489.2.  Part B 
physician groups  the supplier type that most people normally associate with the term 
clinics  do not have certified provider or certified supplier agreements. 
 
  Occupational therapy cannot be substituted for the physical therapy requirement. It may, 
however, be provided in addition to physical therapy or speech pathology services.  (See Pub. 
100-07, chapter 2, section 2292A.) 
 
B.  Processing Instructions for OPT/OSP Initial Form CMS-855A Applications 
 
1.  Receipt of Application 
 
Upon receipt of an OPT/OSP initial Form CMS-855A application, the contractor shall undertake 
the following (in whichever order the contractor prefers unless directed otherwise in this 
chapter): 
 
(A)  Perform all data validations otherwise required per this chapter.    
 
(B) Ensure that the application(s) is complete consistent with the instructions in this chapter. 
 
(C) Ensure that the OPT/OSP has submitted all documentation otherwise required per this 
chapter.  For OPT/OSP initial enrollment, this also includes the following: 
 
  Form CMS-1561 (Health Insurance Benefit Agreement, also known as a provider 
agreement)   
 
  Evidence of successful electronic submission of the Form HHS-690 through the Office of 
Civil Rights (OCR) portal, as applicable.  (Evidence should be either written or electronic 
documentation.) (See https://www.hhs.gov/sites/default/files/forms/hhs-690.pdf for more 
information.)   
 
(The OPT/OSP must complete, sign, date, and include the Form CMS-1561, though the 
OPT/OSP need not complete those sections of the form reserved for CMS.  For organizational 
OPT/OSPs, an authorized official (as defined in  424.502) must sign the form; for sole 
proprietorships, the sole proprietor must sign.)   
  Notwithstanding the foregoing, if the Form CMS-1561 or the Form HHS-690 evidence is 
missing, unsigned, undated, or otherwise incomplete, the contractor need not develop for the 
form(s) or the information thereon; the contractor shall instead notify the state in its 
recommendation letter which document(s) was/were missing or otherwise incomplete.  For all 
other missing or incomplete required documentation, the contractor shall follow the normal 
development instructions in this chapter. 
 
2.  Conclusion of Initial Contractor Review 
 
(Nothing in this section 10.2.1.11(B) prohibits the contractor from returning or rejecting the 
OPT/OSP application if otherwise permitted to do so per this chapter.  When returning or 
rejecting the application, the contractor shall follow this chapters procedures for doing so.)     
 
(A) Approval Recommendation 
 
If, consistent with the instructions in section 10.2.1.11(B) and this chapter, the contractor 
believes an approval recommendation is warranted, the contractor shall send the 
recommendation to the state pursuant to existing practice and this chapters instructions.  The 
contractor need not copy the SOG Location or PEOG on the recommendation.  Unless CMS 
directs otherwise, the contractor shall also send to the provider the notification letter in section 
10.7.5.1(E) of this chapter. 
 
The state will: (1) review the recommendation package for completeness; (2) review the 
contractors recommendation for approval; (3) perform any state-specific functions; and (4) 
contact the contractor with any questions.  The contractor shall respond to any state inquiry in 
Item (4) within 5 business days.  If the inquiry involves the need for the contractor to obtain 
additional data, documentation, or clarification from the OPT/OSP, however, the timeframe is 15 
business days; if the provider fails to respond to the contractor within this timeframe, it shall 
notify the state thereof.  The contractor may always contact its PEOG BFL should it need the 
latters assistance with a particular state inquiry. 
 
(B) Denial 
 
If the contractor determines that a denial is warranted, it shall follow the denial procedures 
outlined in this chapter.  This includes: (1) using the appropriate denial letter format in section 
10.7.8 of this chapter; and (2) if required under section 10.6.6 (or another CMS directive) of this 
chapter, referring the matter to PEOG for review prior to denying the application. 
 
3.  Completion of State Review 
 
The state will notify the contractor once it has completed its review.  There are two potential 
outcomes: 
 
(A) Approval Not Recommended 
 
If the state does not recommend approval, it will notify the contractor thereof.  (The contractor 
may accept any notification that is in writing (e-mail is fine).)  No later than 5 business days after  receiving this notification the contractor shall commence the actions described in section 
10.2.1.11(B)(2)(B) above.   
 
(B) Approval Recommended 
 
If the state recommends approval, it will typically (though not always) do so via a Form CMS-
1539; the contractor may accept any documentation from the state signifying that the latter 
recommends approval.  (Note that the contractor will not receive a formal tie-in notice.) 
 
No later than 5 business days after receipt of the recommendation from the state, the contractor 
shall send an e-mail to MedicareProviderEnrollment@cms.hhs.gov with the following 
information and documents:  
 
  The Form CMS-855 application (or PECOS Application Data Report) and all application 
attachments  
  A copy of the Form CMS-1539 or similar documentation received from the state 
  A copy of the provider-signed Form CMS-1561 
  A copy of the draft approval letter, with the effective date shown on the Form CMS-1539 (or 
similar documentation) included in the draft letter.  (See section 10.7.5.1 for the model 
approval letter.)  
 
PEOG will countersign the provider agreement.  Based on the information received from the 
contractor, PEOG will also (1) assign an effective date, (2) assign a CCN, and (3) enter the 
applicable data into ASPEN, and (4) approve (with possible edits) the approval letter.   
 
Within 5 business days of receiving from PEOG the signed provider agreement, effective date, 
and CCN, the contractor shall: (1) send the approval letter and a copy of the CMS-countersigned 
provider agreement to the OPT/OSP; (2) send a copy of both the approval letter and the provider 
agreement to the state and/or AO (as applicable)); and (3) switch the PECOS record from 
approval recommended to approved consistent with existing instructions. 
 
C.  Extension Locations 
 
As discussed in Pub. 100-07, chapter 2, sections 2298 and 2298A, an OPT/OSP provider can, in 
certain instances, furnish services from locations other than its primary site.  (The provider must 
designate one location as its primary location on the Form CMS-855A, however.)  These sites 
are called extension locations. An extension location is defined at 42 CFR  485.703 as a 
location or site from which a rehabilitation agency provides services within a portion of the total 
geographic area served by the primary site.  The extension location is part of the agency.  The 
extension location should be located sufficiently close to share administration, supervision, and 
services in a manner that renders it unnecessary for the extension location to independently meet 
the conditions of participation as a rehabilitation agency.  Per Pub. 100-07, chapter 2, section 
2298A, only rehabilitation agencies are permitted to have extension locations.  The clinics 
operated by physicians and public health clinics are not permitted extension locations.  These 
two providers must provide outpatient therapy services at their Medicare approved location. 
  An OPT/OSP provider may also furnish therapy services in a patients home or in a patients 
room in a SNF.  (See Pub. 100-07, chapter 2, section 2300.  Note that when the OPT provides 
services away from the primary site or extension location(s), this is referred to as off-premises 
activity at other locations.  Section 2300 (referenced) above discusses such activities.)  Because 
these are not considered extension locations, neither the home nor the patients room need be 
listed as a practice location on the providers Form CMS-855A.  (See Pub. 100-07, chapter 2, 
section 2298B.) 
 
If an OPT/OSP provider wants to add an extension site, a Form CMS-855A change of 
information request should be submitted.  
 
There is no prohibition against an organization operating on the premises of a supplier (e.g., 
physician or chiropractor) or another provider as long as they are not operating in the same space 
at the same time.  (See Pub. 100-07, chapter 2, section 2304.) 
 
D.  CHOWs and Changes of Information 
 
For OPT/OSP CHOWs, the contractor shall follow the instructions in section 10.6.1.1 of this 
chapter.  For OPT/OSP changes of information, the contractor shall follow the instructions in 
section 10.6.1.2 of this chapter. 
 
E.  Additional Information  
 
For more information on OPT/OSP providers, refer to: 
 
  Section 1861(p) of the Social Security Act 
 
  42 CFR Part 485, subpart H 
 
  Pub. 100-07, chapter 2, sections 2290  2308  
 
  Pub. 100-07, Appendix E 
 
10.2.1.12 - Religious Non-Medical Health Care Institutions (RNHCIs) 
(Rev. 10868; Issued: 07-14-21; Effective: 08-13-21; Implementation: 08-13-21) 
 
A. General Background Information 
 
RNHCIs furnish only nonmedical nursing services and items to people who choose to rely 
solely on obtaining a religious method of healing and for whom the acceptance of medical 
services would be inconsistent with their religious views.  Such nonmedical services are 
performed exclusively through nonmedical nursing personnel who are experienced in caring 
for the physical needs of nonmedical patients (e.g., caring for the physical needs such as 
assistance with activities of daily living; assistance in moving, positioning, and ambulation; 
nutritional needs; and comfort and support measures).  RNHCIs do not perform any medical 
screenings, examinations, diagnoses, or treatments, including the administration of drugs.  
Each beneficiary who wishes to receive services in an RNHCI must make a valid and formal  written statement (or election) to do so.  (The specific election requirements are discussed 
in 42 CFR  403.724 and Pub. 100-07, chapter 2, section 2054.1B.) 
 
CMSs Boston Northeast SOG Location (in coordination with the CMS Central Office) has 
primary responsibility over the approval and certification of RNHCIs.  RNHCIs are not 
certified by the state but must meet all of the conditions of coverage outlined in 42 CFR 
403.720 as well as all conditions of participation.  (See 42 CFR  403.730 through 403.746 
regarding RNCHI conditions of participation.)  For purposes of provider enrollment, the 
three most important conditions are that the provider: 
 
a.   Must not be owned by, under common ownership with, or have an ownership interest of 5 
percent or more in a provider of medical treatment or services. 
 
b.   Must not be affiliated with a provider of medical treatment or services or with an 
individual who has an ownership interest of 5 percent or more in a provider of medical 
treatment or services.  (Permissible affiliations are described in 42 CFR  403.738(c)).  
 
c.   Must be a non-profit organization per subsection (c)(3) of  501 of the Internal Revenue 
Code of 1986, and exempt from taxes under subsection 501(a). 
 
(See Pub. 100-07, chapter 2, section 2054.1 for additional conditions.) 
 
To this end, the contractor shall (1) examine Sections 5 and 6 of the Form CMS-855A and 
(2) verify the providers non-profit status to ensure that the aforementioned conditions are 
met. 
 
B. Additional Information 
 
For more information on RNCHIs, refer to: 
 
  Section 1861(ss)(1) of the Social Security Act 
 
  42 CFR Part 403, subpart G 
 
  Pub. 100-07, chapter 2, sections 2054, 2054.1, 2054.1A and 2054.1B  
 
  Pub. 100-04, chapter 3, sections 170 - 180   
 
  Pub. 100-02, chapter 1, sections 130  130.4.2  
 
For guidance on the appropriate contractor jurisdiction for incoming RNCHI applications, 
please see Pub. 100-04, chapter 1, section 20. 
 
10.2.1.13 - Rural Health Clinics (RHCs) 
(Rev. 10868; Issued: 07-14-21; Effective: 08-13-21; Implementation: 08-13-21) 
 
A. General Background Information   
An RHC is a facility located in a rural area designated as a shortage area and is neither a 
rehabilitation agency nor a facility primarily for the care and treatment of mental diseases.  It 
must meet all other requirements of the RHC regulations at 42 CFR Part 491, subpart A.  
RHCs: 
 
  Are considered to be Part B certified suppliers even though they enroll in Medicare 
via the Form CMS-855A.  
 
  Are defined in section 1861(aa)(2) of the Social Security Act as facilities that are 
engaged primarily in providing services that are typically furnished in an outpatient 
clinic. 
  
  Sign a supplier agreement with CMS (akin to those signed by certified providers).  
Specifically, RHCs sign the Health Insurance Benefit Agreement (Form CMS-
1561A). 
 
  Can be either mobile in nature or fixed/permanent locations.     
 
  Can be freestanding or provider-based.  (As stated in Pub. 100-07, provider-based 
RHCs are an integral and subordinate part of a hospital (including a critical access 
hospital (CAH), skilled nursing facility (SNF), or a home health agency (HHA)). 
 
There are certain services performed by RHCs that do not actually qualify as RHC services.  
To bill for these services, the clinic must enroll as a Clinic/Group Practice via the Form 
CMS-855B.   It is not uncommon to see RHCs simultaneously enrolled in Medicare via the 
Form CMS-855A (to bill for RHC services) and the Form CMS-855B (to bill for non-RHC 
services).  
 
Note that a facility cannot be simultaneously enrolled as an FQHC and an RHC.  Though 
there are similarities between these two supplier types, there are key differences as well.  For 
instance, FQHCs can service rural or urban regions.  To be eligible for certification as an 
RHC, however, a clinic must be located in a non-urbanized area, as determined by the U.S. 
Census Bureau, and in an area designated or certified within the previous 4 years by the 
Secretary of Health and Human Services (HHS), in any one of the four types of shortage area 
designations that are accepted for RHC certification.  (See Pub. 100-02, chapter 13, sections 
10.1 and 20.)  Also: (1) RHCs are surveyed by the state while FQHCs are not; and (2) 
FQHCs furnish preventive services while RHCs do not. 
 
B. Additional Information 
 
For more information on RHCs, refer to: 
  Section 1861(aa)(1-2) of the Social Security Act 
  42 CFR Part 491, subpart A 
  Pub. 100-07, chapter 2, sections 2240  2249  
  Pub. 100-04, chapter 9     Pub. 100-02, chapter 13  
For guidance on the appropriate contractor jurisdictions for incoming RHC applications, refer 
to Pub. 100-04, chapter 1, section 20.  
 
10.2.1.14 - Skilled Nursing Facilities (SNFs)  
(Rev. 11808; Issued: 01-24-23; Effective: 01-01-23; Implementation: 01-03-23) 
 
A.  General Background Information 
 
As stated in Pub. 100-07, chapter 7, section 7004.2, a SNF is a facility that: 
 
  Is primarily engaged in providing to residents skilled nursing care and related services for 
residents who require medical or nursing care; or   
  Is primarily engaged in providing to residents skilled rehabilitation services for the 
rehabilitation of injured, disabled, or sick persons; while the care and treatment of mental 
disease is not the primary action of SNFs, the ability to provide appropriate resources and 
support for these beneficiaries is necessary; 
  Has in effect a transfer agreement (meeting the requirements of 1861(1) of the Social 
Security Act with one or more hospitals having agreements in effect under  1866 of the 
Social Security Act); and 
  Meets the requirements for a skilled nursing facility described in subsections (b), (c), and (d) 
of 1819 of the Social Security Act. 
 
Like other certified providers, SNFs receive a state survey and sign a provider agreement.   
 
SNFs cannot have multiple practice locations under one Form CMS-855A enrollment.   
 
Effective January 1, 2023, SNFs that are initially enrolling or undergoing a change in ownership 
(as described in sections 10.6.15 and 10.6.21(E)(3) of this chapter) fall within the high 
screening category under 42 CFR  424.518.  SNF revalidations are processed at the moderate 
screening level. 
 
B.  Processing Instructions for SNF Initial Form CMS-855A Applications 
 
1.  Receipt of Application  
 
Upon receipt of a SNF initial Form CMS-855A application, the contractor shall undertake the 
following (in whichever order the contractor prefers unless directed otherwise in this chapter): 
 
(i)  Perform all data validations otherwise required per this chapter.    
 
(ii)  Ensure that the application(s) is complete consistent with the instructions in this chapter. 
 
(iii)  Ensure that the SNF has submitted all documentation otherwise required per this chapter.  
For SNF initial enrollment, this also includes the following: 
    Form CMS-1561 (Health Insurance Benefit Agreement, also known as a provider 
agreement)   
 
  Evidence of successful electronic submission of the Form HHS-690 through the Office of 
Civil Rights (OCR) portal, as applicable.  (Evidence should be either written or electronic 
documentation.) (See https://www.hhs.gov/sites/default/files/forms/hhs-690.pdf for more 
information.)   
 
  A signed SNF patient transfer agreement.  (See https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/Facility-Transfer-
Agreement-Example.pdf for an example.)   
 
(The SNF must complete, sign, date, and include the Form CMS-1561 and transfer agreement 
described above, though the SNF need not complete those sections of the forms reserved for 
CMS.  For organizational SNFs, an authorized official (as defined in  424.502) must sign the 
forms; for sole proprietorships, the sole proprietor must sign.)   
 
Notwithstanding the foregoing, if the Form CMS-1561, Form HHS-690 evidence, or SNF 
transfer agreement is missing, unsigned, undated, or otherwise incomplete, the contractor need 
not develop for the form(s) or the information thereon; the contractor shall instead notify the 
state in its recommendation letter which document(s) was/were missing or otherwise incomplete.  
For all other missing or incomplete required documentation, the contractor shall follow the 
normal development instructions in this chapter. 
 
2.  Conclusion of Initial Contractor Review 
 
(Nothing in this section 10.2.1.14(B) prohibits the contractor from returning or rejecting the SNF 
application if otherwise permitted to do so per this chapter.  When returning or rejecting the 
application, the contractor shall follow this chapters procedures for doing so.)     
 
a.  Approval Recommendation 
 
If, consistent with the instructions in section 10.2.1.14(B) and this chapter, the contractor 
believes an approval recommendation is warranted, the contractor shall send the 
recommendation to the state pursuant to existing practice and this chapters instructions.  (This 
includes sending recommendations via hard copy mail if the state only accepts this method of 
transmission.)  The contractor need not copy the SOG Location or PEOG on the 
recommendation.  Unless CMS directs otherwise, the contractor shall also send to the provider 
the notification letter in section 10.7.5.1(E) of this chapter. 
 
The state will: (1) review the recommendation package for completeness; (2) review the 
contractors recommendation for approval; (3) perform any state-specific functions; and (4) 
contact the contractor with any questions.  The contractor shall respond to any state inquiry in 
Item (4) within 5 business days.  If the inquiry involves the need for the contractor to obtain 
additional data, documentation, or clarification from the SNF, however, the timeframe is 15 
business days; if the provider fails to respond to the contractor within this timeframe, it shall  notify the state thereof.  The contractor may always contact its PEOG BFL should it need the 
latters assistance with a particular state inquiry. 
 
b.  Denial 
 
If the contractor determines that a denial is warranted, it shall follow the denial procedures 
outlined in this chapter.  This includes: (1) using the appropriate denial letter format in section 
10.7.5.1 of this chapter; and (2) if required under section 10.6.6 (or another CMS directive) of 
this chapter, referring the matter to PEOG for review prior to denying the application. 
 
3.  Completion of State Review 
 
The state will notify the contractor once it has completed its review.  There are two potential 
outcomes: 
 
a.  Approval Not Recommended 
 
If the state does not recommend approval, it will notify the contractor thereof.  (The contractor 
may accept any notification that is in writing (e-mail is fine).)  No later than 5 business days after 
receiving this notification, therefore, the contractor shall commence the actions described in 
section 10.2.1.14(B)(2)(b) above.   
 
b.  Approval Recommended 
 
If the state recommends approval, it will typically (though not always) do so via a Form CMS-
1539; the contractor may accept any documentation from the state signifying that the latter 
recommends approval.  (Note that the contractor will not receive a formal tie-in notice.) 
 
No later than 5 business days after receipt of the recommendation from the state, the contractor 
shall order the site visit described in subsection (D)(1) below. 
 
If the SNF fails the site visit, the contractor shall follow the denial procedures addressed in 
subsection (B)(2)(b) above.  If the SNF passes the site visit, the contractor shall (within 3 
business days of completing its review of the results) send an e-mail to 
MedicareProviderEnrollment@cms.hhs.gov with the following information and documents:  
 
  The Form CMS-855 application (or PECOS Application Data Report) and all application 
attachments  
  A copy of the Form CMS-1539 or similar documentation received from the state. 
  A copy of the provider-signed Form CMS-1561. 
  A copy of the provider-signed SNF transfer agreement.   
  A copy of the draft approval letter, with the effective date shown on the Form CMS-1539 (or 
similar documentation) included in the draft letter.  (See section 10.7.5.1 for the model 
approval letter.) 
 
PEOG will countersign the provider agreement.  Based on the information received from the 
contractor, PEOG will also (1) assign an effective date, (2) assign a CCN, (3) enter the  applicable data into ASPEN, and (4) approve (with possible edits) the approval letter.   
 
Within 5 business days of receiving from PEOG the signed provider agreement, transfer 
agreement, effective date, and CCN, the contractor shall: (1) send the approval letter and a copy 
of the CMS-countersigned provider agreement to the SNF; (2) send a copy of both the letter and 
the provider agreement sent to the state and/or AO (as applicable)); (3) switch the PECOS record 
from approval recommended to approved consistent with existing instructions; and (3) retain 
the provider-signed transfer agreement (which CMS does not counter-sign) on file. 
 
C.  SNF Distinct Parts 
 
A SNF can be a separate institution or a distinct part of an institution.  The term distinct part 
means an area or portion of an institution (e.g., a hospital) that is certified to furnish SNF 
services.  The hospital and the SNF distinct part will each receive a separate CCN.  Also: 
 
  A hospital may have only one SNF distinct part. 
 
  Distinct part designation is not equivalent to being provider-based.   
 
A SNF distinct part unit must enroll separately (i.e., it cannot be listed as a practice location on 
the hospitals Form CMS-855A), be separately surveyed, and sign a separate provider 
agreement.  (Note how this is different from swing-bed units, which do not enroll separately 
and do not sign separate provider agreements.)   
 
D.  Site Visits 
 
1.  Initial application - The scope of the site visit shall be consistent with sections 10.6.20(A) and 
10.6.20(B) of this chapter.  The NSVC will perform the site visit.  The contractor shall not 
convey Medicare billing privileges to the provider prior to the completion of the NSVCs site 
visit and the contractors review of the results. 
 
2.  Revalidation  If a SNF submits a revalidation application, the contractor shall order a site 
visit through PECOS.  This is to ensure that the provider is still in compliance with CMSs 
enrollment requirements.  The scope of the site visit shall be consistent with sections 10.6.20(A) 
and 10.6.20(B) of this chapter.  The NSVC will perform the site visit.  The contractor shall not 
make a final decision regarding the revalidation application prior to the completion of the 
NSVCs site visit and the contractors review of the results. 
 
(See sections 10.6.15 and 10.6.21(E)(3) for instructions regarding site visits for ownership 
changes.) 
 
E.  Additional Information 
 
For more information on SNFs, refer to: 
 
  Section 1819 of the Social Security Act 
    Pub. 100-07, chapter 7  
 
  Pub. 100-02, chapter 8 
 
10.2.2  Suppliers That Enroll Via the Form CMS-855B                       
 (Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
 
10.2.2.1  Ambulatory Surgical Centers (ASCs)  
(Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
ASCs are a certified supplier type that enroll via the Form CMS-855B. 
 
A.  Background  
 
An ASC is defined in 42 CFR  416.2 as any distinct entity that operates exclusively for the 
purpose of providing surgical services to patients not requiring hospitalization and in which the 
expected duration of services would not exceed 24 hours following an admission; the entity must 
have an agreement with CMS to participate in Medicare as an ASC and must meet the conditions 
set forth in 42 CFR Part 416, subparts B and C  (The ASC supplier agreement (Form CMS-370) 
is similar to the provider agreement signed by Part A providers.) 
 
An ASC satisfies the criterion of being a distinct entity when it is separate and clearly 
distinguishable from any other healthcare facility or office-based physician practice.  Thus, 
distinct entity means that surgical services may only be provided at the single location listed in 
the Medicare supplier agreement.  Medicare-certified ASCs are not permitted to have multiple 
locations under the same supplier agreement.  If an entity owns multiple surgical locations and 
wishes them to participate in Medicare as an ASC, each location must seek separate participation 
and enrollment and must demonstrate independent compliance with the ASC conditions of 
coverage, for the regulations do not permit configurations of multiple ASC locations under one 
Medicare agreement. (Each location would be considered a new, initial enrollment; thus, if an 
enrolled ASC wishes to add a second practice location, the transaction would constitute a new, 
initial enrollment rather than the addition of a practice location to an existing enrollment.) ASCs 
may only have one surgical location per CMS Certification Number (CCN). See also CMS 
Publication (Pub. 100-07), State Operations Manual, chapter 2, section 2210 for more 
information. 
 
As stated in  416.26(a), CMS may deem an ASC to be in compliance with any or all of the ASC 
conditions of coverage set forth in 42 CFR Part 416, subpart C if: 
 
  The ASC is accredited by a national accrediting body, or licensed by a state agency, that 
CMS determines provides reasonable assurance that the conditions are met; 
 
  In the case of deemed status through accreditation by a national accrediting body, where state 
law requires licensure, the ASC complies with state licensure requirements; and 
 
  The ASC authorizes the release to CMS of the findings of the accreditation survey.   
Unless CMS deems the ASC to be in compliance with the ASC conditions of coverage in 42 
CFR Part 416, subpart C, the state survey agency must survey the facility to ascertain 
compliance with those conditions.  (See 42 CFR  416.26(b).)   
 
B.  Processing Instructions for ASC Initial Form CMS-855B Applications 
 
1.  Receipt of Application 
 
Upon receipt of an ASC initial Form CMS-855B application, the contractor shall undertake the 
following (in whichever order the contractor prefers unless directed otherwise in this chapter): 
 
(A) Perform all data validations otherwise required per this chapter.    
 
(B) Ensure that the application(s) is complete consistent with the instructions in this chapter. 
 
(C) Ensure that the ASC has submitted all documentation otherwise required per this chapter.  
For ASC initial enrollment, this also includes the Form CMS-370 (ASC supplier agreement). 
 
(The ASC must complete, sign, date, and include the Form CMS-370, though the ASC need not 
complete those sections of the form reserved for CMS.  For organizational ASCs, an authorized 
official (as defined in  424.502) must sign the form; for sole proprietorships, the sole proprietor 
must sign.)   
 
Notwithstanding the foregoing, if the Form CMS-370 or the Form HHS-690 evidence is missing, 
unsigned, undated, or otherwise incomplete, the contractor need not develop for the form(s) or 
the information thereon; the contractor shall instead notify the state in its recommendation letter 
which document(s) was/were missing or otherwise incomplete. For all other missing or 
incomplete required documentation, the contractor shall follow the normal development 
instructions in this chapter. 
 
2.  Conclusion of Initial Contractor Review 
 
(Nothing in this section 10.2.2.1(B) prohibits the contractor from returning or rejecting the ASC 
application if otherwise permitted to do so per this chapter.  When returning or rejecting the 
application, the contractor shall follow this chapters procedures for doing so.)     
 
(A) Approval Recommendation 
 
If, consistent with the instructions in section 10.2.2.1(B) and this chapter, the contractor believes 
an approval recommendation is warranted, the contractor shall send the recommendation to the 
state pursuant to existing practice and this chapters instructions.  The contractor need not copy 
the SOG Location or PEOG on the recommendation.  Unless CMS directs otherwise, the 
contractor shall also send to the provider the notification letter in section 10.7.5.1(E) of this 
chapter. 
 
The state will: (1) review the recommendation package for completeness; (2) review the 
contractors recommendation for approval; (3) perform any state-specific functions; and (4)  contact the contractor with any questions.  The contractor shall respond to any state inquiry in 
Item (4) within 5 business days.  If the inquiry involves the need for the contractor to obtain 
additional data, documentation, or clarification from the ASC, however, the timeframe is 15 
business days; if the provider fails to respond to the contractor within this timeframe, it shall 
notify the state thereof.  The contractor may always contact its PEOG BFL should it need the 
latters assistance with a particular state inquiry. 
 
(B) Denial 
 
If the contractor determines that a denial is warranted, it shall follow the denial procedures 
outlined in this chapter.  This includes: (1) using the appropriate denial letter format in section 
10.7.8 of this chapter; and (2) if required under section 10.6.6 (or another CMS directive) of this 
chapter, referring the matter to PEOG for review prior to denying the application. 
 
3.  Completion of State Review 
 
The state will notify the contractor once it has completed its review.  There are two potential 
outcomes: 
 
(A) Approval Not Recommended 
 
If the state does not recommend approval, it will notify the contractor thereof.  (The contractor 
may accept any notification that is in writing (e-mail is fine).)  No later than 5 business days after 
receiving this notification, the contractor shall commence the actions described in section 
10.2.2.1(B)(2)(B) above.   
 
(B)  Approval Recommended 
 
If the state recommends approval, it will typically (though not always) do so via a Form CMS-
1539; the contractor may accept any documentation from the state signifying that the latter 
recommends approval.  (Note that the contractor will not receive a formal tie-in notice.) 
 
No later than 5 business days after receipt of the recommendation from the state, the contractor 
shall send an e-mail to MedicareProviderEnrollment@cms.hhs.gov with the following 
information and documents:  
 
  The Form CMS-855 application (or PECOS Application Data Report) and all application 
attachments  
  A copy of the Form CMS-1539 or similar documentation received from the state 
  A copy of the supplier Form CMS-370 
  A copy of the draft approval letter, with the effective date shown on the Form CMS-1539 (or 
similar documentation) included in the draft letter.  (See section 10.7.5.1 for the model 
approval letter.) 
 
PEOG will countersign the supplier agreement.  Based on the information received from the 
contractor, PEOG will also (1) assign an effective date, (2) assign a CCN, and (3) enter the 
applicable data into ASPEN, and (4) approve (with possible edits) the approval letter.  Within 5  business days of receiving from PEOG the signed supplier agreement, effective date, and CCN, 
the contractor shall: (1) send the approval letter and a copy of the CMS-countersigned supplier 
agreement to the ASC; (2) send a copy of both the approval letter and the supplier agreement to 
the state and/or AO; and (3) switch the PECOS record from approval recommended to 
approved consistent with existing instructions. 
 
C.  Additional Enrollment Information 
 
The contractor shall ensure that, as applicable, all licenses, certifications, and accreditations 
submitted by ASCs are included in the enrollment package that is forwarded to the state.  
 
If the ASC applicants address or telephone number cannot be verified, the contractor shall 
contact the applicant for further information.  If the supplier states that the facility or its phone 
number is not yet operational, the contractor shall continue processing the application.  However, 
it shall indicate in its recommendation letter to the state agency (state)/SOG Location that the 
address and telephone number of the facility could not be verified. 
 
When enrolling the ASC, and except as otherwise stated in this chapter or as otherwise instructed 
by PEOG, the contractor shall use the effective date indicated on the state approval notice/letter 
(e.g. CMS-1539).  This is the date from which the supplier can bill for services.   
 
D.  ASCs and Reassignment 
 
Physicians and non-physician practitioners who meet the reassignment exceptions in 42 CFR  
424.80, and CMS Pub. 100-04, Claims Processing Manual, chapter 1, sections 30.2.6 and 30.2.7 
may reassign their benefits to an ASC.  In such a reassignment, the individual and the ASC must 
sign the Form CMS-855R.  However, the ASC need not separately and additionally enroll as a 
group practice in order to receive benefits.  It can accept reassignment as an ASC. 
 
E.  ASCs Changes of Ownership (CHOWs) and Changes of Information 
 
Though ASCs are not mentioned in 42 CFR  489.18, CMS generally applies the CHOW 
provisions of  489.18 to them.  CHOWs involving ASCs are thus handled in accordance with 
the principles in  489.18 and Pub. 100-07, chapter 3, sections 3210 through 3210.5(C).  For 
ASC CHOW processing instructions, see section 10.6.1.1 of this chapter.  
 
The contractor shall process ASC changes of information in accordance with section 10.6.1.2 of 
this chapter. 
 
F.  Additional General ASC Information 
 
For more information on ASCs, refer to: 
 
  42 CFR Part 416 
    Pub. 100-07, chapter 2, section 2210 and Appendix L.  (See Pub. 100-07, chapter 2, section 
2210 for information regarding the sharing of space between ASCs and other providers and 
suppliers.) 
 
  Pub. 100-02, Benefit Policy Manual, chapter 15, sections 260  260.5.3  
 
  Pub. 100-04, chapter 14 
 
G.  ASCs and Hospitals 
 
See the following instructions for guidance regarding hospital-operated/affiliated ASCs: 
 
  Pub. 100-04, chapter 14, section 10.1 
 
  Pub. 100-02, chapter 15, section 260.1  
 
10.2.2.2  Home Infusion Therapy Suppliers 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
Home infusion therapy suppliers are a supplier type that enroll via the Form CMS-855B. 
 
A.  General Background Information 
 
Section 5012 of the 21st Century Cures Act (the Cures Act) (Pub. L. 114-255), which amended 
sections 1861(s)(2) and 1861(iii) of the Act, established a new Medicare home infusion therapy 
services benefit. The Medicare home infusion therapy services benefit covers the professional 
services, including nursing services, furnished in accordance with the plan of care, patient 
training and education (not otherwise covered under the durable medical equipment benefit), 
remote monitoring, and monitoring services for the provision of home infusion therapy and home 
infusion drugs furnished by a qualified home infusion therapy supplier. This benefit will ensure 
consistency in coverage for home infusion benefits for all Medicare beneficiaries.  
 
Section 1861(iii)(3)(D)(i) of the Act defines a qualified home infusion therapy supplier as a 
pharmacy, physician, or other provider of services or supplier licensed by the state in which 
supplies or services are furnished. A qualified home infusion therapy supplier must: (1)furnish 
infusion therapy to individuals with acute or chronic conditions requiring administration of home 
infusion drugs; (2) ensure the safe and effective provision and administration of home infusion 
therapy on a 7-day-a-week, 24-hour-a-day basis; (3) be accredited by an organization designated 
by the Secretary; and (4) meet other such requirements as the Secretary deems appropriate, 
taking into account the standards of care for home infusion therapy established by Medicare 
Advantage plans under Part C and in the private sector.  
 
B.  Home Infusion Therapy Supplier Eligibility and Enrollment Requirements 
 
An entity that wishes to furnish home infusion therapy services to Medicare beneficiaries must 
enroll as a home infusion therapy supplier. The supplier must meet the following requirements: 
    Obtain and maintain a valid tax identification number and National Provider Identifier at 
the organizational level. 
 
  Be currently and validly accredited as such by a CMS-recognized home infusion therapy 
supplier accreditation organization in order to enroll and remain enrolled in Medicare. 
The CMS-recognized home infusion therapy supplier accreditation organizations include 
the Joint Commission (TJC), the Utilization Review Accreditation Commission (URAC), 
the Accreditation Commission for Health Care (ACHC), the Community Health 
Accreditation Partner (CHAP), the National Association Boards of Pharmacy (NABP), 
and the Compliance Team (TCT).  
 
  Submit documentation containing an effective date of accreditation as well as the 
locations accredited for home infusion therapy with its application.  (This may, but is not 
required to be, a copy of the accreditation certification and/or accreditation approval 
letter.) 
  
  Be compliant with  414.1515 and all provisions of 42 CFR Part 486, subpart I in order 
to enroll and maintain Medicare enrollment.   
 
  Certify via the Form CMS-855B application that it meets and will continue to meet the 
specific requirements for enrollment described in 42 CFR  424.68 and 42 CFR Part 424, 
subpart P.   
 
  Successfully complete application screening at the limited categorical risk level per  
424.518(a). 
 
  Pay an application fee at initial enrollment, revalidation, and when adding a practice 
location. 
 
  Enroll in each state in which it has an accredited practice location. The supplier may 
provide services in patients homes across state borders as long as it is appropriately 
licensed (if the state requires licensure); the supplier must be appropriately licensed (if 
the state requires licensure) in each state in which it furnishes home infusion therapy 
services in patients homes.  (See section 10.3 of this chapter for certain PECOS 
application submission policies with respect to enrolling in multiple states within one 
contractor jurisdiction.)  
 
The supplier completes Section 4D (Rendering Services in Patients Homes) of the Form CMS-
855B application to report all locations where health care services are rendered in patients 
homes. This includes locations across state borders. As an illustration, suppose the supplier has 
two accredited practice locations in Arkansas and furnishes home infusion therapy services in 
patients homes in Arkansas and in Oklahoma; here, the supplier only needs to enroll in 
Arkansas. If, however, this same supplier wants to add another accredited practice location in 
Texas, it would have to enroll in in Texas. 
 
10.2.2.3  Independent Clinical Laboratory Improvement Act (CLIA) 
Labs    (Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
Independent CLIA labs are a certified supplier type that enroll via the Form CMS-855B.  In the 
context of provider enrollment, it is important to keep in mind when reviewing this section 
10.2.2.3 the distinction between (1) a CLIA lab enrolling as an independent Medicare supplier 
and (2) a different provider/supplier type (e.g., physician group, rural health clinic) that has a 
CLIA certificate and whose laboratory services are under the same ownership and at the same 
location as the main provider/supplier. 
 
A.  General Background Information 
 
As explained in CMS Publication (Pub.) 100-07, chapter 6, sections 6000 and 6002, the Clinical 
Laboratory Improvement Amendments of 1988 amended the Public Health Service Act (42 
U.S.C. 263a) to extend jurisdiction of the Department of Health and Human Services (HHS) to 
regulate all laboratories that test human specimens for the purpose of providing information for 
diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the 
health of, human beings.  Except as provided at 42 CFR  493.3, entities that meet the definition 
of a laboratory at 42 CFR  493.2 must meet applicable federal requirements and have a CLIA 
certificate in order to operate.   
 
Regulations implementing CLIA are codified under 42 CFR Part 493.  These regulations require 
that all laboratories or entities performing laboratory testing: 
 
  Pay user fees as assessed by CMS to finance the entire cost of administering the CLIA 
program; 
 
  Submit specific information to HHS or its designee; 
 
  Comply with specific administrative and program requirements; 
 
  Submit to surveys to assess compliance with CLIA requirements; 
 
  Be subject to specified enforcement actions; and 
 
  (1) Apply for CLIA certificates based on the complexity of testing performed in the 
laboratory or based on accreditation by a CMS-approved accreditation organization, or 
(2) be licensed or approved in accordance with state requirements if located in a state 
with a CMS-approved state laboratory licensure program.  
 
Section 6141 of the Omnibus Budget Reconciliation Act of 1989 requires that laboratories 
participating in the Medicare program comply with CLIA requirements.  Therefore, all 
laboratories, with the exception of laboratories located in and licensed or approved by a state 
with a CMS-approved state laboratory licensure program (CLIA-exempt laboratories) must 
obtain a CLIA certificate to operate and to be eligible for payment under Medicare and 
Medicaid.  Although CLIA-exempt laboratories do not need a CLIA certificate to operate, they 
are assigned a CLIA identification number for Medicare and Medicaid payment purposes. 
  As stated in Pub. 100-07, chapter 6, section 6002, certain types of laboratories and laboratory 
tests are NOT subject to meeting CLIA requirements.  These include: 
 
  Any facility or component of a facility that performs testing strictly for forensic purposes; 
 
  Research laboratories that test human specimens but do not report patient specific results 
for the diagnosis, prevention, or treatment of any disease or impairment of, or the 
assessment of the health of individual patients; 
 
  Components or functions of laboratories certified by the Substance Abuse and Mental 
Health Services Administration (SAMHSA), in which drug testing is performed that 
meets SAMHSA guidelines and regulations.  (However, all other testing conducted by a 
SAMHSA certified laboratory is subject to this rule.); 
 
  Laboratories under the jurisdiction of the Department of Veterans Affairs; 
 
  Department of Defense (DoD) laboratories are subject to requirements that CMS has 
determined to be comparable to those in CLIA.  The DoD is responsible for assuring 
compliance with these requirements and for oversight of its laboratories under a 
Memorandum of Understanding (MOU) between the Secretary of HHS and the Secretary 
of DoD;  
 
  Laboratory testing conducted in conjunction with the provision of home health or hospice 
care in an individuals home, where the home health agency or hospice employee merely 
assists the individual in performing a test, since tests performed by individuals in the 
home are not subject to CLIA (see Pub. 100-7, chapter 6, section 6010.1.2.1); 
 
  Laboratories located in and licensed or approved by a state with a CMS-approved 
laboratory licensure program is approved by CMS (i.e., CLIA exempt as approved under 
42 CFR part 493, Subpart E);  
 
  Facilities which serve only as collection stations.  A collection station receives specimens 
to be forwarded to a laboratory performing diagnostic tests;  
 
  Radiological facilities that perform only imaging procedures (e.g., x-rays, ultrasounds, 
magnetic resonance imaging, computerized tomography); 
 
  Facilities performing only physiological testing (e.g., spirometry, slit-lamp test for eyes, 
breath analysis, pulse oximetry); and 
 
  Any facility or component of a facility that performs substance use disorder testing (such 
as for alcohol and/or drugs) solely for employment purposes (such as disciplinary, 
administrative, or legal action).  
 
B. Certificates 
  See Pub. 100-07, chapter 6, sections 6006 through 6006.7, 6008, and 6014 for information 
regarding the various types of CLIA certificates.  
 
C. Independent CLIA Lab Enrollment 
 
1. Integrated Labs vs. Independent Labs 
 
Labs that are integrated into an existing provider or supplier do not require a separate Form 
CMS-855B enrollment.  Integrated labs typically are those that have exactly the same 
ownership and physical location as another enrolled supplier or provider.  (Common examples 
include: (1) hospital labs and (2) a lab at a physician's office.)  If a lab is considered integrated, 
the parent provider/supplier shall identify the lab as a practice location in Section 4 of its Form 
CMS-855 and list the applicable CLIA number. 
 
If the lab is not integrated, the lab must enroll as an independent CLIA lab via the Form CMS-
855B application.  The contractor shall advise the lab that it must contact the applicable CLIA 
office; the lab cannot be enrolled until it receives a CLIA number.  The contractor shall also 
ensure that the lab is CLIA-certified and, as applicable, state-licensed.   
 
2.  Additional Enrollment Policies 
 
Unless stated otherwise in this chapter or in another CMS directive: 
 
i.  Practice Locations - Each practice location at which laboratory tests are performed must 
submit to the contractor a separate CLIA certificate for that location.  (This includes 
applications submitted via PECOS.)  The only exceptions to this requirement are: (1) 
laboratories within a hospital that are located at contiguous buildings, on the same campus, 
and under common direction; (2) non-profit or governmental laboratories that engage in 
limited public health testing; and (3) laboratories that are not at a fixed location (i.e., are 
mobile). 
 
ii.  States - The laboratory must submit to the contractor a separate certificate for each state in 
which testing is performed. 
 
D.  Procedure to Update CLIA Certificate for an Enrolled CLIA Lab 
 
A Medicare-enrolled CLIA lab shall submit any updated CLIA certificate to its contractor with a 
Form CMS-855.   
 
E.  Site Visits of Independent CLIA Labs 
 
1.  Initial and revalidation applications  If an independent CLIA lab submits an initial or 
revalidation application, the contractor shall order a site visit through PECOS.  This is to 
ensure that the supplier is (or is still) in compliance with CMSs enrollment requirements.  
The scope of the site visit will be consistent with sections 10.6.20(A) and 10.6.20(B) of this 
chapter.  The National Site Visit Contractor (NSVC) will perform the site visit.  The 
contractor shall not convey Medicare billing privileges to the supplier (or, in the case of  revalidation, make a final decision regarding the application) prior to the completion of the 
NSVCs site visit and the contractors review of the results. 
 
2.  New/changed location - If an independent CLIA lab is (1) adding a new location or (2) 
changing the physical location of an existing location, the contractor shall order a site visit of 
the new/changed location through PECOS. This is to ensure that the new/changed location is 
in compliance with CMSs enrollment requirements.  The scope of the site visit will be 
consistent with sections 10.6.20(A) and 10.6.20(B) of this chapter.  The NSVC will perform 
the site visit.  The contractor shall not switch the suppliers enrollment record to Approved 
prior to the completion of the NSVCs site visit and the contractors review of the results. 
 
F.  Additional Information 
 
For additional data on CLIA laboratories, refer to: 
 
  42 CFR Part 493 
 
  Pub. 100-07, chapter 6  
 
  Pub. 100-04, chapter 16 
 
  Form CMS-116 (CLIA Application for Certification) 
 
10.2.2.4  Independent Diagnostic Testing Facilities (IDTFs) 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
IDTFs are a supplier type that enrolls via the Form CMS-855B. 
 
A.  Introduction 
 
1.  General Background  
 
An IDTF is a facility that is independent both of an attending or consulting physicians office 
and of a hospital. However, IDTF general coverage and payment policy rules apply when an 
IDTF furnishes diagnostic procedures in a physicians office (see 42 CFR  410.33(a)(1)).  
 
Effective for diagnostic procedures performed on or after March 15, 1999, MACs pay for 
diagnostic procedures under the physician fee schedule when performed by an IDTF. An IDTF 
may be a fixed location or a mobile entity. It is independent of a physicians office or hospital. 
 
2.  Place of IDTF Service 
 
i.  Indirect IDTFs  Background  
 
IDTFs generally perform diagnostic tests on beneficiaries in, for instance, a health care facility, 
physicians office, or mobile setting.  The IDTF standards at  410.33(g) (as well as other 
provisions in  410.33) were, in fact, designed for traditional IDTF suppliers that engage in 
direct or in-person beneficiary interaction, treatment, and/or testing.  Yet some health care  entities have developed or utilize diagnostic tests that do not require such interaction (hereafter 
occasionally referenced as indirect IDTFs).  That is, certain IDTFs perform diagnostic services 
via computer modeling and analytics, or other forms of testing not involving direct beneficiary 
interaction.  The service is often conducted by a technician who undertakes a computer analysis 
offsite or at another location at which the patient is not present.  The physician then reviews the 
image to determine the appropriate course of action.  In short, these entities generally, though not 
exclusively, have two overriding characteristics.  First, the tests they perform do not involve 
direct patient interaction, meaning that the test is conducted away from the patients physical 
presence and is non-invasive.  Second, the test involves off-site computer modeling and 
analytics.   
 
Despite the comparatively new and innovative forms of testing these entities undertake, they can 
still qualify as IDTFs (notwithstanding the offsite and indirect nature of the test) so long as they 
meet the applicable requirements of  410.33.  In the past, however, these entities have often 
been unable to meet certain IDTF requirements (and thus cannot enroll in Medicare) strictly 
because of the tests indirect nature.  In other words, the types of tests at issue do not fall within 
the category of those to which several of the standards in  410.33 were intended to apply 
(specifically, to in-person procedures).  
 
ii.  Indirect IDTFs  General Description, Exemptions, and Verification 
 
To account for such technological advances in diagnostic testing, we revised  410.33 in the CY 
2022 Physician Fee Schedule final rule such that IDTFs that have no beneficiary interaction, 
treatment, or testing whatsoever at their practice location are wholly exempt from the 
following requirements in  410.33(g).   
 
   410.33(g)(6)) - The IDTF must have a comprehensive liability insurance policy of at least 
$300,000 per location that covers both the place of business and all customers and employees 
of the IDTF. 
 
   410.33(g)(8)) - The IDTF must answer, document, and maintain documentation of a 
beneficiary's written clinical complaint at the physical site of the IDTF.   
 
   410.33(g)(9)) - The IDTF must openly post the standards outlined in  410.33(g) for review 
by patients and the public. 
 
In addition. 42 CFR  410.33(c) previously stated in full: Any nonphysician personnel used by 
the IDTF to perform tests must demonstrate the basic qualifications to perform the tests in 
question and have training and proficiency as evidenced by licensure or certification by the 
appropriate State health or education department. In the absence of a State licensing board, the 
technician must be certified by an appropriate national credentialing body. The IDTF must 
maintain documentation available for review that these requirements are met.  This requirement 
(now codified in  410.33(c)(1)) remains intact for IDTFs that perform direct, in-person testing.  
For indirect IDTFs, however, new  410.33(c)(2) states that---for services that do not require 
direct or in-person beneficiary interaction, treatment, or testing---any nonphysician personnel 
performing the test must meet all applicable state licensure requirements for doing so; if such 
state licensure requirements exist, the IDTF must maintain documentation available for review  that these requirements have been met.  If no state licensure requirements for such personnel 
exist, the contractor need not undertake additional verification activities under  410.33(c)(2) 
concerning the technician in question; the contractor shall not establish its own additional 
certification, credentialing, or similar technician requirements (e.g., federal accreditation) above 
and beyond the requirements in  410.33(c)(2). 
 
The only complete or partial exemptions in  410.33 that apply to indirect IDTFs are those 
described in this subsection (A)(2) (i.e.,  410.33(c)(2), (g)(6), (g)(8), and (g)(9)).  
 
iii.  Synopsis 
 
In sum: 
 
(A) IDTFs that perform direct, in-person testing on beneficiaries must still meet all requirements 
and standards in 42 CFR  410.33.  Also, the personnel performing these tests must comply with 
the requirements in  410.33(c)(1). 
 
(B) Indirect IDTFs need not meet the standards in  410.33(g)(6), (g)(8), and (g)(9).  The 
personnel performing these tests must comply with the requirements in  410.33(c)(2) rather than 
 410.33(c)(1).   
 
(C) If an IDTF performs both direct and indirect tests: 
 
  It must meet the standards in  410.33(g)(6), (g)(8), and (g)(9).  An IDTF must exclusively 
and only perform tests involving no beneficiary interaction, treatment, or testing in 
order to be exempt from  410.33(g)(6), (g)(8), and (g)(9).  Thus, even if the 
overwhelming majority of the IDTFs tests are those described in the previous sentence, 
the aforementioned exemptions are inapplicable if the IDTF conducts any tests 
requiring direct, in-person patient interaction.  
 
  Personnel performing direct patient interaction tests must meet the requirements of  
410.33(c)(1).  Personnel conducting indirect, non-person tests must meet the requirements of 
 410.33(c)(2).  If a particular technician at an IDTF performs both categories of tests, he or 
she must meet  410.33(c)(1)s requirements for the direct, in-person tests and  
410.33(c)(2)s requirements for the indirect, non-in-person tests. 
 
(D) The contractor will typically be able to determine during application processing whether the 
IDTF is an indirect IDTF.  This can be done via, for instance, reviewing: (1) the site visit 
results; or (2) the tests reported in Attachment 2 of the Form CMS-855B.  In this matter, the 
contractor shall abide by the following: 
 
  Unless there is evidence that the IDTF only performs indirect tests, the contractor may 
assume that the supplier is not an indirect IDTF. 
  If the contractor determines that the IDTF performs both indirect and direct tests, it shall 
follow the instructions described in this subsection (A)(2). 
  Note that the contractor is not required to submit all potential indirect IDTF applications to 
PEOG for review or prior approval.  The contractor need only contact its PEOG BFL if it: (1) is 
truly unsure if an indirect IDTF situation is involved; or (2) does not believe the supplier is an 
indirect IDTF but the supplier states that it is. 
 
B.  IDTF Standards 
 
Consistent with 42 CFR  410.33(g)and excluding  410.33(g)(6), (g)(8), and (g)(9) for 
indirect IDTFs---each IDTF must certify on its Form CMS-855B enrollment application that it 
meets the following standards and all other requirements: 
 
1.  Operates its business in compliance with all applicable federal and state licensure and 
regulatory requirements for the health and safety of patients ( 410.33(g)(1)). 
 
  The purpose of this standard is to ensure that suppliers are licensed in the business and 
specialties being provided to Medicare beneficiaries.  Licenses are required by state and/or 
federal agencies to make certain that guidelines and regulations are being followed and to 
ensure that businesses are furnishing quality services to Medicare beneficiaries. 
 
  The responsibility for determining what licenses are required to operate a suppliers business 
is the sole responsibility of the supplier.  The contractor is not responsible for notifying any 
supplier of what licenses are required or that any changes have occurred in the licensure 
requirements.  No exemptions to applicable state licensing requirements are permitted, 
except when granted by the state. 
 
  The contractor shall not grant billing privileges to any business not appropriately licensed as 
required by the appropriate state or federal agency.  If a supplier is found providing services 
for which it is not properly licensed, billing privileges may be revoked and appropriate 
recoupment actions taken. 
 
2.  Provides complete and accurate information on its enrollment application.  Changes in 
ownership, changes of location, changes in general supervision, and final adverse actions must 
be reported to the contractor within 30 calendar days of the change.  All other changes to the 
enrollment application must be reported within 90 days ( 410.33(g)(2)). 
 
(NOTE:  This 30-day requirement takes precedence over the certification in Section 15 of 
the Form CMS-855B whereby the supplier agrees to notify Medicare of any changes to its 
enrollment data within 90 days of the effective date of the change.  By signing the 
certification statement, the IDTF agrees to abide by all Medicare rules for its supplier type, 
including the 30-day rule in 42 CFR 410.33(g)(2)). 
 
3.  Maintain a physical facility on an appropriate site.  (For purposes of this standard, a post 
office box, commercial mailbox, hotel, or motel is not an appropriate site.  The physical facility, 
including mobile units, must contain space for equipment appropriate to the services designated 
on the enrollment application, facilities for hand washing, adequate patient privacy 
accommodations, and the storage of both business records and current medical records within the  office setting of the IDTF, or IDTF home office, not within the actual mobile unit.) 
(410.33(g)(3)). 
 
  IDTF suppliers that provide services remotely and do not see beneficiaries at their practice 
location are exempt from providing hand washing and adequate patient privacy 
accommodations. 
 
  The requirements in 42 CFR  410.33(g)(3) take precedence over the guidelines in section 
10.3.1(B)(1)(d) of this chapter pertaining to the suppliers practice location requirements. 
 
  The physical location must have an address, including the suite identifier, which is 
recognized by the United States Postal Service (USPS). 
 
4.  Has all applicable diagnostic testing equipment available at the physical site excluding 
portable diagnostic testing equipment.  The IDTF must 
 
(i)  Maintain a catalog of portable diagnostic equipment, including diagnostic testing equipment 
serial numbers at the physical site; 
 
(ii) Make portable diagnostic testing equipment available for inspection within 2 business days 
of a CMS inspection request; and 
 
(iii) Maintain a current inventory of the diagnostic testing equipment, including serial and 
registration numbers, and provide this information to the designated fee-for-service contractor 
upon request, and notify the contractor of any changes in equipment within 90 days. ( 
410.33(g)(4)). 
 
5.  Maintain a primary business phone under the name of the designated business.  The IDTF 
must have its  
 
(i)  Primary business phone located at the designated site of the business or within the home 
office of the mobile IDTF units. 
 
(ii)  Telephone or toll free telephone numbers available in a local directory and through directory 
assistance. ( 410.33(g)(5)). 
 
The requirements in 42 CFR  410.33(g)(5) take precedence over the guidelines in section 
10.3.1(B)(1)(d) of this chapter regarding the suppliers telephone requirements. 
 
IDTFs may not use call forwarding or an answering service as their primary method of 
receiving calls from beneficiaries during posted operating hours. 
 
6.  Have a comprehensive liability insurance policy of at least $300,000 per location that covers 
both the place of business and all customers and employees of the IDTF. The policy must be 
carried by a non-relative-owned company.  Failure to maintain required insurance at all times 
will result in revocation of the IDTFs billing privileges retroactive to the date the insurance  lapsed.  IDTF suppliers are responsible for providing the contact information for the issuing 
insurance agent and the underwriter.  In addition, the IDTF must-- 
 
(i)  Ensure that the insurance policy must remain in force at all times and provide coverage of at 
least $300,000 per incident; and 
 
(ii) Notify the CMS designated contractor in writing of any policy changes or cancellations.  ( 
410.33(g)(6)) 
 
7.  Agree not to directly solicit patients; this includes - but is not limited to - a prohibition on 
telephone, computer, or in-person contacts.  The IDTF must accept only those patients referred 
for diagnostic testing by an attending physician who: (a) is furnishing a consultation or treating a 
beneficiary for a specific medical problem; and (2) uses the results in the management of the 
beneficiarys specific medical problem.  Non-physician practitioners may order tests as set forth 
in  410.32(a)(3). ( 410.33(g)(7)) 
 
  By the signature of the authorized official in Section 15 of the Form CMS-855B, the IDTF 
agrees to comply with 42 CFR  410.33(g)(7). 
 
  The supplier is prohibited from directly contacting any individual beneficiary for the purpose 
of soliciting business for the IDTF.  This includes contacting the individual beneficiary by 
telephone or via door-to-door sales. 
 
  There is no prohibition on television, radio, or Internet advertisements, mass mailings, or 
similar efforts to attract potential clients to an IDTF. 
 
8.  Answer, document, and maintain documentation of a beneficiarys written clinical complaint 
at the physical site of the IDTF.  (For mobile IDTFs, this documentation would be stored at their 
home office.)  This includes, but is not limited to, the following: 
 
(i) The name, address, telephone number, and health insurance claim number of the beneficiary. 
 
(ii) The date the complaint was received, the name of the person receiving the complaint, and a 
summary of actions taken to resolve the complaint. 
 
(iii) If an investigation was not conducted, the name of the person making the decision and the 
reason for the decision. ( 410.33(g)(8)) 
 
9.  Openly post these standards for review by patients and the public. ( 410.33(g)(9)) 
 
10.  Disclose to the government any person having ownership, financial, or control interest or 
any other legal interest in the supplier at the time of enrollment or within 30 days of a change. ( 
410.33(g)(10)) 
 
11.  Have its testing equipment calibrated and maintained per equipment instructions and in 
compliance with applicable manufacturers suggested maintenance and calibration standards.  ( 
410.33(g)(11))   
12.  Have technical staff on duty with the appropriate credentials to perform tests.  The IDTF 
must be able to produce the applicable federal or state licenses or certifications of the individuals 
performing these services.  ( 410.33(g)(12)) 
 
13.  Have proper medical record storage and be able to retrieve medical records upon request 
from CMS or its fee-for-service contractor within 2 business days.  ( 410.33(g)(13)) 
 
14.  Permit CMS, including its agents, or its designated fee-for-service contractors, to conduct 
unannounced, on-site inspections to confirm the IDTFs compliance with these standards.  The 
IDTF must--- 
 
(i) Be accessible during regular business hours to CMS and beneficiaries; and 
 
(ii) Maintain a visible sign posting its normal business hours.  ( 410.33(g)(14)) 
 
15.  With the exception of hospital-based and mobile IDTFs, a fixed-base IDTF is prohibited 
from the following: 
(i)  Sharing a practice location with another Medicare-enrolled individual or organization; 
(ii) Leasing or subleasing its operations or its practice location to another Medicare-enrolled 
individual or organization; or 
(iii) Sharing diagnostic testing equipment used in the initial diagnostic test with another   
Medicare-enrolled individual or organization. ( 410.33(g)(15)) 
 
16.  Enrolls in Medicare for any diagnostic testing services that it furnishes to a Medicare 
beneficiary, regardless of whether the service is furnished in a mobile or fixed-base location. ( 
410.33(g)(16)) 
 
17.  Bills for all mobile diagnostic services that are furnished to a Medicare beneficiary, unless 
the mobile diagnostic service is part of a service provided under arrangement as described in 
section 1861(w)(1) of the Act ( 410.33(g)(17)) (Section 1861(w)(1) states that the term 
arrangements is limited to arrangements under which receipt of payments by the hospital, 
critical access hospital, skilled nursing facility, home health agency or hospice program (whether 
in its own right or as an agent), with respect to services for which an individual is entitled to have 
payment made under this title, discharges the liability of such individual or any other person to 
pay for the services.) 
 
If the IDTF claims that it is furnishing services under arrangement as described in section 
1861(w)(1), the IDTF must provide documentation of such with its initial or revalidation Form 
CMS-855 application. 
 
The IDTF must meet all of the standards in 42 CFR  410.33  as well as all other federal and 
state statutory and regulatory requirements  in order to be enrolled in, and to maintain its 
enrollment in, the Medicare program.  Failure to meet any standard in 42 CFR  410.33 or any  other applicable requirement will result in the denial of the suppliers Form CMS-855 
application or, if the supplier is already enrolled in Medicare, the revocation of its Medicare 
billing privileges. 
 
C.  Leasing and Staffing 
 
For purposes of the provisions in 42 CFR  410.33, a "mobile IDTF" does not include entities 
that lease or contract with a Medicare enrolled provider or supplier to provide: (1) diagnostic 
testing equipment; (2) non-physician personnel described in 42 CFR  410.33(c); or (3) 
diagnostic testing equipment and non-physician personnel described in 42 CFR  410.33(c).  
This is because the provider/supplier is responsible for providing the appropriate level of 
physician supervision for the diagnostic testing. 
 
An IDTF is not required to report equipment that the IDTF is leasing for a period less than 90 
days unless the IDTF is leasing equipment for services that they have not already reported on a 
Form CMS-855B IDTF Attachment. For all new services being provided, IDTFs would need to 
complete a change of information to include the equipment and CPT/HCPCS codes that will be 
billed. Any accreditation for the services provided would need to be obtained by the IDTF. 
 
D.  Sharing of Space and Equipment 
 
As previously noted, the standard in  410.33(g)(15) states that, with the exception of hospital-
based and mobile IDTFs, a fixed-base IDTF cannot: (i) share a practice location with another 
Medicare-enrolled individual or organization; (ii) lease or sublease its operations or its practice 
location to another Medicare-enrolled individual or organization; or (iii) share diagnostic testing 
equipment used in the initial diagnostic test with another Medicare-enrolled individual or 
organization.   
 
If the contractor determines that an IDTF is violating at least one of the three prohibitions in  
410.33(g)(15), the contractor shall revoke the suppliers Medicare billing privileges. 
 
E.  Multi-State IDTFs 
 
As stated in 42 CFR  410.33(e)(1), an IDTF that operates across state boundaries must: 
 
a.  Maintain documentation that its supervising physicians and technicians are licensed and 
certified in each of the states in which it operates; and 
 
b.  Operate in compliance with all applicable federal, state, and local licensure and regulatory 
requirements with regard to the health and safety of patients. 
 
Under  410.33(e)(2), the point of the actual delivery of service means the place of service on the 
claim form. When the IDTF performs or administers an entire diagnostic test at the beneficiary's 
location, the beneficiarys location is the place of service.  When one or more aspects of the 
diagnostic testing are performed at the IDTF, the IDTF is the place of service. 
 
F.  One Enrollment per Practice Location 
  An IDTF must separately enroll each of its practice locations (with the exception of locations 
that are used solely as warehouses or repair facilities).  This means that an enrolling IDTF can 
only have one practice location on its Form CMS-855B enrollment application; thus, if an IDTF 
is adding a practice location to its existing enrollment, it must submit a new, complete Form 
CMS-855B application for that location and have that location undergo a separate site visit.  
Also, each of the IDTFs mobile units must enroll separately; if a fixed IDTF site also contains a 
mobile unit, the mobile unit must therefore enroll separately from the fixed location. 
 
Each separately enrolled practice location of the IDTF must meet all applicable IDTF 
requirements.  The locations failure to comply with any of these requirements will result in the 
revocation of its Medicare billing privileges. 
 
If an IDTF adds equipment for diagnostic testing that is mobile in nature but is fixed 
permanently to the IDTFs physical location (i.e., a CT scanner that is mounted in a bus or trailer 
but is parked at the IDTFs site for use by the IDTF), a second enrollment is not necessary. This 
equipment can be listed in the Form CMS-855B along with the services performed on the 
equipment. In these cases, the contractor shall indicate the use of a fixed mobile unit is in use at 
the IDTFs site in the site visit request so the site inspector will know to view the fixed mobile 
equipment as part of the IDTF. 
 
G.  Interpreting Physicians 
 
1.  Reporting Interpreting Physicians on the Form CMS-855B 
 
The applicant shall list all physicians for whose diagnostic test interpretations it will bill.  This 
includes physicians who will provide interpretations subject to the anti-markup payment 
limitation as detailed in CMS Pub. 100-04, chapter 1,  30.2.9 - whether the service is provided 
to the IDTF on a contract basis or is reassigned. 
 
The contractor shall ensure and document that: 
 
  All listed physicians are enrolled in Medicare 
 
  All interpreting physicians who are reassigning their benefits to the IDTF have the right to do 
so 
 
  The interpreting physicians listed are qualified to interpret the types of tests (codes) listed.  
(The contractor may need to contact another contractor to obtain this information.)  If the 
applicant does not list any interpreting physicians, the contractor need not request additional 
information because the applicant may not be billing for the interpretations; that is, the 
physicians may be billing for the interpretation themselves. 
 
If an interpreting physician has been recently added or changed, the new interpreting physician 
must have met all of the interpreting physician requirements at the time any tests were 
performed. 
  A Form CMS-855R need not accompany a Form CMS-855B application submitted by an IDTF 
that employs or contracts with an interpreting physician. 
 
2.  Changes of Interpreting Physicians 
 
If an interpreting physician is being added or changed, the updated information must be reported 
via a Form CMS-855B change request. To perform services as an interpreting physician, the new 
interpreting physician must have met all requirements at the time any tests were performed. 
 
If the contractor receives notification from an interpreting physician that he/she is no longer 
interpreting tests at the IDTF, the contractor shall request from the supplier a Form CMS-855B 
change of information to end date the interpreting physician from the enrollment.  
 
H.  Effective Date of IDTF Billing Privileges 
 
As stated in 42 CFR  410.33(i), the filing date of an IDTF Medicare enrollment application is 
the date the contractor receives a signed application that it is able to process to approval.  The 
effective date of billing privileges for a newly enrolled IDTF is the later of the following: 
 
(1) The filing date of the Medicare enrollment application that was subsequently approved by the 
contractor; or 
 
(2) The date the IDTF first started furnishing services at its new practice location. 
 
A newly-enrolled IDTF, therefore, may not receive reimbursement for services furnished before 
the effective date of billing privileges. 
 
The contractor shall note that if it rejects an IDTF application under 42 CFR  424.525 and a 
new application is later submitted, the date of filing is the date the contractor receives the new 
enrollment application. 
 
If an IDTF undergoes an ownership change that results in a new enrollment (e.g., a new federal 
tax information number (TIN) results from this change), the contractor should use the transfer of 
ownership/business date as indicated by the IDTF, instead of establishing a new effective date. 
 
I.  IDTF Technicians Must Be Listed on the Form CMS-855B 
 
Each non-physician who performs IDTF diagnostic tests must be listed.  These persons are often 
referred to as technicians. 
 
J.  IDTF Technician Licensure and Certification Requirements   
 
All technicians must meet state licensure or state certification standards at the time of the IDTFs 
enrollment.  The contractor may not grant temporary exemptions from such requirements. 
  
In lieu of requiring a copy of the technicians certification card, the contractor may validate a 
technicians credentials online via organizations such as the American Registry for Diagnostic 
Medical Sonography (ARDMS), the American Registry of Radiology Technologists (ARRT),  and the Nuclear Medicine Technology Certification Board (NMTCB).  If online verification is 
not available or cannot be made, the contractor shall request a copy of the technicians 
certification card. 
 
K.  IDTF - Changes of Technicians 
 
If a technician is being added or changed, the updated information must be reported via a Form 
CMS-855B change request.  The new technician must have met all of the necessary credentialing 
requirements at the time any tests were performed. 
 
If the contractor receives notification from a technician that he/she is no longer performing tests 
at the IDTF, the contractor shall request from the supplier a Form CMS-855B change of 
information.  If the supplier did not have another technician qualified to perform the tests listed 
on the current application, the supplier must submit significant documentation in the form of 
payroll records, etc. to substantiate the performance of the test by a properly qualified technician 
after the date the original technician was no longer performing procedures at the IDTF. 
 
L.  IDTF Supervising Physicians  General Principles 
 
An IDTF must have one or more supervising physicians who are responsible for: 
 
  The direct and ongoing oversight of the quality of the testing performed; 
 
  The proper operation and calibration of equipment used to perform tests; and  
 
  The qualifications of non-physician IDTF personnel who use the equipment. 
 
Not every supervising physician has to be responsible for all of these functions.  For instance, 
one supervising physician can be responsible for the operation and calibration of equipment, 
while another supervising physician can be responsible for test supervision and the qualifications 
of non-physician personnel.  The basic requirement, however, is that all supervising physician 
functions must be properly met at each location, regardless of the number of physicians involved.  
This is particularly applicable to mobile IDTF units that are allowed to use different supervising 
physicians at different locations.  They may have a different physician supervise the test at each 
location.  The physicians used need only meet the proficiency standards for the tests they are 
supervising. 
 
Under 42 CFR  410.33(b)(1), each supervising physician must be limited to providing general 
supervision at no more than three IDTF sites.  This applies to both fixed sites and mobile units 
where three concurrent operations are capable of performing tests. 
 
M.  IDTF - Information about Supervising Physicians 
 
The contractor shall ensure and document in PECOS that each supervising physician is: (1) 
licensed to practice in the state(s) where the diagnostic tests he or she supervises will be 
performed; (2) Medicare-enrolled; and (3) not currently excluded or debarred.  The physician(s) 
need not necessarily be Medicare-enrolled in the state where the IDTF is enrolled; moreover, the  physician need not be furnishing medical services outside of his/her role as a supervising 
physician (i.e., he/she need not have his/her own medical practice separate from the IDTF).  If 
the physician is enrolled in another state or with another contractor, however, the contractor shall 
ensure that he or she is appropriately licensed in that state. 
 
In addition: 
 
  Each physician of the group who actually performs an IDTF supervisory function must be 
listed. 
 
  If a supervising physician has been recently added or changed, the updated information must 
be reported via a Form CMS-855B change request.  The new physician must have met all of 
the supervising physician requirements at the time any tests were performed. 
 
  If the contractor knows that a reported supervising physician has been listed with several 
other IDTFs, the contractor shall check with the physician to determine whether he or she is 
still acting as supervising physician for these other IDTFs. 
 
  If the supervising physician is enrolling in Medicare and does not intend to perform medical 
services outside of his/her role as a supervising physician: (1) the contractor shall still send 
the physician an approval letter (assuming successful enrollment) and issue a PTAN; (2) the 
physician shall list the IDTFs address as a practice location; and (3) the space-sharing 
prohibition in 42 CFR  410.33(g) does not apply in this particular scenario. 
 
N.  IDTF - General, Direct, and Personal Supervision 
 
Section 410.33(b)(2) states that if a procedure requires the direct or personal supervision of a 
physician as set forth in, respectively, 42 CFR  410.32(b)(3)(ii) or (iii), the contractor shall 
ensure that the IDTFs supervising physician furnishes this level of supervision. 
 
The contractor shall: (a) be familiar with the definitions of personal, direct and general 
supervision set forth at 42 CFR  410.32(b)(3); and (b) ensure that the applicant has checked the 
highest required level of supervision for the tests being performed. 
 
Each box that begins with Assumes responsibility must be checked.  However, as indicated 
previously, the boxes can be checked through the use of more than one physician. 
 
O.  IDTF - Attestation Statement for Supervising Physicians 
 
A separate attestation statement must be completed and signed by each supervising physician 
listed.  If Question E2 is not completed, the contractor may assume  unless it has reason to 
suspect otherwise - that the supervising physician in question supervises for all codes listed in 
Section 2 of the IDTF attachment.  If Question E2 is completed, the contractor shall ensure that 
all codes listed in Section 2 are covered through the use of multiple supervising physicians. 
 
With respect to physician verification, the contractor shall contact each supervisory physician by 
telephone to verify that the physician: (1) actually exists (e.g., is not using a false or inactive  physician number); (2) indeed signed the attestation; and (3) is aware of his or her 
responsibilities. 
 
If the physician is enrolled with a different contractor, the contractor shall contact the latter 
contractor and obtain the listed telephone number of the physician. 
 
P.  IDTF - Changes of Supervising Physicians  
 
If a supervising physician is being added or changed, the updated information must be reported 
via a Form CMS-855B change request. To perform services as a supervising physician, the new 
supervising physician must have met all requirements at the time any tests were performed.  
 
If the contractor receives notification from a supervising physician that he/she is no longer 
supervising tests at the IDTF, the contractor shall request from the supplier a Form CMS-855B 
change of information.  If the IDTF did not have another supervising physician listed on the 
current application, the IDTF must submit a change of information adding a new supervising 
physician. If the IDTF does not provide this information, the contractor shall proceed with non-
compliance revocation procedures as noted in section 10.4(M) of this chapter. 
 
Q.  Desk and Site Reviews 
 
All initial and revalidating IDTF applicants shall receive: (1) a thorough desk review; and (2) a 
mandatory site visit prior to the contractors approval of the application.  The general purposes of 
these reviews are to determine whether: 
 
  The information listed on Attachment 2 of the Form CMS-855B is correct, verifiable, and in 
accordance with all IDTF regulatory and enrollment requirements. 
 
  To the extent applicable, the IDTF meets the criteria outlined in sections 10.6.20(A) and 
10.6.20(B) of this chapter. 
 
  The IDTF meets the supplier standards in 42 CFR  410.33. 
 
The contractor shall order the site visit through PECOS.  The NSVC will perform the site visit.  
The contractor shall not make a final decision regarding the application prior to the completion 
of the NSVCs site visit and the contractors review of the results. 
 
R.  Mobile Units 
 
Mobile units must list their geographic service areas in Section 4 of the Form CMS-855B.  Based 
on the information furnished therein, the NSVC will generally perform the site visit via one of 
the following methods: (1) the mobile unit visits the office of the NSVC (or some other agreed-to 
location) for inspection; (2) the NSVC visits the mobile units base of operations to inspect the 
unit; or (3) the NSVC obtains an advance schedule of the locations at which the IDTF will be 
performing services and conducts the site visit at one of those locations. 
  Units performing CPT-4 or HCPCS code procedures that require direct or personal supervision 
mandate special attention.  To this end, the contractor shall maintain a listing of all mobile IDTFs 
that perform procedure codes that require such levels of supervision.  The contractor shall also 
discuss with the applicant and all supervising physicians listed: 
 
  How they will perform these types of supervision on a mobile basis; 
 
  What their responsibilities are; and 
 
  That a patients physician who is performing direct or personal supervision for the IDTF on 
their patient should be aware of the prohibition concerning physician self-referral for testing 
(in particular, this concerns potentially illegal compensation to the supervisory physician 
from the IDTF). 
 
S.  Addition of Codes 
 
An enrolled IDTF that wants to perform additional CPT-4 or HCPCS codes must submit a Form 
CMS-855B change request.  If the additional procedures are of a type and supervision level 
similar to those previously reported (e.g., an IDTF that performs MRIs for shoulders wants to 
perform MRIs for hips), a new site visit is typically not required, though the contractor reserves 
the right to request that the NSVC perform one.   
 
If, however, the enrolled IDTF wants to perform additional procedures that are not similar to 
those previously reported (e.g., an IDTF that conducts sleep studies wants to perform ultrasound 
tests or skeletal x-rays), the contractor shall order an NSVC site visit through PECOS.  All IDTF 
claims for the additional procedures shall be suspended until the IDTF: (1) passes all enrollment 
requirements for the additional procedures (e.g., supervisory physician, non-physician personnel, 
equipment); and (2) presents evidence that all requirements for the new procedures were met 
when the tests were actually performed. 
 
If the enrolled IDTF (1) originally listed only general supervision codes, (2) was only reviewed 
for general supervision tests, and (3) now wants to perform tests that require direct or personal 
supervision, the contractor shall promptly suspend all payments for all codes other than those 
requiring general supervision.  The contractor shall order an NSVC site visit through PECOS.  
All IDTF claims for the additional procedures shall be suspended until the IDTF: (1) passes all 
enrollment requirements for the additional procedures (e.g., supervisory physician, non-
physician personnel, equipment); and (2) presents evidence that all requirements for the new 
procedures were met when the tests were actually performed. 
 
In the situations described in the two previous paragraphs, the contractor shall not approve the 
application prior to the completion of the NSVCs site visit and the contractors review of the 
results. 
 
T.  IDTF That Performs Diagnostic Mammography 
 
If an IDTF performs diagnostic mammography services, it must have a Food and Drug 
Administration certification to perform the mammography.  However, an entity that only  performs diagnostic mammography services should not be enrolled as an IDTF.  Rather, it 
should be separately enrolled as a mammography screening center. 
 
U.  IDTF Ownership of CLIA Laboratory 
 
An IDTF may not perform or bill for CLIA tests.  However, an entity with one tax identification 
number may own both an IDTF and an independent CLIA laboratory.  In such a situation, they 
should be separately enrolled and advised to bill separately.  The contractor shall also advise its 
claims unit to ensure that the CLIA codes are not being billed under the IDTF provider number. 
 
10.2.2.5  Intensive Cardiac Rehabilitation (ICR) 
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
ICR suppliers are a supplier type that enrolls via the Form CMS-855B. 
 
A.  Background               
 
Under 42 CFR  410.49(a), an intensive cardiac rehabilitation (ICR) program is defined as 
a physician-supervised program that furnishes cardiac rehabilitation and has shown, in 
peer-reviewed published research, that it improves patients' cardiovascular disease through 
specific outcome measurements described in  410.49(c).  An ICR site under  410.49(a) 
means a hospital outpatient setting or physician's office that is providing ICR utilizing an 
approved ICR program. 
 
ICR programs must be approved by CMS through the national coverage determination 
(NCD) process and must meet certain criteria for approval.   Individual sites seeking to 
provide ICR services via an approved ICR program must enroll with their local Medicare 
contractor as an ICR program supplier. 
 
B.  ICR Enrollment 
 
In order to enroll as an ICR site, a supplier must complete a Form CMS-855B with the 
supplier type of Intensive Cardiac Rehabilitation selected.  The contractor shall verify 
that CMS has approved the ICR program through the NCD process.  A list of approved 
ICR programs will be identified through the NCD listings, the CMS Web site, and the 
Federal Register.  The contractor shall use one of these options to verify that the ICR 
program has met CMS approval. 
 
An ICR supplier must separately and individually enroll each of its practice locations.  The 
supplier can therefore only have one practice location (which shall receive its own Provider 
Transaction Access Number (PTAN)) on its Form CMS-855B enrollment application. The 
contractor shall use specialty code 31 for these enrollments. 
 
The contractor shall only accept and process reassignments (Form CMS-855Rs) to ICR 
suppliers from physicians defined in section 1861(r)(1) of the Social Security Act. 
However, reassignments are not required. 
  It is important that the contractor review and adhere to the following regulations and 
instructions regarding the required qualifications of ICR suppliers:   
 
  42 CFR  410.49 
 
  Pub. 100-04, chapter 32, sections 140.2.2 - 140.2.2.6  
 
  Pub. 100-02, chapter 15, section 232 
 
10.2.2.6  Mammography Screening Centers (MSCs)    
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
MSCs are a certified supplier type that enroll via the Form CMS-855B. 
 
A.  General Background Information 
 
As defined in 42 CFR  410.34(a)(2), a screening mammography is a radiologic procedure 
furnished to a woman without signs or symptoms of breast disease for the purpose of early 
detection of breast cancer, and includes a physician's interpretation of the results of the 
procedure.  Section 410.34(a)(4) defines a supplier of screening mammography as a 
facility that is certified and responsible for ensuring that all screening mammography 
services furnished to Medicare beneficiaries meet the conditions and limitations for 
coverage of screening mammography services as specified in  410.34(c) and (d). 
 
B.  Enrollment of MSCs 
Consistent with  410.34(a)(7), in order to qualify for coverage of its services under the 
Medicare program (and to thus enroll in Medicare), an MSC supplier must meet the 
following requirements: 
1.   Must have a valid provisional certificate, or a valid certificate, that has been issued by 
the Food and Drug Administration (FDA) indicating that the supplier meets the 
certification requirements of section 354 of the PHS Act, as implemented by 21 CFR 
part 900, subpart B. 
2.   Has not been issued a written notification by the FDA that states that the supplier must 
cease conducting mammography examinations because the supplier is not in 
compliance with certain critical certification requirements of section 354 of the PHS 
Act, implemented by 21 CFR part 900, subpart B. 
3.   Must not employ for provision of the professional component of mammography 
services a physician or physicians for whom the facility has received written 
notification by the FDA that the physician (or physicians) is (or are) in violation of the 
certification requirements set forth in section 354 of the PHS Act, as implemented by 
21 CFR 900.12(a)(1)(i).  (The FDA is responsible for collecting certificate fees and surveying mammography 
facilities (screening and diagnostic).)   
 
Unless stated otherwise in this chapter or in another CMS directive, the MSC shall submit a 
copy of its FDA certificate with its application. If the supplier fails to submit the FDA 
certificate within 30 days of the MACs request, the MAC shall reject the application 
consistent with section 10.4(H)(2) of this chapter. 
 
It is important that the contractor review and adhere to the following regulations and 
instructions regarding the required qualifications of MSCs: 
 
  42 CFR  410.34  
 
  Pub. 100-04, chapter 18, sections 20 through 20.1.2  
 
  Pub. 100-02, chapter 15, section 280.3 
 
 
10.2.2.7  Pharmacies     
(Rev. 11859; Issued: 02-16-23; Effective: 03-17-23; Implementation: 03-17-23) 
 
Pharmacies are a supplier type that---depending upon the circumstances involved and as 
discussed below---enroll via the Form CMS-855S or Form CMS-855B. 
 
A.  General Background Information 
 
Pharmacies typically enroll via the Form CMS-855S.  However, there are certain covered 
drugs that are billed through the physician fee schedule and not the schedule for durable 
medical equipment, prosthetics, orthotics and supplies.  These drugs must be billed to the 
Part A/B Medicare Administrative Contractor (MAC), meaning that the pharmacy must 
enroll via the Form CMS-855B. 
 
B.  Additional Information 
 
For more information on the billing and coverage policies for Part B drugs, see: 
 
  Pub. 100-04, chapter 17  
 
  Pub. 100-02, chapter 15, sections 50 through 50.6 
 
10.2.2.8  Portable X-Ray Suppliers (PXRSs) 
(Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
PXRSs are a certified supplier type that enroll via the Form CMS-855B. 
 
A.  Background  
  To qualify as a PXRS, an entity must meet the conditions for coverage discussed in 42 CFR  
486.100-110. 
 
A PXRS can be simultaneously enrolled as a mobile independent diagnostic testing facility 
(IDTF), though they cannot bill for the same service.  A PXRS requires a state survey, while a 
mobile IDTF does not (although an IDTF requires a site visit). 
 
A PXRS does not have a supplier agreement. 
 
B.  Processing Instructions for PXRS Initial Form CMS-855B Applications 
 
1.  Receipt of Application 
 
Upon receipt of a PXRS initial Form CMS-855B application, the contractor shall undertake the 
following (in whichever order the contractor prefers unless directed otherwise in this chapter): 
 
(A) Perform all data validations otherwise required per this chapter.    
 
(B) Ensure that the application(s) is complete consistent with the instructions in this chapter. 
 
(C) Ensure that the PXRS has submitted all documentation otherwise required per this chapter.  
For PXRS initial enrollment, this includes the Form CMS-1880 (Request for Certification as 
Supplier of Portable X-Ray Suppliers)  
 
If the Form CMS-1880 is missing, unsigned, undated, or otherwise incomplete, the contractor 
need not develop for the form(s) or the information thereon; the contractor shall instead notify 
the state in its recommendation letter which document(s) was/were missing or otherwise 
incomplete. For all other missing or incomplete required documentation, the contractor shall 
follow the normal development instructions in this chapter. 
 
2.  Conclusion of Initial Contractor Review 
 
(Nothing in this section 10.2.2.8(B) prohibits the contractor from returning or rejecting the PXRS 
application if otherwise permitted to do so per this chapter.  When returning or rejecting the 
application, the contractor shall follow this chapters procedures for doing so.)     
 
(A) Approval Recommendation 
 
If, consistent with the instructions in section 10.2.2.8(B) and this chapter, the contractor believes 
an approval recommendation is warranted, the contractor shall send the recommendation to the 
state pursuant to existing practice and this chapters instructions.  The contractor need not copy 
the SOG Location or PEOG on the recommendation.  Unless CMS directs otherwise, the 
contractor shall also send to the provider the notification letter in section 10.7.5.1(E) of this 
chapter. 
 
The state will: (1) review the recommendation package for completeness; (2) review the 
contractors recommendation for approval; (3) perform any state-specific functions; and (4) 
contact the contractor with any questions.  The contractor shall respond to any state inquiry in  Item (4) within 5 business days.  If the inquiry involves the need for the contractor to obtain 
additional data, documentation, or clarification from the PXRS, however, the timeframe is 15 
business days; if the provider fails to respond to the contractor within this timeframe, it shall 
notify the state thereof.  The contractor may always contact its PEOG BFL should it need the 
latters assistance with a particular state inquiry. 
 
(B) Denial  
 
If the contractor determines that a denial is warranted, it shall follow the denial procedures 
outlined in this chapter.  This includes: (1) using the appropriate denial letter format in section 
10.7.8 of this chapter; and (2) if required under section 10.6.6 (or another CMS directive) of this 
chapter, referring the matter to PEOG for review prior to denying the application. 
 
3.  Completion of State Review 
 
The state will notify the contractor once it has completed its review.  There are two potential 
outcomes: 
 
(A) Approval Not Recommended 
 
If the state does not recommend approval, it will notify the contractor thereof.  (The contractor 
may accept any notification that is in writing (e-mail is fine).)  A site visit need not be 
performed.  No later than 5 business days after receiving this notification, the contractor shall 
commence the actions described in section 10.2.2.8(B)(2)(B) above.   
 
(B) Approval Recommended 
 
If the state recommends approval, it will typically (though not always) do so via a Form CMS-
1539; the contractor may accept any documentation from the state signifying that the latter 
recommends approval.  (Note that the contractor will not receive a formal tie-in notice.) 
 
No later than 5 business days after receipt of the recommendation from the state, the contractor 
shall order a site visit as described in this chapter.   
 
If the PXRS fails the site visit, the contractor shall follow the denial procedures addressed in 
subsection (B)(2)(B) above.  If the PXRS passes the site visit, the contractor shall (within 3 
business days of completing its review of the results) send an e-mail to 
MedicareProviderEnrollment@cms.hhs.gov with the following information and documents:  
 
  The Form CMS-855 application (or PECOS Application Data Report) and all application 
attachments.  
  A copy of the Form CMS-1539 or similar documentation received from the state 
  A copy of the supplier-signed Form CMS-1880 
  A copy of the draft approval letter, with the effective date shown on the Form CMS-1539 (or 
similar documentation) included in the draft letter.  (See section 10.7.5.1 for the model 
approval letter.)  
  PEOG will countersign the provider agreement.  Based on the information received from the 
contractor, PEOG will also (1) assign an effective date, (2) assign a CCN, and (3) enter the 
applicable data into ASPEN, and (4) approve (with possible edits) the approval letter.   
 
Within 5 business days of receiving from PEOG the signed provider agreement, effective date, 
and CCN, the contractor shall: (1) send the approval letter and a copy of the CMS-countersigned 
provider agreement (CMS-1561) to the PXRS; (2) send a copy of both the approval letter and the 
provider agreement to the state and/or AO (as applicable); and (3) switch the PECOS record 
from approval recommended to approved consistent with existing instructions. 
 
C.  Site Visits  
 
1.  Initial application The scope of the site visit will be consistent with sections 10.6.20(A) and 
10.6.20(B) of this chapter.  The NSVC will perform the site visit.  The contractor shall not 
convey Medicare billing privileges to the provider prior to the completion of the NSVCs site 
visit and the contractors review of the results. 
 
2.  New/changed location - If a PXRS is (1) adding a new location or (2) changing the physical 
location of an existing location, the contractor shall order a site visit of the new/changed location 
through PECOS no later than 5 business days after the contractor receives the approval 
recommendation from the state but before the contractor sends to PEOG the applicable e-mail 
described in section 10.6.1.2(A)(3) of this chapter.  (See the latter section for more information.  
This is to ensure that the new/changed location is in compliance with CMSs enrollment 
requirements.  The scope of the site visit will be consistent with sections 10.6.20(A) and 
10.6.20(B) of this chapter.  The NSVC will perform the site visit.  The contractor shall not make 
a final decision regarding the change of information application prior to the completion of the 
NSVCs site visit and the contractors review of the results. 
 
D.  Reassignment 
 
PXRSs may receive reassigned benefits. A PXRS need not separately enroll as a group practice 
in order to receive them. 
 
E.  Practice Location Information  
 
In Section 4 of the Form CMS-855B, the PXRS must furnish certain information, including:  
 
  Whether it furnishes services from a mobile facility or portable unit. (A PXRS can be 
either, though it usually is a portable unit.)  A mobile facility typically describes a vehicle 
that travels from place to place to perform services inside the vehicle. Examples of such 
vehicles include mobile homes and trailers.  A portable unit involves a supplier transporting 
medical equipment to a particular location.  Unlike with mobile facilities, the equipment on a 
portable unit is separate from and unattached to the vehicle. 
 
  Its base of operations.  This is from where personnel are dispatched and where equipment is 
stored.  It may or may not be the same address as the practice location. 
    All geographic locations at which services will be rendered. 
 
  Vehicle information if the services will be performed inside or from the vehicle. Unless 
stated otherwise in this chapter or in another CMS directive, copies of all licenses and 
registrations must be submitted as well. 
 
F.  Additional Enrollment Information 
 
The contractor shall include any licenses, certifications, and accreditations submitted by PXRSs 
in the enrollment package that is forwarded to the state.   
 
If the PXRSs address or telephone number cannot be verified, the contractor shall contact the 
applicant for further information.  If the supplier states that the facility or its phone number is not 
yet operational, the contractor shall continue processing the application.  However, it shall 
indicate in its recommendation letter to the state that the address and telephone number of the 
facility could not be verified. 
 
When enrolling the PXRS, and except as otherwise stated in this chapter or as otherwise 
instructed by PEOG, the contractor shall use the effective date that is indicated on the state 
approval letter/notice.  This is the date from which the supplier can bill for services.   
 
G.  PXRS Changes of Ownership (CHOWs) and Changes of Information 
 
Though PXRSs are not mentioned in 42 CFR  489.18, CMS generally applies the CHOW 
provisions of  489.18 to them.  CHOWs involving PXRSs are thus handled in accordance with 
the principles in  489.18 and Pub. 100-07, chapter 3, sections 3210 through 3210.5(C).  For 
PXRS CHOW processing instructions, see section 10.6.1.1 of this chapter.  
 
The contractor shall process PXRS changes of information in accordance with section 10.6.1.2 of 
this chapter. 
 
H.  Additional Information 
 
For more information on PXRSs, refer to: 
 
  42 CFR  486.100  486.110 
 
  Pub. 100-07, chapter 2, sections 2420  2424B  
 
  Pub. 100-02, chapter 15, sections 80.4 - 80.4.4   
 
  Pub. 100-04, chapter 13, sections 90 - 90.5 
  
10.2.2.9  Radiation Therapy Centers (RTCs) 
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
RTCs are a supplier type that enroll via the Form CMS-855B.   
A.  General Background Information 
 
Under 42 CFR  410.35, Medicare Part B pays for x-ray therapy and other radiation 
therapy services, including radium therapy and radioactive isotope therapy, and materials 
and the services of technicians administering the treatment. 
 
RTCs may receive reassigned benefits.  An RTC need not separately enroll as a group 
practice in order to receive them. 
 
B.  Additional Information 
 
For additional background on radiation therapy services, see: 
 
  42 CFR  410.35 
 
  Pub. 100-04, chapter 13 
 
  Pub. 100-02, chapter 15, section 90 
 
10.2.2.10  Suppliers of Ambulance Services 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
Suppliers of ambulance services are supplier types that enroll via the Form CMS-855B. 
 
A.  General Background Information 
 
It is important that the contractor review and adhere to the following regulations and instructions 
regarding the required qualifications of ambulance suppliers:   
 
  42 CFR  410.40 and 410.41 
  
  42 CFR Part 414, subpart H  
 
  Pub. 100-02, chapter 10  
 
  Pub. 100-04, chapter 15 
 
B.  Types of Ambulance Services 
 
As stated in 42 CFR  410.40(c), there are several levels of ambulance services covered by 
Medicare.  They are generally defined in  414.605 and in Pub. 100-02, chapter 10, section 30.1 
as follows: 
 
1.  Advanced Life Support, level 1 (ALS1) - Transportation by ground ambulance vehicle, 
medically necessary supplies and services, and either an ALS assessment by ALS personnel or 
the provision of at least one ALS intervention.   
2.  Advanced Life Support, level 2 (ALS2) - Either transportation by ground ambulance vehicle, 
medically necessary supplies and services, and the administration of at least three separate 
administrations of one or more medications by intravenous push/bolus or by continuous infusion, 
excluding crystalloid, hypotonic, isotonic, and hypertonic solutions (Dextrose, Normal Saline, 
Ringer's Lactate); or ground ambulance transport, medically necessary supplies and services, and 
the provision of at least one of the seven ALS procedures specified in the definition of 
Advanced Life Support, level 2 in  414.605. 
 
3.  Air Ambulance (Fixed-Wing and Rotary-Wing) (See  414.605 and Pub. 100-02, chapter 10, 
section 30.1.1.for specific definitions of fixed-wing and rotary-wing.) 
 
4.  Basic Life Support (BLS) - Transportation by ground ambulance vehicle and medically 
necessary supplies and services, plus the provision of BLS ambulance services. The ambulance 
must be staffed by at least two people who meet the requirements of state and local laws where 
the services are being furnished and where at least one of the staff members must be certified, at 
a minimum, as an emergency medical technician-basic (EMT-Basic) by the state or local 
authority where the services are furnished and be legally authorized to operate all lifesaving and 
life-sustaining equipment on board the vehicle.  
 
5.  Paramedic ALS Intercept Services (PI) - Per  414.605, EMT-Paramedic services furnished 
by an entity that does not furnish the ground transport, provided that the services meet the 
requirements in  410.40(d).  In general, PI involves an arrangement between a BLS ambulance 
supplier and an ALS ambulance supplier, whereby the latter provides the ALS services and the 
BLS supplier provides the transportation component.  Under  410.40(d)(1) through (3), 
respectively, PI must meet the following requirements:  
 
  Be furnished in an area that is designated as a rural area (see  410.40(d)(1) for more 
information on this requirement). 
 
  Be furnished under contract with one or more volunteer ambulance services that meet 
the following conditions: (1) are certified to furnish ambulance services as required 
under  410.41; (2) furnish services only at the BLS level; and (3) be prohibited by 
state law from billing for any service. 
 
  Be furnished by a paramedic ALS intercept supplier that meets the following 
conditions: (1) is certified to furnish ALS services as required in  410.41(b)(2); and 
(2) bills all the beneficiaries who receive ALS intercept services from the entity, 
regardless of whether or not those beneficiaries are Medicare beneficiaries. 
 
6.  Specialty Care Transport (SCT) - Inter-facility transportation of a critically injured or ill 
beneficiary by a ground ambulance vehicle, including medically necessary supplies and services, 
at a level of service beyond the scope of the EMT-Paramedic.  SCT is necessary when a 
beneficiary's condition requires ongoing care that must be furnished by one or more health 
professionals in an appropriate specialty area (e.g., emergency or critical care nursing, 
emergency medicine, respiratory care, cardiovascular care, or an EMT-Paramedic with 
additional training).   
C.  Ambulance Qualifications 
 
1.  Vehicle Design and Equipment 
 
Section 410.41(a) states that a vehicle used as an ambulance must meet the following 
requirements: 
 
  Be specially designed to respond to medical emergencies or provide acute medical care to 
transport the sick and injured and comply with all state and local laws governing an 
emergency transportation vehicle. 
 
  Be equipped with emergency warning lights and sirens, as required by state or local laws. 
 
  Be equipped with telecommunications equipment as required by state or local law to include, 
at a minimum, one two-way voice radio or wireless telephone. 
 
  Be equipped with a stretcher, linens, emergency medical supplies, oxygen equipment, and 
other lifesaving emergency medical equipment as required by state or local laws. 
 
2.  Vehicle Personnel 
 
Per 42 CFR  410.41(b)(1), a BLS vehicle must be staffed by at least two people who meet the 
requirements of state and local laws where the services are being furnished, and at least one of 
the staff members must be: (i) certified at a minimum as an emergency medical technician-basic 
by the state or local authority where the services are furnished; and (ii) legally authorized to 
operate all lifesaving and life-sustaining equipment on board the vehicle. 
 
Per 42 CFR  410.41(b)(2), an ALS vehicle must be staffed by at least two people who meet the 
requirements of state and local laws where the services are being furnished, and at least one of 
the staff members must: (i) meet the BLS vehicle staff requirements described in 42 CFR  
410.41(b)(1); and (ii) must also have one of the two staff members be certified as a paramedic or 
an emergency medical technician by the state or local authority where the services are being 
furnished to perform one or more ALS services. 
 
D.  Completion of the Form CMS-855B 
 
Pub. 100-02, chapter 10, section 10.1.3 states that, in determining whether the vehicles and 
personnel of the ambulance supplier meet all of the above requirements, the contractor may 
accept the suppliers statement (absent information to the contrary) that its vehicles and 
personnel meet all of the requirements if the statement itself meets the requirements of section 
10.1.3.  However, section 10.1.3 does not obviate the need for the supplier to complete and 
submit to the contractor the Form CMS-855B (including Attachment 1 and all supporting 
documents), and does not excuse the contractor from having to verify the data on the Form 
CMS-855B in accordance with this chapter and all other applicable CMS instructions.  In other 
words, the statement referred to in section 10.1.3 does not supplant or replace the Form CMS-
855B enrollment process.   
E.  Geographic Area: Single Contractor Jurisdiction 
 
If an ambulance supplier will furnish all of its services in the same contractor jurisdiction, the 
supplier should list: 
 
  Each site at which its vehicles are garaged in Section 4A.  (The site is considered a 
practice location for enrollment purposes, including with respect to payment of the 
application fee.)  
 
  Each site from which its personnel are dispatched in Section 4A.  (The site is considered 
a practice location for enrollment purposes, including with respect to payment of the 
application fee.) 
 
  Its base of operations  which, for ambulance companies, is their primary headquarters  
in Section 4E.  (The supplier can only have one base of operations.) 
 
If the supplier will furnish services in more than one contractor jurisdiction, the applicable 
instructions in sections 10.2.2.10(F) and (G) and 10.3.1(B)(1)(d)(iii) of this chapter apply. 
 
 
F.  Geographic Area: Multiple States 
 
The supplier must list the geographic areas in which it provides services.  If the supplier 
indicates that it furnishes services: 
 
  In more than one contractor's jurisdiction, it must submit a separate Form CMS-855B to 
each contractor. 
 
  In more than one state but within the same contractor jurisdiction, the contractor shall 
review sections 10.2.2(G)(7), 10.3, and 10.3.1(B)(1)(d)(iii) of this chapter to determine 
whether a separate enrollment for the additional state is required. 
 
G.  Practice Locations 
 
For purposes of provider enrollment (and as indicated in section 10.2.2.10(E) above), the 
following are considered ambulance practice locations:  
 
  A site at which the suppliers vehicles are garaged  
 
  A site from which the suppliers personnel are dispatched   
 
  The suppliers base of operations (i.e., the suppliers primary headquarters).  The supplier 
can only have one base of operations.   
  Hence, if an ambulance supplier submits a Form CMS-855B to add to its enrollment record a site 
at which the suppliers vehicles are garaged or from which personnel are dispatched, the supplier 
must pay an application fee.  
 
Consider the following scenarios: 
 
a. The ambulance supplier is enrolling and performing services in multiple states but within only 
one contractor jurisdiction: The supplier would have to list on its Form CMS-855B each 
city/state/zip code in which it performs services. Its base of operations and all other practice 
locations would also have to be listed, and all licensure/certification requirements would have to 
be met for each state in which it performs services.  However, separate Form CMS-855B 
applications for each state would only be required if all five conditions described in section 
10.3.1(B)(1)(d)(iii) of this chapter are met.   
 
b. The ambulance supplier is enrolling (and has its base of operations) in Contractor Jurisdiction 
X.  Its vehicles perform services in X and in adjacent Contractor Jurisdiction Y: The supplier 
would have to enroll with X and Y.  For its Contractor X Form CMS-855B, the supplier would 
have to list all of the data mentioned in Example (a) above.  For its Contractor Y Form CMS-
855B, the supplier would have to (1) list the cities/zip codes in Y in which it performs services, 
(2) list its Jurisdiction X base of operations and any practice locations in Jurisdiction Y, and (3) 
meet all licensure/certification requirements for the state(s) in Y in which the supplier performs 
services. 
 
H.  Licensure Information 
 
With respect to licensure: 
 
  The contractor shall ensure that the supplier is appropriately licensed and/or certified, as 
applicable. 
 
  An air ambulance supplier that is enrolling in a state to which it flies in order to pick up 
patients (that is, a state other than where its base of operations is located) is not required 
to have a practice location or place of business in that state.  So long as the air ambulance 
supplier meets all other criteria for enrollment in Medicare, the contractor for that state 
may not deny the supplier's enrollment application solely on the grounds that the supplier 
does not have a practice location in that state. (This policy only applies to air ambulance 
suppliers.) 
 
I.  Paramedic Intercept Information 
 
If the applicant indicates that it has a paramedic intercept arrangement, it must include a copy of 
the agreement/contract with its application. 
 
J.  Air Ambulances 
  Air ambulance suppliers must submit proof that it or its leasing company possesses a valid 
charter flight license (FAA Part 135 Certificate) for the aircraft being used as an air ambulance.  
Any of the following constitutes acceptable proof: 
 
  If the air ambulance supplier or provider owns the 
aircraft, the owner's name on the FAA Part 135 
certificate must be the same as the supplier's or 
providers name on the enrollment application. 
 
  If the air ambulance supplier or provider owns the 
aircraft but contracts with an air services vendor to 
supply pilots, training, and/or vehicle maintenance, 
the FAA Part 135 certificate must be issued in the 
name of the air services vendor.  A certification 
from the supplier or provider must also attest that it 
has an agreement with the air services vendor and 
must list the date of that agreement.  A copy of the 
FAA Part 135 certificate must accompany the 
enrollment application. 
 
  If the air ambulance supplier or provider leases the 
aircraft from another entity, a copy of the lease 
agreement must accompany the enrollment 
application. The name of the company leasing the 
aircraft from that other entity must be the same as 
the supplier's or providers name on the enrollment 
application. 
 
The air ambulance supplier shall maintain all applicable federal and state licenses and 
certifications, including pilot certifications, instrument and medical certifications, and air 
worthiness certifications. 
 
In addition: 
 
  The contractor shall access the following FAA Web site on a quarterly basis to validate 
all licenses/certifications of air ambulance operators that are enrolled with the contractor: 
https://www.faa.gov/about/office_org/headquarters_offices/agc/practice_areas/enforceme
nt/reports/.  This helps ensure that the suppliers licenses/certifications are active and in 
good-standing. 
 
  The contractor shall deny or revoke the enrollment of an air ambulance supplier if the 
supplier does not maintain its FAA certification or any other applicable licenses. 
 
  Section 424.516(e)(3) states that within 30 days of any revocation or suspension of a 
federal or state license or certification (including an FAA certification), an air ambulance 
supplier must report the revocation or suspension of its license or certification to the 
applicable Medicare contractor. The following FAA certifications must be reported: (i)  specific pilot certifications including, but not limited to, instrument and medical 
certifications; and (2) airworthiness certification. 
 
K.  Hospital-Based Ambulances 
 
An ambulance service that is owned and operated by a hospital need not complete a Form CMS-
855B if: 
 
  The ambulance services will appear on the hospitals cost-report; and 
 
  The hospital possesses all licenses required by the state or locality to operate the 
ambulance service. 
 
If the hospital decides to divest itself of the ambulance service, the latter will have to complete a 
Form CMS-855B if it wishes to bill Medicare. 
 
10.2.3 - Individual Practitioners Who Enroll Via the Form CMS-
855I 
(Rev. 11020; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21) 
 
This section provides background information on physicians and non-physician practitioners 
(NPPs).  While Medicare has established federal standards governing these supplier types, these 
practitioners must also comply with all applicable state and local laws as a precondition of 
enrollment. 
 
It is important that contractors review Publication (Pub). 100-02, Medicare Benefit Policy 
Manual, chapter 15 and Pub. 100-04, Claims Processing Manual, for specific information 
regarding the required qualifications of the suppliers listed in this section 10.2.3 et seq. 
 
 
10.2.3.1  Anesthesiology Assistants 
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
Federal regulations at 42 CFR  410.69(b) define an anesthesiology assistant as a person 
who: 
 
1.  Works under the direction of an anesthesiologist; 
 
2.  Is in compliance with all applicable requirements of state law, including any licensure 
requirements the state imposes on non-physician anesthetists; and 
 
3.  Is a graduate of a medical school-based anesthesiologist's assistant educational program 
that: (i) is accredited by the Committee on Allied Health Education and Accreditation; 
and (ii) includes approximately 2 years of specialized basic science and clinical 
education in anesthesia at a level that builds on a premedical undergraduate science 
background. 
  10.2.3.2  Audiologists 
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
Section 1861(ll)(3)(B) of the Social Security Act and Pub. 100-02, chapter 15, section 80.3.1 
state that a qualified audiologist means an individual with a masters or doctoral degree in 
audiology who: 
 
1.  Is licensed as an audiologist by the state in which the individual furnishes such 
services; or 
 
2.  In the case of an individual who furnishes services in a state that does not license 
audiologists, has: 
 
  Successfully completed 350 clock hours of supervised clinical practicum (or is in 
the process of accumulating such supervised clinical experience), and 
 
  Performed not less than 9 months of supervised full-time audiology services after 
obtaining a masters or doctoral degree in audiology or a related field, and 
 
  Successfully completed a national examination in audiology approved by the 
Secretary. 
 
Given these requirements (and as stated in the aforementioned section 80.3.1), a Doctor of 
Audiology (AuD) 4th year student with a provisional license from a state does not qualify 
unless he or she also holds a masters or doctoral degree in audiology.   
 
See Pub. 100-04, chapter 12, section 30.3 for further information regarding audiologist 
billing. 
 
10.2.3.3  Certified Nurse-Midwives 
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
Federal regulations at 42 CFR  410.77 list the Medicare qualifications for certified nurse-
midwives (CNMs).  These qualifications require that a CNM:  
 
  Be a registered nurse who is legally authorized to practice as a nurse-
midwife in the state where services are performed; 
 
  Have successfully completed a program of study and clinical experience for 
nurse-midwives that is accredited by an accrediting body approved by the 
U.S. Department of Education; and 
 
  Be certified as a nurse-midwife by the American College of Nurse-
Midwives or the American Midwifery Certification Board. 
 
For more information on CNMs, refer to: 
    Section 1861(gg) of the Social Security Act 
 
  Pub. 100-02, chapter 15, section 180 
 
  Pub. 100-04, chapter 12, section 130.1 
 
10.2.3.4  Certified Registered Nurse Anesthetists  
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
Federal regulations at 42 CFR  410.69(b)(1) through (4) state that a Certified Registered 
Nurse Anesthetists (CRNA) is a registered nurse who: 
 
(1) Is licensed as a registered professional nurse by the state in which the nurse 
practices; 
 
(2) Meets any licensure requirements the state imposes with respect to non-
physician anesthetists; 
 
(3) Has graduated from a nurse anesthesia educational program that meets the 
standards of the Council on Accreditation of Nurse Anesthesia Programs, or 
such other accreditation organization as may be designated by the Secretary; 
and 
 
(4) Meets the following criteria: 
 
(i)  Has passed a certification examination of the Council on Certification of Nurse 
Anesthetists, the Council on Recertification of  Nurse Anesthetists, or any other 
certification organization that may be designated by the Secretary; or 
 
(ii)  Is a graduate of a program described in  410.69(b)(3) and within 24 months 
after that graduation meets the requirements of  410.69(b)(4)(i).  
 
For more information on CRNAs, refer to: 
 
  Section 1861(bb) of the Social Security Act 
 
  Pub. 100-04, chapter 12, section 140.1 
 
 
10.2.3.5  Clinical Nurse Specialists 
(Rev. 11771; Issued:12-30-22; Effective:01-01-23; Implementation: 01-31-23) 
 
 
Federal regulations at 42 CFR  410.76 state that a clinical nurse specialist must meet all of 
the following requirements: 
  1.   Be a registered nurse who is currently licensed to practice in the state where he or she 
practices and be authorized to furnish the services of a clinical nurse specialist in 
accordance with state law. 
 
2.   Have a masters degree in a defined clinical area of nursing from an accredited 
educational institution or a Doctor of Nursing Practice (DNP) doctoral degree; and 
 
3.   Be certified as a clinical nurse specialist by a recognized national certifying body that 
has established standards for clinical nurse specialists and that is approved by the 
Secretary. 
 
Pub. 100-02, chapter 15, section 210 states that CMS recognizes the following 
organizations as national certifying bodies for clinical nurse specialists at the advanced 
practice level: 
 
a.   American Academy of Nurse Practitioners 
 
b.   American Nurses Credentialing Center 
 
c.   National Certification Corporation for Obstetric, Gynecologic and  
      Neonatal Nursing Specialties 
 
d.   Pediatric Nursing Certification Board (previously named the National   
      Certification Board of Pediatric Nurse Practitioners and Nurses) 
 
e.   Oncology Nurses Certification Corporation 
 
f.    AACN Certification Corporation 
 
g.   National Board on Certification of Hospice and Palliative Nurses 
 
h.   Nurses Portfolio Credentialing Commission (NPCC) 
 
10.2.3.6  Clinical Psychologists 
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
Federal regulations at 42 CFR  410.71(d) state that to qualify as a clinical psychologist, a 
practitioner must meet the following requirements: 
 
1.  Hold a doctoral degree in psychology (that is, a Ph.D., Ed.D., Psy.D.), and 
 
2.   Is licensed or certified, on the basis of the doctoral degree in psychology, by the state in 
which he or she practices, at the independent practice level of psychology to furnish 
diagnostic, assessment, preventive, and therapeutic services directly to individuals. 
 
A clinical psychologist must agree to meet the consultation requirements of 42 CFR  
410.71(e)(1) through (e)(3).  Under 42 CFR  410.71(e), the practitioners signing of the  Form CMS-855I indicates his or her agreement to adhere to the requirements of  
410.71(e)(1) through (e)(3).  
 
For more information on clinical psychologists, refer to Pub. 100-02, chapter 15, section 
160. 
 
10.2.3.7  Clinical Social Workers 
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
Federal regulations at 42 CFR  410.73(a) define a clinical social worker as an individual 
who: 
 
1.  Possesses a master's or doctor's degree in social work; 
 
2.  After obtaining the degree, has performed at least 2 years of supervised clinical social 
work; and 
 
3.  Either is licensed or certified as a clinical social worker by the state in which the 
services are performed or, in the case of an individual in a state that does not provide 
for licensure or certification as a clinical social worker 
 
a.   Is licensed or certified at the highest level of practice provided by the laws of the 
state in which the services are performed; and 
 
b.   Has completed at least 2 years or 3,000 hours of post master's degree supervised 
clinical social work practice under the supervision of a master's degree level social 
worker in an appropriate setting, such as a hospital, skilled nursing facility (SNF), 
or clinic. 
 
For more information on clinical social workers, refer to Pub. 100-02, chapter 15, section 
170. 
 
 
 
 
 
10.2.3.8  Nurse Practitioners 
(Rev. 11771; Issued: 12-30-2022; Effective:01-01-2023; Implementation: 01-31-23) 
 
Federal regulations at 42 CFR  410.75(b) state that a nurse practitioner must be a 
registered professional nurse who is authorized by the state in which the services are 
furnished to practice as a nurse practitioner in accordance with state law.  The individual 
must also meet one of the following criteria: 
 
1.   Obtained Medicare billing privileges as a nurse practitioner for the first time on or after 
January 1, 2003, and meets the following requirements:  
  a.   Is certified as a nurse practitioner by a recognized national certifying body that has 
established standards for nurse practitioners. 
 
b.   Possesses a masters degree in nursing or a Doctor of Nursing Practice (DNP) 
doctoral degree. 
 
  (If the aforementioned masters or doctoral degree is required to obtain a license as a 
nurse practitioner in the state, the contractor need not separately verify the degree or 
require the practitioner to submit applicable documentation.)   
 
2.   Obtained Medicare billing privileges as a nurse practitioner for the first time before 
January 1, 2003, and meets the standards in (1)(a) above. 
 
3.   Obtained Medicare billing privileges as a nurse practitioner for the first time before 
January 1, 2001. 
 
Pub. 100-02, chapter 15, section 200 lists the following organizations as CMS-recognized 
national certifying bodies for nurse practitioners at the advanced practice level: 
 
  American Academy of Nurse Practitioners 
 
  American Nurses Credentialing Center 
 
  National Certification Corporation for Obstetric, Gynecologic and Neonatal 
Nursing Specialties 
 
  Pediatric Nursing Certification Board (previously named the National 
Certification Board of Pediatric Nurse Practitioners and Nurses) 
 
  Oncology Nurses Certification Corporation  
 
  AACN Certification Corporation  
 
  National Board on Certification of Hospice and Palliative Nurses 
 
  Nurses Portfolio Credentialing Commission (NPCC) 
 
10.2.3.9  Occupational Therapists in Private Practice 
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
A.  Regulatory Requirements - Occupational Therapist in Private Practice 
 
Section 42 CFR  410.59(c)(i) through (iv) state that an occupational therapist in private 
practice must meet all of the following: 
  (i)  Be legally authorized (if applicable, licensed, certified, or registered) to engage in the 
private practice of occupational therapy by the state in which he or she practices, and 
practice only within the scope of his or her license, certification, or registration. 
 
(ii) Engage in the private practice of occupational therapy on a regular basis as an 
individual, in one of the following practice types: (A) solo practice; (B) a partnership; 
(C) group practice; or (D) as an employee of one of these. 
 
(iii)  Bill Medicare only for services furnished in his or her private practice office space, or 
in the patient's home.  (A therapist's private practice office space refers to the 
location(s) where the practice is operated in the state(s) where the therapist (and 
practice, if applicable) is legally authorized to furnish services, during the hours that 
the therapist engages in practice at that location. When services are furnished in 
private practice office space, such space must be owned, leased, or rented by the 
practice and used for the exclusive purpose of operating the practice.  A patient's home 
does not include any institution that is a hospital, a critical access hospital, or a SNF.)) 
 
(iv) Treat individuals who are patients of the practice and for whom the practice   collects 
fees for the services furnished. 
 
          
B.  Qualified Occupational Therapist Requirements 
 
Pub. 100-02, chapter 15, section 230.2(B) states that a qualified occupational therapist is an 
individual who meets the requirements in one of the four categories below: 
 
Category #1  The occupational therapist: (i) is licensed (if licensure applies) or otherwise 
regulated (if applicable) as an occupational therapist by the state in which practicing; (ii) 
graduated from an accredited education program for occupational therapists; and (iii) is eligible 
to take or has passed the examination for occupational therapists administered by the National 
Board for Certification in Occupational Therapy, Inc. (NBCOT). The phrase by the state in 
which practicing includes any authorization to practice provided by the same state in which the 
service is furnished (including temporary licensure), regardless of the location of the entity 
billing the services. The education program for U.S. trained occupational therapists is accredited 
by the Accreditation Council for Occupational Therapy Education (ACOTE).  
 
The requirements above apply to all occupational therapists effective January 1, 2010 if the 
occupational therapist has not met any of the following requirements prior to January 1, 2010. 
 
Category #2 - On or before December 31, 2009, the individual -- 
 
(a) Is licensed or otherwise regulated as an occupational therapist in the state in which 
practicing (regardless of the qualifications they met to obtain that licensure or regulation); 
or   
 
(b) When licensure or other regulation does not apply-- 
  (i)  Graduated from an occupational therapist education program accredited by 
ACOTE; and 
 
           (ii)  Is eligible to take, or has successfully completed, the NCBOT examination for 
occupational therapists.    
 
Category #3 - On or before January 1, 2008 (and if the individual met the Medicare 
requirements for occupational therapists that were in 42 CFR  484.4 prior to January 1, 
2008), the individual-- 
 
(a)  Graduated from an occupational therapy program approved jointly by the American 
Medical Association and the American Occupational Therapy Association (AOTA); 
or 
 
(b) Is eligible for the National Registration Examination of AOTA or NBCOT. 
 
Category #4 - On or before December 31, 1977, the individual-- 
 
(a) Had 2 years of appropriate experience as an occupational therapist; and 
 
(b) Had achieved a satisfactory grade on an occupational therapist proficiency 
examination conducted, approved, or sponsored by the U.S. Public Health Service. 
 
C.  Occupational Therapist Educated Outside the United States 
 
Pub. 100-02, chapter 15, section 230.2(B) states that individuals educated outside the U.S. may 
meet the same qualifications as domestic trained occupational therapists. For example, the 
individual qualifies if he or she was licensed or otherwise regulated by the state in which 
practicing on or before December 31, 2009.  The individual also qualifies if he or she: 
 
  Graduated from an occupational therapy education program accredited as 
substantially equivalent to a U.S. occupational therapy education program by 
ACOTE, the World Federation of Occupational Therapists, or a credentialing 
body approved by AOTA;   
 
  Passed the NBCOT examination for occupational therapists; and  
 
  Effective January 1, 2010, are licensed or otherwise regulated, if applicable, as an 
occupational therapy by the state in which practicing.  
 
D. Occupational Therapists  Additional References 
 
In Pub. 100-02, chapter 15, see section 230.2(B) for more information regarding the 
required qualifications of occupational therapists and section 230.4 for information 
regarding the term private practice. 
 
E.  Other Enrollment Information - Form CMS-855 Completion   
All occupational therapists in private practice must respond to the questions in Section 2K 
of the Form CMS-855I.  However, Section 2K does not apply if the occupational therapist: 
(1) plans to provide his/her services as a member of an established occupational therapist 
group, an employee of a physician-directed group, or an employee of a non-professional 
corporation; and (2) wishes to reassign his/her benefits to that group.   
 
If the occupational therapist checks that he/she renders all of his/her services in patients' 
homes, the contractor shall verify that he/she has an established private practice where 
he/she can be contacted directly and where he/she maintains patient records.  (This can be 
the persons home address, though all Medicare rules and instructions regarding the 
maintenance of patient records apply.)  In addition, Section 4B of the Form CMS-855I 
should indicate where services are rendered (e.g., county, state, city of the patients' homes).  
Post office boxes are not acceptable. 
 
If the individual answers yes to question 2, 3, 4, or 5, the contractor shall request a copy 
of the lease agreement giving him/her exclusive use of the facilities for occupational 
therapy services only if it has reason to question the accuracy of his/her response.  If the 
contractor makes this request and the supplier cannot furnish a copy of the lease, the 
contractor shall deny the application. 
 
10.2.3.10  Physical Therapists in Private Practice 
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
A.  Regulatory Requirements - Physical Therapist in Private Practice 
Section 42 CFR  410.60(c) states that in order to qualify under Medicare as a supplier of 
outpatient physical therapy services, each individual physical therapist in private practice must 
meet the following requirements: 
1.   Be legally authorized (if applicable, licensed, certified, or registered) to engage in the private 
practice of physical therapy by the state in which he or she practices, and practice only within the 
scope of his or her license, certification, or registration. 
2.   Engage in the private practice of physical therapy on a regular basis as an individual in 
one of the following practice types: (i) a solo practice; (ii) a partnership; (iii) a group 
practice; or (iv) as an employee of any of (i), (ii), or (iii). 
 
3.   Bill Medicare only for services furnished in his or her private practice office space, or 
in the patient's home. A therapist's private practice office space refers to the location(s) 
where the practice is operated, in the state(s) where the therapist (and practice, if 
applicable) is legally authorized to furnish services during the hours that the therapist 
engages in practice at that location. When services are furnished in private practice office 
space, such space must be owned, leased, or rented by the practice and used for the 
exclusive purpose of operating the practice.  A patient's home does not include any 
institution that is a hospital, a CAH, or a SNF. 
  4.   Treat individuals who are patients of the practice and for whom the practice collects 
fees for the services furnished. 
 
B.  Qualified Physical Therapist Definition  
 
Pub. 100-02, chapter 15, section 230.1 states that a qualified physical therapist is a person 
who: (1) is licensed, if applicable, by the state in which he or she is practicing (unless 
licensure does not apply); (2) has graduated from an accredited physical therapist education 
program; and (3) passed an examination approved by the state in which physical therapy 
services are provided.  The phrase by the state in which practicing includes any 
authorization to practice provided by the same state in which the service is provided, 
including temporary licensure, regardless of the location of the entity billing the services.  
The curriculum accreditation is provided by the Commission on Accreditation in Physical 
Therapy Education (CAPTE) or, for those who graduated before CAPTE, curriculum 
approval was provided by the American Physical Therapy Association (APTA).  For 
internationally educated physical therapists, curricula are approved by a credentials 
evaluation organization either approved by the APTA or identified in 8 CFR 212.15(e) as it 
relates to physical therapists.  For example, in 2007, 8 CFR 212.15(e) approved the 
credentials evaluation provided by the Federation of State Boards of Physical Therapy 
(FSBPT) and the Foreign Credentialing Commission on Physical Therapy (FCCPT).   
 
The requirements above do not apply to a physical therapist effective January 1, 2010 if he 
or she has otherwise met the requirements outlined in Category #2, Category #3, Category 
#4, or Category #5 below.  (Category #1 is outlined in the previous paragraph.) 
 
Category #2  A physical therapist whose current license was obtained on or prior to December 
31, 2009 qualifies to provide physical therapy services to Medicare beneficiaries if he or she: 
 
(a) Graduated from a CAPTE approved program in physical therapy on or before 
December 31, 2009 (examination is not required); or 
 
(b) Meets both of the following: 
 
(i)  Graduated on or before December 31, 2009  from a physical therapy program 
outside the U.S. that is determined to be substantially equivalent to a U.S. 
program by a credentialed evaluation organization approved by the APTA or 
identified in 8 CFR  212.15(e).  
 
(ii) Passed an examination for physical therapists approved by the state in which he 
or she is practicing. 
 
Category #3  A physical therapist whose current license was obtained before January 1, 2008, 
may meet the requirements in place on that date (i.e., graduation from a curriculum approved by 
either the APTA, the American Medical Association, or both). 
 
Category #4  A physical therapist meets the requirements if he or she (a) is currently licensed as 
a physical therapist, (b) was licensed or qualified as a physical therapist on or before December  31, 1977, (c) had 2 years of appropriate experience as a physical therapist, and (d) passed a 
proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service. 
 
Category #5  A physical therapist meets the requirements if he or she is currently licensed and 
before January 1, 1966, he or she was: 
 
  Admitted to membership by the APTA; or 
 
  Admitted to registration by the American Registry of Physical Therapists; 
or 
 
  Graduated from a 4-year physical therapist curriculum approved by a state 
Department of Education; or 
 
  Licensed or registered and prior to January 1, 1970, he/she had 15 years of full-time 
experience in physical therapy under the order and direction of attending and referring 
doctors of medicine or osteopathy. 
 
 C.  Physical Therapist Trained Outside the United States 
 
Pub. 100-02, chapter 15, section 230.1(B) states that a physical therapist meets the 
requirements if he or she: (a) is currently licensed; (b) was trained outside the U.S. before 
January 1, 2008; (c) after 1928 graduated from a physical therapy curriculum approved in 
the country in which the curriculum was located and that country had an organization that 
was a member of the World Confederation for Physical Therapy; and (d) he/she qualified 
as a member of that organization. 
 
D.  Physical Therapists - Additional References 
 
In Pub. 100-02, chapter 15, see section 230.2(B) for more information regarding the 
required qualifications of physical therapists and section 230.4 for detailed information 
regarding the term private practice.  
 
E.  Site Visits of Physical Therapists in Private Practice 
 
(This site visit requirement is pursuant to 42 CFR  424.518(b).)  
 
Unless otherwise stated in this chapter or another CMS directive, site visits will be 
performed in accordance with the following: 
 
i.   Initial application  If a physical therapist or physical therapist group submits an initial 
application for private practice, the contractor shall order a site visit through PECOS.   This 
is to ensure that the supplier is in compliance with CMSs enrollment requirements.  The 
scope of the site visit will be consistent with sections 10.6.20(A) and 10.6.20(B) of this 
chapter.  The NSVC will perform the site visit.  The contractor shall not convey Medicare 
billing privileges to the supplier prior to the completion of the NSVCs site visit and the 
contractors review of the results.  
  ii. Revalidation  If a private practice physical therapist or physical therapist group submits 
a revalidation application, the contractor shall order a site visit through PECOS.  This is to 
ensure that the supplier is still in compliance with CMSs enrollment requirements.  The 
scope of the site visit will be consistent with sections 10.6.20(A) and 10.6.20(B) of this 
chapter.  The NSVC will perform the site visit.  The contractor shall not make a final 
decision regarding the revalidation application prior to the completion of the NSVCs site 
visit and the contractors review of the results. 
 
iii. New/changed location  Unless CMS has directed otherwise, if a private practice 
physical therapist or physical therapist group is (1) adding a new location or (2) changing 
the physical location of an existing location, the contractor shall order a site visit of the 
new/changed location through PECOS.  This is to ensure that the new/changed location is 
in compliance with CMSs enrollment requirements.  The scope of the site visit will be 
consistent with sections 10.6.20(A) and 10.6.20(B) of this chapter.  The NSVC will 
perform the site visit.  The contractor shall not make a final decision regarding the 
application prior to the completion of the NSVCs site visit and the contractors review of 
the results. 
 
F.  Physical Therapists:  Additional Site Visit Information 
 
The contractor is also advised of the following: 
 
    In Section 2A of the Form CMS-855B application, physical and occupational therapy 
groups are denoted as Physical/Occupational Therapy Group(s) in Private Practice.  
If a supplier that checks this box in Section 2A is exclusively an occupational 
therapy group in private practice  that is, there are no physical therapists in the 
group  the contractor shall process the application using the procedures in the 
limited screening category.  No site visit is necessary.  If there is at least one 
physical therapist in the group, however, the application shall be processed using 
the procedures in the moderate screening category.  A site visit by the NSVC is 
required, unless CMS has directed otherwise. 
 
    If an entity is enrolled as a physician practice and employs a physical therapist 
within the practice, the practice itself falls within the limited screening category. 
This is because the entity is enrolled as a physician practice and not a physical 
therapy group in private practice. However, this does not exempt the physical 
therapist from the screening required at the moderate risk level.  
 
  If a newly-enrolling private practice physical therapist lists several practice 
locations, the enrollment contractor has the discretion to determine the location at 
which the NSVC will perform the required site visit. 
 
  Unless CMS has directed otherwise, a site visit by the NSVC is required when a 
physical therapist submits an application for private practice initial enrollment and 
reassignment of benefits (Form CMS-855I and Form CMS-855R).  However, a site 
visit is not required for an enrolled private practice physical therapist who is 
reassigning his or her benefits only (Form CMS-855R).   
  If the private practice physical therapists practice location is his or her home 
address and it exclusively performs services in patients homes, nursing homes, etc., 
no site visit is necessary. 
 
G.  Other Enrollment Information 
 
All physical therapists in private practice must respond to the questions in Section 2K of 
the Form CMS-855I.  However, Section 2K does not apply if the physical therapist: (1) 
plans to provide his/her services as a member of an established PT group, an employee of a 
physician-directed group, or an employee of a non-professional corporation; and (2) the 
person wishes to reassign his/her benefits to that group.  Such information will be captured 
on the groups Form CMS-855B application. 
 
If the physical therapist checks that he/she renders all of his/her services in patients' homes, 
the contractor shall verify that he/she has an established private practice where he/she can 
be contacted directly and where he/she maintains patient records.  (This can be the persons 
home address, though all Medicare rules and instructions regarding the maintenance of 
patient records apply.)  In addition, Section 4E of the Form CMS-855I should indicate 
where services are rendered (e.g., county, state, city of the patients' homes).  Post office 
boxes are not acceptable. 
 
If the individual answers yes to question 2, 3, 4, or 5, the contractor shall request a copy 
of the lease agreement giving him/her exclusive use of the facilities for physical therapist 
services only if it has reason to question the accuracy of his/her response.  If the contractor 
makes this request and the supplier cannot furnish a copy of the lease, the contractor shall 
deny the application. 
 
10.2.3.11  Physicians 
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
As described in  1861(r)(1) of the Social Security Act and in 42 CFR  410.20(b), a 
physician must be legally authorized to practice medicine by the state in which he/she 
performs such services in order to enroll in the Medicare program and to retain Medicare 
billing privileges. Such individuals include: (1) doctors of medicine or osteopathy, dental 
surgery or dental medicine, podiatric medicine, or optometry; and (2) a chiropractor who 
meets the qualifications specified in 42 CFR  410.22.  
 
See Pub. 100-04, chapter 19, section 40.1.2 for special licensure rules regarding 
practitioners who work in or reassign benefits to hospitals or freestanding ambulatory care 
clinics operated by the Indian Health Service or by an Indian tribe or tribal organization. 
 
10.2.3.12  Physician Assistants  
(Rev. 12100; Issued: 06-29-23; Effective: 07-31-23; Implementation: 07-31-23) 
 
(The physician assistant (PA) enrollment instructions in this section 10.2.3.12 supersede all other 
PA-specific instructions in this chapter.)    
A.  PA Requirements Under  410.74 
 
Current federal regulations at 42 CFR  410.74 discuss the requirements that a PA must meet.    
 
Among the requirements for coverage of PA services outlined in 42 CFR  410.74(a) are that 
the PA (as listed in  410.74(a)(2)):  
(i)  Meets the qualifications set forth in  410.74(c); 
(ii)  Is legally authorized to perform the services in the state in which they are performed; 
(iii)  Performs services that are not otherwise precluded from coverage because of a statutory 
exclusion; 
(iv)  Performs the services in accordance with state law and state scope of practice rules for PAs 
in the state in which the PAs professional services are furnished. Any state laws and scope of 
practice rules that describe the required practice relationship between physicians and PAs 
(including explicit supervisory or collaborative practice requirements) describe a form of 
supervision for purposes of section 1861(s)(2)(K)(i) of the Social Security Act. For states with 
no explicit state law and scope of practice rules regarding physician supervision of a PAs 
services, physician supervision is a process in which a PA has a working relationship with one or 
more physicians to supervise the delivery of their health care services. Such physician 
supervision is evidenced by documenting at the practice level the PA's scope of practice and the 
working relationships the PA has with the supervising physician(s) when furnishing professional 
services; and 
(v)  Performs the services: (A) in all settings in either rural and urban areas; or (B) as an assistant 
at surgery. 
Section 410.74(c), meanwhile, states that for Medicare Part B coverage of his or her services, a 
PA must meet all of the following conditions: 
  (1) Have graduated from a PA educational program that is accredited by the Commission on 
Accreditation of Allied Health Education Programs; OR (2) have passed the national 
certification examination that is administered by the National Commission on Certification of 
Physician Assistants (NCCPA); 
 
AND  
 
  Be licensed by the state to practice as a PA. (The PA need not be currently NCCPA-
certified.) 
(In other words, either (1) or (2) in the first bullet must be met, and the licensure requirement in 
the second bullet must always be met.)  
B.  PA Employer 
  Prior to January 1, 2022, payment for the PAs services could only be made to the PAs 
employer, not to the PA himself/herself.  That is, the PA could not individually enroll in 
Medicare to receive direct payment for his or her services.  This also meant that the PA could not 
reassign his or her benefits to the employer, for the employer must receive direct payment 
anyway.  Pursuant to the CY 2022 Physician Fee Schedule Final Rule, however, a PA may: 
 
  Individually enroll in Medicare (e.g., as a sole proprietorship, professional corporation) 
  Receive direct payment for his/her services 
  Establish PA groups (e.g., LLCs) 
  Reassign his/her benefits to his/her employer.  
 
The previous requirement that the PAs employer must bill for his/her services has hence been 
eliminated. 
 
C.  PA Enrollment Information 
 
With the aforementioned change concerning PA employers (and except as stated in this 
subsection (C)), the contractor is advised of and/or shall adhere to the below policies, which are 
effective January 1, 2022.  Although these policies can be applied to PA applications that are 
pending or in process as of January 1, 2022, it is important that the contractor adhere to the 
effective date instructions in subsection (C)(2)(e) below. 
 
1.  Newly enrolling, revalidating, and reactivating PAs shall complete the applicable Form CMS-
855I sections to the same extent as would any other individual practitioner who is able to 
individually enroll in and bill Medicare.   
 
2.  Transactions 
 
a.  Initial Enrollment - If a PA is initially enrolling in Medicare and does not intend to reassign 
his/her benefits, he/she need not complete Section 2(I) of the Form CMS-855I. (The PAs 
practice location information, however, shall be furnished.) 
 
b.  Initial Enrollment - If a PA is initially enrolling in Medicare and intends reassign his/her 
benefits, the PA shall complete Section 2(I) with the name, PTAN (if assigned), NPI, and EIN of 
the employer/entity/supplier to which benefits will be reassigned.  With PECOS unable to 
accommodate Form CMS-855R PA reassignments at this time, Section 2(I) will effectively 
constitute a reassignment application in the interim.  (For purposes of this section 10.2.3.12, such 
situations will be labeled PA payment arrangements.)  Reassigned payments can therefore be 
made to the employer/entity/supplier listed in Section 2(I), similar to how employers have 
previously been paid for PA services.   
 
Regarding verification, the contractor: 
 
  Shall follow this chapters existing instructions for validating PA employer information 
rather than those for Form CMS-855R submissions   
 
  Shall apply the Form CMS-855Is effective date to the PA payment arrangement   
  Consistent with existing policy concerning PA employers, shall confirm that the 
employer/entity/supplier is enrolled in Medicare  
 
  Need not secure the employer/entity/suppliers signature to effectuate the PA payment 
arrangement (as occurs with Form CMS-855R reassignees) 
 
  If Section 2(I) is blank, the contractor can assume that the PA seeks direct payment.  If there 
is evidence to the contrary, however, the contractor can (via any means) ask the PA whether 
reassignment is or is not desired.  If it is, the contractor shall develop for the completion of 
Section 2(I).   
 
c.  Change Request Involving Section 2(I)  
 
On and after January 1, 2022, the contractor shall continue to pay the employer/entity/supplier 
listed in Section 2(I) unless or until the PA submits a Form CMS-855I that removes or changes 
the employer/entity/supplier.  The contractor need not contact every enrolled PA upon the 
January 1, 2022 effective date to determine whether the PA wishes to continue his/her existing 
payment arrangement or instead receive payment directly.  It is the PAs responsibility to report 
or change this data, if applicable, via the Form CMS-855I. 
 
Form CMS-855Rs shall not be submitted to establish, change, or terminate a PA payment 
arrangement.  If a Form CMS-855R is nonetheless submitted, the contractor shall not return the 
form; instead, the contractor shall place it in the provider file and develop with the PA for a 
Form CMS-855I change request that updates Section 2(I).   
 
If, after a change request or other Form CMS-855I transaction, no employers/entities/suppliers 
are left in Section 2(I), payments shall be made directly to the PA. 
 
d.  Form CMS-855B 
 
Effective January 1, 2022, PAs can establish PA group practices and be enrolled via the Form 
CMS-855B.  The contractor shall process the Form CMS-855B in the same fashion it would any 
other group practice application, and the application shall be completed to the same extent as 
would any other such application.  PA payment arrangements to the group (e.g., Section 2(I)) 
shall be processed consistent with the instructions in this subsection (C).  
 
e.  Effective Date  
 
The effective date under  424.520(d) and  424.521(a) for PAs enrolling as sole 
proprietors/solely-owned entities and/or PA groups shall be on or after January 1, 2022 -- even if 
the application was received prior to that date and the effective date might thus otherwise be 
before January 1, 2022.  In this latter situation, an effective date of January 1, 2022 is 
appropriate.   
 
10.2.3.13  Psychologists Practicing Independently 
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21)   
Pub. 100-02, chapter 15, section 80.2 states that a psychologist practices independently 
when: 
 
  He/she render services on his/her own responsibility, free of the administrative and 
professional control of an employer, such as a physician, institution, or agency; 
 
  The persons he/she treats are his/her own patients; 
 
  He/she has the right to bill directly, collect and retain the fee for his/her services; 
and  
 
  The psychologist is state-licensed or certified in the state where furnishing services. 
 
A psychologist practicing in an office located in an institution may be considered an 
independently practicing psychologist when both of the following conditions are met: (1) 
the office is confined to a separately-identified part of the facility that is used solely as the 
psychologists office and cannot be construed as extending throughout the entire 
institution; and (2) the psychologist conducts a private practice (i.e., services are rendered 
to patients from outside the institution as well as to institutional patients). 
 
Independently practicing psychologists have a more limited benefit under the Medicare 
program than clinical psychologists. With a degree starting at the masters level of 
psychology, independently practicing psychologists are authorized to bill the program 
directly solely for diagnostic psychological and neuropsychological tests that have been 
ordered by a physician, clinical psychologist, or non-physician practitioner who is 
authorized to order diagnostic tests.  Independently practicing psychologists are not 
authorized to supervise diagnostic psychological and neuropsychological tests. Any tests 
performed by an independently practicing psychologist must fall under the psychologists 
state scope of practice. 
 
The contractor shall ensure that all persons who check Psychologist Billing 
Independently in Section 2H of the Form CMS-855I answer all questions in Section 2J2.  
If the supplier answers no to question 1, 2, 3, 4a, or 4b, the contractor shall deny the 
application. 
 
See Pub. 100-04, chapter 12, sections 160 and 160.1 for more information on psychologists 
billing independently. 
 
10.2.3.14  Registered Dietitians/Nutrition Professionals 
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
Federal regulations at 42 CFR  410.134(a) through (c) state that a registered dietitian (or 
nutrition professional) is an individual who, on or after December 22, 2000: 
 
(a) Holds a bachelor's or higher degree granted by a regionally accredited college or 
university in the United States (or an equivalent foreign degree) with completion of  the academic requirements of a program in nutrition or dietetics accredited by an 
appropriate national accreditation organization recognized for this purpose; 
 
(b) Has completed at least 900 hours of supervised dietetics practice under the 
supervision of a registered dietitian or nutrition professional; and 
 
(c) Is licensed or certified as a dietitian or nutrition professional by the state in which 
the services are performed.  In a state that does not provide for licensure or 
certification, the individual will be deemed to have met this requirement if he or she 
is recognized as a registered dietitian' by the Commission on Dietetic Registration 
or its successor organization, or meets the requirements of paragraphs (a) and (b) 
above. 
 
There are two exceptions to these requirements (as stated in 42 CFR  410.134(d)(i) and 
(ii)): 
 
(i)  A dietitian or nutritionist licensed or certified in a state as of December 21, 
2000, is not required to meet the requirements of (a) and (b) above. 
 
(ii)  A registered dietitian in good standing, as recognized by the Commission of 
Dietetic Registration or its successor organization, is deemed to have met the 
requirements of (a) and (b) above. 
 
10.2.3.15  Speech Language Pathologists in Private Practice 
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
Consistent with 42 CFR  410.62(c), in order to qualify as an outpatient speech-language 
pathologist in private practice, an individual must meet the following requirements: 
 (i)  Be legally authorized (if applicable, licensed, certified, or registered) to engage in the 
private practice of speech-language pathology by the state in which he or she practices, 
and practice only within the scope of his or her license and/or certification. 
(ii) Engage in the private practice of speech-language pathology on a regular basis as an 
individual in one of the following practice types: a solo practice, partnership, group 
practice, or as an employee of one of these. 
(iii) Bill Medicare only for services furnished in one of the following: 
(A) A speech-language pathologist's private practice office space that meets all of the 
following: (1) the location(s) where the practice is operated, in the state(s) where 
the therapist (and practice, if applicable) is legally authorized to furnish services 
and during the hours that the therapist engages in practice at that location; and (2) 
the space must be owned, leased, or rented by the practice, and used for the 
exclusive purpose of operating the practice; or 
(B) A patient's home not including any institution that is a hospital, a CAH, or a SNF.  (iv) Treat individuals who are patients of the practice and for whom the practice collects fees 
for the services furnished. 
For more information on speech language pathologists in private practice, refer to Pub. 
100-02, chapter 15, section 230. 
 
10.2.3.16  Manufacturers of Replacement Parts/Supplies for Prosthetic 
Implants or Implantable Durable Medical Equipment (DME) Surgically 
Inserted at an Ambulatory Surgical Center (ASC) 
(Rev. 11859; Issued: 02-16-23; Effective: 03-17-23; Implementation: 03-17-23) 
 
Part A/B MACs make payments for implantable prosthetics and DME to hospitals, 
physicians, or ASCs.  A manufacturer of non-implantable prosthetics and DME and 
replacement parts and supplies for prosthetic implants and surgically implantable 
DME may enroll in the Medicare program as a DMEPOS supplier via the Form 
CMS-855S if it meets the definition of a supplier as well as the requirements of 42 
CFR  424.57. 
 
10.2.4 - Other Medicare Part B Services                                                  
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Residents and Interns 
 
1.  General Background Information 
 
If the applicant is a "resident" in an "approved medical residency program" (as these two terms 
are defined at 42 CFR  413.75(b)), the contractor shall refer to Pub. 100-02, chapter 15, section 
30.3 for further instructions.  (The contractor can also refer to 42 CFR  415.200, which states 
that services furnished by residents in approved programs are not "physician services.) 
 
The physician should indicate the exact date on which its residency program, internship, or 
fellowship was completed, so that the appropriate effective date can be issued. 
 
2.  Interns are Ineligible to Enroll in the Medicare Program 
 
An intern cannot enroll in the Medicare program.  (For purposes of this requirement, the term 
intern means an individual who is not licensed by the state because he/she is still in post-
graduate year (PGY) 1.) 
 
B.  Diabetes Self-Management Training  
 
Diabetes self-management training (DSMT) is not a separately recognized provider type, such as 
a physician or nurse practitioner.  A person or entity cannot enroll in Medicare for the sole 
purpose of performing DSMT. Rather, DSMT is an extra service that an enrolled provider or 
supplier can bill for, assuming it meets all of the necessary DSMT requirements.  If the person or 
entity enrolls as a provider type (i.e., pharmacy, mass immunizer) that requires the submission of 
an application fee, the fee shall be submitted with the application.    
All DSMT programs must be accredited as meeting quality standards by a CMS-approved 
national accreditation organization.  CMS recognizes the American Diabetes Association (ADA) 
and the Association of Diabetes Care & Education Specialists (ADCES) (formerly known as the 
American Association of Diabetes Educators or AADE) as approved national accreditation 
organizations. A Medicare-enrolled provider or non-DMEPOS supplier that wishes to bill for 
DSMT may simply submit the appropriate accreditation certificate to its contractor.  No Form 
CMS-855 is required unless the provider or supplier is not in the Provider Enrollment, Chain and 
Ownership System (PECOS), in which case a complete Form CMS-855 application must be 
submitted.  
 
If the supplier is exclusively a DMEPOS supplier, it must complete and submit a Form CMS-
855B application to its local Part A/B MAC.  This is because A/B MACs, rather than Durable 
Medical Equipment Medicare Administrative Contractors, pay DSMT claims. Thus, the 
DMEPOS supplier must separately enroll with its A/B MAC even if it has already completed a 
Form CMS-855S.  If an A/B MAC receives an application from a DMEPOS supplier that would 
like to bill for DMST, it shall verify with the applicable NPE contractor that the applicant is 
currently enrolled and eligible to bill the Medicare program.  
 
For more information on DSMT, refer to:  
 
  42 CFR Part 410 (subpart H)  
 
  Publication 100-02, Medicare Benefit Policy Manual, chapter 15, sections 300  300.5.1  
 
C.  Mass Immunizers Who Roster Bill 
 
An entity or individual who wishes to furnish mass immunization services - but may not 
otherwise qualify as a Medicare provider - may be eligible to enroll as a Mass Immunizer via 
the Form CMS-855I (individuals) or the Form CMS-855B (entities).  Such suppliers must meet 
the following requirements:  
 
1.  They may not bill Medicare for any services other than pneumococcal pneumonia vaccines 
(PPVs), influenza virus vaccines, and their administration.  
 
2.  They must submit claims through the roster billing process.  
 
3.  The supplier, as well as all personnel who administer the shots, must meet all applicable state 
and local licensure or certification requirements.  
 
The roster billing process was developed to enable Medicare beneficiaries to participate in mass 
PPV and influenza virus vaccination programs offered by public health clinics and other 
organizations.  
 
In addition:  
    See 42 CFR  424.520(d) and 424.521(a) for information regarding mass immunizer 
effective dates.  
 
  In Section 4 of the Form CMS-855, the supplier need not list each off-site location (e.g., 
county fair, shopping mall) at which it furnishes services. It need only list its base of operations 
(e.g., county health department headquarters, drug store location).  
 
For more information on mass immunization roster billing, refer to:  
 
  Publication 100-02, Benefit Policy Manual, chapter 15, section 50.4.4.2  
 
  Publication 100-04, Claims Processing Manual, chapter 18, sections 10 through 10.3.2.3 
 
D.  Advanced Diagnostic Imaging 
 
Section 135(a) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) 
amended section 1834(e) of the Social Security Act.  It required the Secretary to designate 
organizations to accredit suppliers  including, but not limited to, physicians, non-physician 
practitioners, and independent diagnostic testing facilities - that furnish the technical component 
(TC) of advanced diagnostic imaging services.  MIPPA specifically defined advanced diagnostic 
imaging procedures as including diagnostic magnetic resonance imaging (MRI), computed 
tomography (CT), and nuclear medicine imaging, such as positron emission tomography (PET).  
The law also authorizes the Secretary to specify other diagnostic imaging services in consultation 
with physician specialty organizations and other stakeholders.   
 
The CMS has approved four national accreditation organizations (AOs)  the American College 
of Radiology, the Inter-societal Accreditation Commission, the Joint Commission, and Rad Site - 
to provide accreditation services for suppliers of the TC of advanced diagnostic imaging 
procedures.  The accreditation applies only to: (1) the suppliers of the images, not to the 
physician's interpretation of the image; and (2) those who are paid under the Physician Fee 
Schedule.  All AOs have quality standards that address the safety of the equipment as well as the 
safety of the patients and staff.  Each of these designated AOs submits monthly reports to CMS 
that list the suppliers who have been or are accredited, as well as the beginning and end-dates of 
the accreditation and the respective modalities for which they receive accreditation. 
 
Newly enrolling physicians and non-physician practitioners described above do not need to 
complete the appropriate boxes for Advanced Diagnostic Imaging (ADI) on Internet-based 
PECOS or the appropriate Form CMS-855.  Information for all ADI accredited suppliers is 
provided to CMS by the approved ADI AOs.  The contractor need not verify ADI information 
submitted on the application. 
 
10.2.5  Suppliers That Enroll Via the Form CMS-855S 
(Rev. 11682; Issued: 11-04-2022; Effective: 12-05-2022; Implementation: 12-05-2022) 
 
Section 10.2.5, et al. instructs the contractor on the appropriate handling of certain situations 
involving DMEPOS suppliers.  
   10.2.5.1  DMEPOS Supplier Accreditation 
(Rev. 12100; Issued: 06-29-23; Effective: 07-31-23; Implementation: 07-31-23) 
 
A.  General Requirement 
 
DMEPOS suppliers must be accredited prior to submitting an application to the contractor.  The 
contractor shall deny any DMEPOS supplier's enrollment application if the enrollment package 
does not contain an approved accreditation upon receipt. 
 
The contractor shall revoke an enrolled DMEPOS suppliers billing privileges if the supplier 
fails to: (1) obtain and submit supporting documentation that it has been accredited; or (2) 
maintain its required accreditation. 
 
In the future, Medicare will deny claims for DMEPOS suppliers that fail to maintain 
accreditation information on file with the contractor.   
 
B. Exemptions 
 
Individual medical practitioners, inclusive of group practices of same, do not require 
accreditation as a condition of enrollment.  The practitioner types are those specifically stated in 
Sections 1848(K)(3)(B) and 1842(b)(18)(C) of the Social Security Act.  In addition, the 
practitioner categories of physicians, orthotists, prosthetists, optometrists, opticians, audiologists, 
occupational therapists, physical therapists, and suppliers who provide drugs and 
pharmaceuticals (only) do not require accreditation as a condition of enrollment. 
 
Although suppliers that provide only drugs and pharmaceuticals are exempt from the 
accreditation requirement, suppliers that provide equipment to administer drugs or 
pharmaceuticals must be accredited. 
 
C.  Changes of Ownership 
 
A DMEPOS supplier undergoing a change of ownership for an existing supplier location with a 
new tax identification number (TIN) must submit an initial Form CMS-855S enrollment 
application to enroll as a new supplier.  The suppliers application shall be denied (consistent 
with 42 CFR  424.57) if the new owner does not have an accreditation that covers all of its 
locations.  If the old owner has such an accreditation, the new owner can be enrolled as of the 
date of sale if the accreditor determines that the accreditation should remain in effect as of the 
date of sale.  (This, however, is only applicable when the new owner also meets all other 
enrollment criteria found at 42 CFR  424.57).   
 
Some ownership changes do not result in a complete change of ownership, since the business 
entity remains the same with no change in TIN.  However, in cases where more than 5 percent of 
the ownership has changed, the following principles apply: 
 
(i) If the change in ownership has not been reported to the contractor within the required 30-day 
period, the contractor shall proceed with revocation action. 
  (ii) If the change has been received within the required 30-day period and the supplier has been 
accredited, the contractor shall immediately notify the accreditor of the ownership change and 
request that the latter advise the contractor if the accreditation should still remain in effect. 
 
D. Accreditation and Deactivation/Revocation 
 
A non-exempt DMEPOS supplier requesting reactivation after a deactivation (regardless of the 
deactivation reason) is required to be accredited. 
 
A revoked DMEPOS supplier that has submitted an acceptable corrective action plan can be 
reinstated without accreditation unless the accreditation was already required prior to revocation. 
 
10.2.5.2  Fraud Level Indicators for DMEPOS Suppliers - Development and 
Use 
(Rev. 11682; Issued: 11-04-2022; Effective: 12-05-2022; Implementation: 12-05-2022) 
 
A.  General Information 
 
The contractor shall perform a fraud potential analysis of all DMEPOS applicants and current 
DMEPOS suppliers.  The fraud level indicator shall represent the potential for fraud and/or 
abuse.  The contractor shall use four fraud level indicator codes as follows: 
 
  Low Risk (e.g., national drug store chains) 
 
  Limited Risk (e.g., prosthetist in a low fraud area) 
 
  Medium Risk (e.g., midsize general medical supplier in a high fraud area) 
 
  High Risk (e.g., very small space diabetic supplier with low inventory in a high fraud area 
whose owner has previously had a chapter 7 bankruptcy). High fraud areas shall be 
determined by contractor analysis with concurrence of the contractor project officer. 
 
(NOTE:  These risk categories are in addition to, and not in lieu of, those specified in 42 CFR  
424.518.) 
 
In assessing a fraud level indicator, the contractor shall consider such factors as: 
 
  Experience as a DMEPOS supplier with other payers 
  Prior Medicare experience 
  The geographic area 
  Fraud potential of products and services listed 
  Site visit results 
  Inventory observed and contracted 
  Accreditation of the supplier 
  After a fraud level indicator is assigned and the DMEPOS supplier is enrolled, the contractor 
shall establish a DMEPOS Review Plan based on the fraud level assessment.  The DMEPOS 
Review Plan shall contain information regarding: 
 
  Frequency of unscheduled site visits 
  Maximum billing amounts before recommendation for prepay medical review 
  Maximum billing spike amounts before recommendation for payment suspensions/prepay 
medical review, etc. 
 
The fraud level indicator shall be updated based upon information obtained through the Medicare 
enrollment process, such as reported changes of information. 
 
Information obtained by the Office of Inspector General (OIG), CMS (including CMS satellite 
office), and/or a Unified Program Integrity Contractor (UPIC) shall be reported to the contractor 
project officer.  The contractor shall update the fraud level indicator based on information 
obtained by the OIG, CMS (including CMS satellite office), and/or a UPIC only after the review 
and concurrence of the contractor project officer. 
 
In addition, the contractor shall monitor and assess geographic trends that indicate or 
demonstrate that one geographic area has a higher potential for having fraudulent suppliers. 
 
B.  When a DMEPOS Fraud Level Indicator Differs from Risk Screening Category under 
42 CFR  424.518 
 
The fraud level indicator described in this subsection is unrelated to the risk screening categories 
required under 42 CFR  424.518.  Under  424.518(c)(1)(ii), for example, newly enrolling 
DMEPOS suppliers are assigned to the high risk screening category.  Such DMEPOS suppliers 
are therefore subject to screening activities that correspond to the high risk screening category, 
including an on-site visit and a fingerprint-based criminal background check for all individuals 
who maintain a 5 percent or greater direct or indirect ownership interest in the supplier. (See  
424.518(c)(2).)  The on-site visits that the contractor conducts are responsive to the requirement 
at  424.518(c)(2)(i) for a site visit and include gathering information concerning fraud level 
indicator assignment as required in this subsection.  A DMEPOS supplier therefore has both a 
risk-based screening category assignment pursuant to requirements under  424.518, and a 
separate fraud level indicator based upon the guidance in this subsection.   
 
C.  Fraud Level Indicator Standards 
 
The contractor shall have documented evidence that it has, at a minimum, met the following 
requirements: 
 
  Assigned an appropriate fraud level indicator for at least 95 percent of all DMEPOS suppliers 
upon initial enrollment or revalidation. The fraud level indicator shall accurately reflect the 
risk the supplier poses to the Medicare program based on pre-defined criteria above. 
 
  Updated the DMEPOS fraud level indicator for each enrolled DMEPOS supplier on an 
annual basis.   
D.  Alert Codes for DMEPOS Suppliers 
 
The contractor shall receive and maintain the following alert indicators from the DME MACs 
and UPICs: 
    
Alert Code and Definition 
 
A - Possible fraudulent or abusive claims identified 
B - Overpayments 
D - Violations of disclosure of ownership requirements 
E - Violations of participation agreements 
L - Suspended by contractor outside alert code process 
M - Supplier is going through claims appeal process 
 
The contractor shall append the supplier file and transfer to the DME-MACs and/or UPICs the 
following alert codes in the following circumstances: 
   
Alert Code and Definition 
 
C - Violations of supplier standards 
F - Excluded by the OIG or debarred per the System for Award Management 
H - Meets supplier standards; however, the contractor recommends increased scrutiny by the 
contractor (initiated by the contractor only)  
N - Supplier being investigated under the "Do Not Forward" initiative (initiated by contractor 
only) 
Q - Low Risk Fraud Level Indicator 
 
R - Limited Risk Fraud Level Indicator 
S - Medium Risk Fraud Level Indicator 
T - High Risk Fraud Level Indicator 
 
The contractor shall append an Alert Code "H" for any supplier that meets present supplier 
standards but appears suspect in one of the areas that are verified by the contractor.  This alert 
code notifies the contractors that a supplier may be inclined to submit a high percentage of 
questionable claims. 
 
The contractor shall share the above information with the DME MACs and/or UPICs by sending 
alerts within 7 calendar days after identification of a supplier having common ownership or 
business ties with a sanctioned or suspect supplier for their research and/or action.  The 
contractor also shall forward alert codes submitted by the contractors with the other contractors 
within 7 calendar days after receipt. 
 
10.2.5.3  Surety Bonds 
(Rev. 11682; Issued: 11-04-2022; Effective: 12-05-2022; Implementation: 12-05-2022) 
 
10.2.5.3.1  Basics of the Surety Bond Requirement  (Rev. 11682; Issued: 11-04-2022; Effective: 12-05-2022; Implementation: 12-05-2022) 
 
A.  Parties Subject and Not Subject to Surety Bond Requirement 
 
All DMEPOS suppliers are subject to the surety bond requirement except: 
 
(1) Government-operated DMEPOS suppliers are exempted if the supplier has provided CMS 
with a comparable surety bond under state law.  
 
(2) State-licensed orthotic and prosthetic personnel (which, for purposes of the surety bond 
requirement, does not include pedorthists) in private practice making custom- made orthotics and 
prosthetics are exempted if 
 
  The business is solely-owned and operated by the orthotic and prosthetic personnel, and  
 
  The business is only billing for orthotic, prosthetics, and supplies. 
 
(3) Physicians and non-physician practitioners, as defined in section 1842(b)(18) of the Social 
Security Act, are exempted if the items are furnished only to the physician or non-physician 
practitioners own patients as part of his or her physician service.  The non-physicians covered 
under this exception are: physician assistants, nurse practitioners, clinical nurse specialists, 
certified registered nurse anesthetists, certified nurse-midwives, clinical social workers, clinical 
psychologists, and registered dietitians or nutrition professionals. 
 
(4) Physical and occupational therapists in private practice are exempted if 
 
  The business is solely-owned and operated by the physical or occupational therapist;  
 
  The items are furnished only to the physical or occupational therapists own patients as part 
of his or her professional service; and  
 
  The business is only billing for orthotics, prosthetics, and supplies. 
 
If a previously-exempted supplier no longer qualifies for an exception, it must submit a surety 
bond to the contractor - in accordance with the requirements in 42 CFR  424.57 - within 60 
days after it knows or has reason to know that it no longer meets the criteria for an exception. 
 
B. Bond Submission 
 
Effective May 4, 2009, DMEPOS suppliers submitting: (1) an initial enrollment application to 
enroll in the Medicare program for the first time, (2) an initial application to establish a new 
practice location, or (3) an enrollment application to change the ownership of an existing 
supplier, are required to obtain and submit a copy of its required surety bond to the contractor 
with their Form CMS-855S enrollment application. (NOTE: Ownership changes that do not 
involve a change in the status of the legal entity as evidenced by no change in the tax 
identification number (or changes that result in the same ownership at the level of individuals 
(corporate reorganizations and individuals incorporating)) are not considered to be changes of  ownership for purposes of the May 4, 2009, effective date  meaning that such suppliers are 
considered existing suppliers). 
 
For any Form CMS-855S application submitted on or after May 4, 2009 by a non-exempt 
supplier described in this subsection (B), the contractor shall reject the application if the supplier 
does not furnish a valid surety bond at the time it submits its application.  The rejection shall be 
done in accordance with existing procedures (e.g., reject application after 30 days). 
 
C.  Amount and Basis 
 
The surety bond must be in an amount of not less than $50,000 and is predicated on the NPI, not 
the tax identification number.  Thus, if a supplier has two separately-enrolled DMEPOS 
locations, each with its own NPI, a $50,000 bond must be obtained for each site. 
 
A supplier may obtain a single bond that encompasses multiple NPIs/locations.  For instance, if a 
supplier has 10 separately-enrolled DMEPOS locations, it may obtain a $500,000 bond that 
covers all 10 locations. 
 
As stated in 42 CFR  424.57(d)(3), a supplier will be required to maintain an elevated surety 
bond amount of $50,000 for each final adverse action imposed against it within the 10 years 
preceding enrollment or reenrollment.  This amount is in addition to, and not in lieu of, the base 
$50,000 amount that must be maintained.  Thus, if a supplier has had two adverse actions 
imposed against it, the bond amount will be $150,000. 
 
A final adverse action is one of the following: 
 
  A Medicare-imposed revocation of Medicare billing privileges; 
  Suspension or revocation of a license to provide health care by any State licensing authority; 
  Revocation or suspension by an accreditation organization; 
  A conviction of a federal or state felony offense (as defined in  424.535(a)(3)(i)) within the 
last 10 years preceding enrollment or re-enrollment; or  
  An exclusion or debarment from participation in a federal or state health care program. 
 
D.  Bond Terms 
 
The supplier is required to submit a copy of the bond that - on its face - reflects the requirements 
of 42 CFR 424.57(d).  Specific terms that the bond must contain include: 
 
  A guarantee that the surety will - within 30 days of receiving written notice from CMS 
containing sufficient evidence to establish the surety's liability under the bond of unpaid 
claims, civil money penalties (CMPs), or assessments - pay CMS a total of up to the full 
penal amount of the bond in the following amounts: 
 
a.  The amount of any unpaid claim, plus accrued interest, for which the DMEPOS supplier is 
responsible, and 
  b.  The amount of any unpaid claims, CMPs, or assessments imposed by CMS or the OIG on the 
DMEPOS supplier, plus accrued interest. 
 
  A statement that the surety is liable for unpaid claims, CMPs, or assessments that occur 
during the term of the bond. 
 
  A statement that actions under the bond may be brought by CMS or by CMS contractors. 
 
  The surety's name, street address or post office box number, city, state, and zip code. 
 
  Identification of the DMEPOS supplier as the Principal, CMS as the Obligee, and the surety 
(and its heirs, executors, administrators, successors and assignees, jointly and severally) as 
the surety. 
 
The term of the initial surety bond must be effective on the date that the application is submitted 
to the contractor.  Moreover, the bond must be continuous. 
 
E.  List of Sureties 
 
The list of sureties from which a bond can be secured is found at Department of the Treasury's 
Listing of Certified (Surety Bond) Companies; the Web site is 
https://www.fiscal.treasury.gov/fsreports/ref/suretyBnd/c570_a-z.htm. For purposes of the surety 
bond requirement, these sureties are considered authorized sureties, and are therefore the only 
sureties from which the supplier may obtain a bond. 
 
F.  Bond Cancellations and Gaps in Coverage 
 
A DMEPOS supplier may cancel its surety bond, but it must provide written notice of such to the 
contractor and the surety at least 30 days before the effective date of the cancellation.  
Cancellation of a surety bond is grounds for revocation of the supplier's Medicare billing 
privileges unless the supplier provides a new bond before the effective date of the cancellation.  
The liability of the surety continues through the termination effective date. 
 
The contractor shall: 
 
  Process post-dated surety bond cancellations within 45 calendar days from the date the 
contractor received the cancellation.   
  Process future-dated surety bond cancellations within 45 calendar days from the effective 
date of cancellation. 
(The contractor may apply a clock stoppage if a surety bond gap is involved and the case 
must be sent to PEOG for review.  The clock stoppage remains in effect until the 
contractor receives PEOGs final determination.)   
 
If a supplier changes its surety during the term of the bond, the new surety is responsible for any 
overpayments, CMPs, or assessments incurred by the DMEPOS supplier beginning with the  effective date of the new surety bond.  The previous surety is responsible for any overpayments, 
CMPs, or assessments that occurred up to the date of the change of surety. 
 
Pursuant to 42 CFR  424.57(d)(6)(iv), the surety must notify the contractor if there is a lapse in 
the suretys coverage of the DMEPOS supplier.  This can be done via letter, fax, or e-mail to the 
contractor. 
 
G.  Reenrollment and Reactivation 
 
The supplier must furnish the paperwork described above with any Form CMS-855S 
reenrollment or reactivation application it submits to the contractor unless it already has the 
information on file with the contractor.  For example, if a supplier has submitted a continuous 
surety bond to the contractor prior to submission of its reenrollment application, a new copy of 
surety bond is not be required unless the contractor specifically requests it. 
 
 
H.  Surety Bond Changes 
 
A DMEPOS supplier must submit an addendum to the existing bond (or, if the supplier prefers, a 
new bond) to the contractor in the following instances: (1) change in bond terms; (2) change in 
bond amount; or (3) a location on a bond covering multiple non-chain locations is being added or 
deleted. 
 
10.2.5.3.2  Claims against Surety Bonds 
(Rev. 11682; Issued: 11-04-2022; Effective: 12-05-2022; Implementation: 12-05-2022) 
 
(For purposes of this section, the term contractor means the enrollment contractor, unless 
otherwise indicated.  Durable Medical Equipment Medicare Administrative Contractors will be 
referenced as DME MACs.) 
 
Pursuant to 42 CFR  424.57(d)(5)(i), the surety must pay CMS - within 30 days of receiving 
written notice to do so - the following amounts up to the full penal sum of the bond: 
 
1.  The amount of any unpaid claim, plus accrued interest, for which the DMEPOS supplier is 
responsible. 
 
2.. The amount of any unpaid claim, CMP, or assessment imposed by CMS or the OIG on the 
DMEPOS supplier, plus accrued interest. 
 
This section 10.2.5.3.2 describes the procedures involved in making a claim against a surety 
bond. 
 
A.  Background 
 
For purposes of the surety bond requirement, 42 CFR  424.57(a) defines an unpaid claim as 
an overpayment (including accrued interest, as applicable) made by the Medicare program to the 
DMEPOS supplier for which the supplier is responsible. 
  The policies in this section 10.2.5.3.2 only apply to overpayment determinations relating to 
demands first made on or after March 3, 2009.  A surety is liable for any overpayments based on 
dates of service occurring during the term of the surety bond.  (For purposes of determining 
surety liability, the date of the initial demand letter was sent to the provider is the date on which 
the service was performed/furnished.)  Even if the overpayment determination is made after the 
expiration of the surety bond, the surety remains liable if the date of service was within the 
surety bond coverage period.  In short, the date of service  rather than the date of the 
overpayment determination or the date the overpayment demand letter was sent to the supplier---
is the principal factor in ascertaining surety liability. 
 
As an illustration, assume that a supplier has a surety bond with Company X on August 1, 
2015.  It performs a service on October 1, 2015.  The supplier ends its coverage with Company 
X effective January 1, 2016 and obtains a new surety bond with Company Y effective that same 
date.  On February 1, 2016, CMS determines that the October 1, 2015 service resulted in an 
overpayment; on March 2, 2016, CMS sends an overpayment demand letter to the 
supplier.  While the overpayment determination and the sending of the demand letter occurred 
during Company Ys coverage period, the date of service was within the Company X coverage 
period.  Thus, liability (and responsibility for payment) rests with Company X, even though the 
supplier no longer has a surety bond with X.  
 
B.  Collections  Unpaid Claims  
 
1.  Delinquency Period  
 
If the DME MAC determines  in accordance with CMSs existing procedures for making 
overpayment determinations - that (1) the DMEPOS supplier has an unpaid claim for which it is 
liable, and (2) no waiver of recovery under the provisions of section 1870 of the Social Security 
Act is warranted, the DME MAC shall attempt to recover the overpayment in accordance with 
the instructions in CMS Pub. 100-06, chapter 4. 
 
If 80 days have passed since the initial demand letter was sent to the DMEPOS supplier and full 
payment has not been received, the DME MAC shall attempt to recover the overpayment.  The 
DME MAC shall review the List of Bonded Suppliers the last week of each month to 
determine which suppliers that have exceeded this 80-day period have a surety bond.  Said list: 
 
  Will be electronically sent to the DME MACs by CMS Provider Enrollment & Oversight 
Group on a monthly basis.  
 
  Will be in the form of an Excel spreadsheet. 
 
  Will contain the suppliers legal business name, tax identification number, NPI, surety bond 
amount, and other pertinent information. 
 
If the supplier does not have a surety bond (i.e., is exempt from the surety bond requirement), the 
DME MAC shall continue to follow the instructions in Pub. 100-06, chapter 4 regarding 
collection of the overpayment. 
  2.  Request for Payment from Surety  General Requirements 
 
If, however, the supplier has a surety bond (and subject to situations (a) through (f) below), the 
DME MAC shall send an Intent to Refer (ITR) letter to the supplier and a copy thereof to the 
suppliers surety.  The letter ITR and copy shall be sent to the supplier on day 66 after the initial 
demand letter was sent, and the surety notification shall be sent within 5 days.  (The copy to the 
surety can be sent via mail, e-mail, or fax.) 
 
(NOTE: Under federal law, a delinquent debt must be referred to the Department of Treasury 
within 120 days.  (Per the chart below, this represents Day 150 of the entire collection cycle.)  To 
ensure that the DME MAC meets this 120-day limit but has sufficient time to prepare the surety 
letter as described in the following paragraph, it is recommended that the DME MAC send the 
ITR letter several days prior to the 90-day limit referenced in the previous paragraph.  This will 
give the DME MAC a few additional days beyond the 30-day deadline referenced in the next 
paragraph to send the surety letter.) 
 
If the DME MAC does not receive full payment from the supplier within 30 days of sending the 
ITR letter (and subject to situations (a) through (f) below), the contractor shall notify the surety 
via letter that, in accordance with 42 CFR  424.57(d)(5)(i)(A), the surety must make payment of 
the claim to CMS within 30 days from the date of the surety letter.  (The DME MAC shall send a 
copy of the surety letter to the supplier on the same date.)  The DME MAC shall send the surety 
letter no later than 30 days after sending the ITR letter (subject to the previous paragraph), 
depending on the facts of the case.  Consider the following situations: 
 
a.  If a DMEPOS supplier has withdrawn from Medicare or has had its enrollment deactivated or 
revoked, the contractor shall send the ITR and the surety letter on the earliest possible day. 
 
b.  If the supplier has an extended repayment schedule (ERS) and is currently making payments, 
the DME MAC shall not send an ITR letter or a surety letter.  If the DME MAC is currently 
reviewing an ERS application from the supplier, the contractor shall delay sending the ITR letter 
and the surety letter until after the ERS review is complete. 
 
c.  If the aggregated principal balance of the debt is less than $25, the DME MAC shall not send an 
ITR letter or a surety letter.  It shall instead follow the instructions in CMS Pub. 100-06, chapter 4 
regarding collection of the overpayment. 
 
d.  If the DME MAC believes the debt will be collected through recoupment, it shall not send an ITR 
letter or a surety letter.  It shall instead follow the instructions in Pub. 100-06, chapter 4 regarding 
collection of the overpayment. 
 
e.  If the supplier has had a recent offset, the DME MAC may wait to see if future offsets will 
close the debt, without sending the surety a letter.  If the debt is still not paid in full or an ERS 
has not been established, the DME MAC shall send the surety letter no later than the 115th day 
after the initial demand letter was sent. 
 
f.  A payment demand letter shall not be sent to the surety if the DME MAC is certain that the 
$50,000 surety bond amount in question has been completely exhausted. 
  (NOTE: The DME MAC may choose to aggregate debts from the same supplier into one surety 
letter, provided they are at least 30 days delinquent.) 
 
3.  Contents of Surety Letter 
 
The surety letter shall: 
     
a.  Follow the format of the applicable model letter found in section 10.7.16 of this chapter.  
 
b.  Identify the specific amount to be paid and be accompanied by sufficient evidence of the 
unpaid claim. Sufficient evidence is defined in 42 CFR 424.57(a) as documents that CMS 
may supply to the DMEPOS suppliers surety to establish that the supplier had received 
Medicare funds in excess of the amount due and payable under the statute and regulations.   
 
c.  Be accompanied by the following documents, which constitute sufficient evidence for 
purposes of 424.57(a): 
 
(i) Overpayment Services Report - A computer-generated Overpayment Services Report 
containing the following information: 
 
  Date of service (i.e., the date the service was furnished/performed, not the date of the 
o
overpayment determination or the date of the overpayment or demand letter) 
  Date on which supplier was paid 
o
  Paid Amount 
o
  Overpayment Amount  
o
 
(NOTE:  The report shall not include HICN or any information otherwise protected under the 
Privacy Act.) 
 
(ii) A copy of the overpayment determination letter that was sent to the supplier  
 
(iii) A statement that payment shall be made via check or money order and that the Payee shall 
be the DME MAC 
 
(iv) Identification of the address to which payment shall be sent 
 
The DME MAC shall only seek repayment up to the full penal sum amount of the surety bond.  
Thus, if the supplier has a $60,000 unpaid claim and the amount of the suppliers bond coverage 
is $50,000, the DME MAC shall only seek the $50,000 amount.  The remaining $10,000 will 
have to be obtained from the supplier via the existing overpayment collection process. 
 
4.  Follow-Up Contact 
 
Between 8 and 12 calendar days after sending the surety letter, the DME MAC shall contact the 
surety by telephone or e-mail to determine whether the surety received the letter and, if it did, 
whether and when payment will be forthcoming. 
  If the surety indicates that it did not receive the letter, the DME MAC shall immediately fax or e-
mail a copy of the letter to the surety.  The surety will have 30 days from the original date of the 
letter  not 30 days from the date the letter was resent to the surety  to submit payment.  To 
illustrate, suppose the DME MAC on April 1 sends the surety letter, which is also dated April 1.  
It places the follow-up call to the surety on April 11.  The surety states that it never received the 
letter, so the contractor e-mails a copy of it to the surety that same day.  Payment must be 
received by May 1, or 30 days from the original date of the letter. 
 
If the surety cannot be reached (including situations where a voicemail message must be left) or 
if the surety indicates that it did receive the letter and that payment is forthcoming, no further 
action by the contractor is required.  If the surety indicates that payment is not forthcoming, the 
contractor shall (1) attempt to ascertain the reason, and (2) follow the steps outlined below after 
the 30-day period expires. 
 
The contractor shall document any attempts to contact the surety by telephone and the content of 
any resultant conversations with the surety. 
 
5.   Verification of Payment 
 
a.   Full Payment of the Claim is Made 
 
If full payment (including interest, as applicable) is made within the aforementioned 30-day 
period, the DME MAC shall, no later than 10 calendar days after payment was made: 
 
(i) Update all applicable records to reflect that payment was made.  (Payment from the surety 
shall be treated as payment from the supplier for purposes of said record updates.) 
 
(ii) Send a mailed, faxed, or (preferably) e-mailed letter to the supplier (on which the contractor 
shall be copied): 
 
  Stating that payment has been made, the date the payment was received, and the amount of 
the payment 
 
  Containing the following quoted verbiage: 
 
You must, within 30 calendar days of the date of this letter, obtain and submit to the 
contractor additional surety bond coverage in the amount of (insert the amount that the surety 
paid) so as to ensure that your total coverage equals or exceeds the required $50,000 amount 
(or higher if an elevated bond amount is involved due to a final adverse action). Failure to 
timely do so will result in the revocation of your Medicare enrollment.    
 
Additional surety bond coverage may be obtained by (1) adding to the amount of your 
existing surety bond so as to equal or exceed $50,000, or (2) cancelling your current surety 
bond and securing a new $50,000 surety bond.  (Obtaining a separate (insert the amount the 
surety paid) surety bond is impermissible.)  In either case, the effective date of the additional 
coverage must be on or before the date that you submit the additional coverage to the 
contractor.   
If the contractor does not receive the additional bond coverage within this 30-day period, it shall 
revoke the DMEPOS suppliers Medicare enrollment under  424.535(a)(1) in accordance with 
existing procedures. (The effective date of revocation shall be the date on which the DME MAC 
received payment from the surety.)  It is important that the contractor: (1) monitor the suppliers 
surety bond status upon receiving a copy of the DME MACs letter to the supplier; and (2) take 
prompt action against the supplier (consistent with existing procedures) if the supplier does not 
secure and timely submit the required additional coverage. 
 
b.  No Payment of the Claim Made 
 
If the surety fails to make any payment within 30 calendar days of the date of the letter to the 
surety, the DME MAC shall: 
 
(i)  Refer the debt to the Department of Treasury (by HIGLAS on the 120-day deadline) 
immediately upon the expiration of said 30-day timeframe (i.e., preferably on the same day or 
the day after, but in all cases no later than the 120-day deadline for sending delinquent debts to 
the Department of Treasury) and as outlined in Pub. 100-06, chapter 4; 
 
(ii)  No later than 14 days after the 30-day period expires, contact the surety via e-mail or 
telephone to ascertain the reason for non-payment.  Only one contact is necessary.  A voice mail 
message may be left.  The contractor shall document any attempts to contact the surety by 
telephone and the content of any resultant conversations with the surety. 
 
(iii)  No later than 14 days after Step 2 has been completed  and if full payment still has not 
been received -- send the letter found in section 10.7.16 of this chapter.   
 
(iv)  Include information relating to the suretys non-payment in the report identified in section 
10.2.5.3.2(D). 
 
c.   Partial Payment of the Claim is Made 
 
If the surety pays part of the claim within the 30-day period and a balance is still due and owing, 
the DME MAC shall do the following: 
 
(i) Refer the unpaid debt to the Department of Treasury (by HIGLAS on the 12-day deadline) 
immediately upon the expiration of said 30-day timeframe (i.e., preferably on the same day or 
the day after, but in all cases no later than the 120-day deadline for sending delinquent debts to 
the Department of Treasury) and as outlined in Pub. 100-06, chapter 4. 
 
(ii) No later than 14 days after the 30-day period expires, contact the surety via e-mail or 
telephone to ascertain the reason for the partial non-payment.  Only one contact is necessary.  A 
voice mail message may be left.  The contractor shall document any attempts to contact the 
surety by telephone and the content of any resultant conversations with the surety. 
 
(iii) No later than 14 days after Step (ii) has been completed  and if full payment still has not 
been received -- send the letter found in Section 10.7.16 of this chapter. 
  (iv) Include information relating to the suretys partial non-payment in the report identified in 
section 10.2.5.3.2(D). 
 
(v) No later than 10 calendar days after the partial payment was made: 
 
  Update all applicable records to reflect that partial payment was made.  (Payment from the 
surety shall be treated as payment from the supplier for purposes of said record updates.) 
 
  Send a mailed, faxed, or (preferably) e-mailed letter to the supplier (on which the contractor 
shall be copied): 
 
  Stating that partial payment was made, the date the payment was received, and the 
o
amount of said payment 
 
  Containing the following quoted verbiage: 
o
 
You must, within 30 calendar days of the date of this letter, obtain and submit to the 
contractor additional surety bond coverage in the amount of (insert the amount that the 
surety paid) so as to ensure that your total coverage equals or exceeds the required 
$50,000 amount (or higher if an elevated bond amount is involved due to a final adverse 
action).  Failure to timely do so will result in the revocation of your Medicare 
enrollment. 
 
Additional surety bond coverage may be obtained by (1) adding to the amount of your 
existing surety bond so as to equal or exceed $50,000, or (2) cancelling your current 
surety bond and securing a new $50,000 surety bond.  (Obtaining a separate (insert the 
amount the surety paid) surety bond is impermissible.)  In either case, the effective date 
of the additional coverage must be on or before the date that you submit the additional 
coverage to the contractor. 
 
If the contractor does not receive the additional bond coverage within this 30-day period, it shall 
revoke the DMEPOS suppliers Medicare enrollment under  424.535(a)(1) in accordance with 
existing procedures.  (The effective date of revocation shall be the date on which the DME MAC 
received payment from the surety.)  It is important that the contractor (1) monitor the suppliers 
surety bond status upon receiving a copy of the DME MACs letter to the supplier and (2) take 
prompt action against the supplier (consistent with existing procedures) if the supplier does not 
secure and timely submit the required additional coverage. 
 
6.  Successful Appeal 
 
If the supplier successfully appeals the overpayment and the surety has already made payment to 
the DME MAC on the overpayment, the DME MAC shall  within 30 calendar days of receiving 
notice of the successful appeal - notify the surety via letter of the successful appeal and repay the 
surety via check or money order. 
 
7.   Summary 
  The following chart outlines the timeframes involved in the surety bond collection process for 
overpayments: 
 
Day 1  Initial Demand Letter Sent 
Day 31  Debt is Delinquent/Interest Starts 
Day 41  Recoupment Starts 
Day 66  Intent to Refer Letter Sent 
Day 115  Surety Bond Letter Sent 
Day 150  Referral to Treasury 
 
C.  Claims Pertaining to Assessments and CMPs 
 
1.   Request for Payment from Surety 
 
Per 42 CFR  424.57(a), an assessment is defined as a sum certain that CMS or the OIG may 
assess against a DMEPOS supplier under Titles XI, XVIII, or XXI of the Social Security Act.  
Under 42 CFR  424.57(a), a CMP is defined as a sum that CMS has the authority, as 
implemented by 42 CFR  402.1(c) (or the OIG has the authority, under section 1128A of the 
Act or 42 CFR Part 1003) to impose on a supplier as a penalty. 
 
The CMS will notify the DME MAC of the need for the latter to collect payment from the surety 
on an assessment or CMP imposed against a particular bonded DMEPOS supplier.  Upon receipt 
of this notification, the DME MAC shall  regardless of the amount of the assessment or CMP - 
notify the surety via letter that, in accordance with 42 CFR  424.57(d)(5)(i)(B), payment of the 
assessment or CMP must be made within 30 calendar days from the date of the letter.  The letter 
(on which the contractor and the supplier/debtor shall be copied) shall: 
 
  Follow the format of the applicable model letter found in Section 10.7.16 of this chapter. 
 
  Identify the specific amount to be paid and be accompanied by sufficient evidence.  This 
includes all documentation that CMS (in its notification to the DME MAC as described 
above) requests the DME MAC to include with the letter (e.g., OIG letter).   
 
  State that payment shall be made via check or money order and that the Payee shall be CMS. 
 
  Identify the address to which payment shall be sent. 
 
2.   Follow-Up Contact 
 
Between 8 and 12 calendar days after sending the surety letter, the DME MAC shall contact the 
surety by telephone or e-mail to determine whether the surety received the letter and, if it did, 
whether and when payment is forthcoming; 
 
If the surety indicates that it did not receive the letter, the DME MAC shall immediately fax or e-
mail a copy of the letter to the surety.  The surety will have 30 days from the original date of the 
letter  not 30 days from the date the letter was resent to the surety  to submit payment.  To 
illustrate, suppose the DME MAC on April 1 sends the surety letter, which is also dated April 1.   It places the follow-up call to the surety on April 11.  The surety states that it never received the 
letter, so the contractor e-mails a copy of it to the surety that same day.  Payment must be 
received by May 1, or 30 days from the original date of the letter. 
 
If the surety cannot be reached (including situations where a voicemail message must be left) or 
if the surety indicates that it received the letter and that payment is forthcoming, no further action 
by the contractor is required.  If the surety indicates that payment is not forthcoming, the 
contractor shall (1) attempt to ascertain the reason and (2) follow the steps outlined below after 
the 30-day period expires.   
 
The contractor shall document any attempts to contact the surety by telephone and the content of 
any resultant conversations with the surety. 
 
3.  Verification of Payment 
 
a.  Full Payment of the Claim is Made 
 
If full payment (including interest, as applicable) is made within 30 calendar days of the date of 
the letter to the surety, the DME MAC shall, no later than 10 calendar days after payment was 
made: 
 
(i) Update all applicable records to reflect that payment was made.  (Payment from the surety 
shall be treated as payment from the supplier for purposes of said record updates.) 
 
(ii) Notify the applicable CMS Location (formerly CMS Regional Office) via letter or e-mail that 
payment was made. 
 
(iii) If the OIG imposed the CMP or assessment, notify the OIG via letter that payment was 
made. 
 
(iv) Send a mailed, faxed, or (preferably) e-mailed letter to the supplier (on which the enrollment 
contractor shall be copied): 
 
  Stating that payment has been made, the date the payment was received, and the amount of 
said payment 
 
  Containing the following quoted verbiage: 
 
You must, within 30 calendar days of the date of this letter, obtain and submit to the 
contractor additional surety bond coverage in the amount of (insert the amount that the 
surety paid) so as to ensure that your total coverage equals or exceeds the required $50,000 
amount (or higher if an elevated bond amount is involved due to a final adverse action). 
Failure to timely do so will result in the revocation of your Medicare enrollment. 
 
Additional surety bond coverage may be obtained by (1) adding to the amount of your 
existing surety bond so as to equal or exceed $50,000, or (2) cancelling your current surety 
bond and securing a new $50,000 surety bond.  (Obtaining a separate (insert the amount the  surety paid) surety bond is impermissible.)  In either case, the effective date of the 
additional coverage must be on or before the date that you submit the additional coverage to 
the contractor. 
 
If the contractor does not receive the additional bond coverage within this 30-day period, it shall 
revoke the DMEPOS suppliers Medicare enrollment under  424.535(a)(1) enrollment in 
accordance with existing procedures.  (The effective date of revocation shall be the date on 
which the DME MAC received payment from the surety.)  It is important that the contractor (1) 
monitor the suppliers surety bond status upon receiving a copy of the DME MACs letter to the 
supplier and (2) take prompt action against the supplier (consistent with existing procedures) if 
the supplier does not secure and timely submit the required additional coverage. 
 
b.  No Payment of the Claim is Made 
 
If the surety fails to make any payment within the aforementioned 30-day timeframe, the DME 
MAC shall: 
 
(i) Continue collection efforts as outlined in Pub. 100-06, chapter 4; 
 
(ii) No later than 14 days after the 30-day period expires, contact the surety via e-mail or 
telephone to ascertain the reason for non-payment.  Only one contact is necessary.  A voice mail 
message may be left.   The contractor shall document any attempts to contact the surety by 
telephone and the content of any resultant conversations with the surety. 
 
(iii) No later than 14 days after Step 2 has been completed  and if full payment still has not been 
received -- send the letter found in Section 10.7.16 of this chapter. 
 
(iv) Include information relating to the suretys non-payment in the report outlined in section 
10.2.5.3.2(D).  
 
c.  Partial Payment of the Claim is Made 
 
If the surety pays part of the claim within the 30-day period and a balance is still due and owing, 
the DME MAC shall do the following: 
 
(i) Continue collection efforts as outlined in Pub. 100-06, chapter 4; 
 
(ii) No later than 14 days after the 30-day period expires, contact the surety via e-mail or 
telephone to ascertain the reason for the partial non-payment. Only one contact is necessary.  A 
voice mail message may be left.  The contractor shall document any attempts to contact the 
surety by telephone and the content of any resultant conversations with the surety. 
 
(iii) No later than 14 days after Step (ii) has been completed  and if full payment still has not 
been received -- send the letter found in Section 10.7.16 of this chapter.   
     
(iv) Include information relating to the suretys partial non-payment in the report identified in 
section 10.2.5.3.2(D). 
  (v) No later than 10 calendar days after the partial payment was made: 
 
  Update all applicable records to reflect that partial payment was made.  (Payment from the 
surety shall be treated as payment from the supplier for purposes of said record updates.) 
 
  Send a mailed, faxed, or (preferably) e-mailed letter to the supplier (on which the contractor 
shall be copied): 
 
  Stating that partial payment was made, the date the payment was received, and the 
o
amount of said payment 
 
  Containing the following quoted verbiage: 
o
 
You must, within 30 calendar days of the date of this letter, obtain and submit to the 
contractor additional surety bond coverage in the amount of (insert the amount that the surety 
paid) so as to ensure that your total coverage equals or exceeds the required $50,000 amount 
(or higher if an elevated bond amount is involved due to a final adverse action).  Failure to 
timely do so will result in the revocation of your Medicare enrollment. 
 
Additional surety bond coverage may be obtained by (1) adding to the amount of your 
existing surety bond so as to equal or exceed $50,000, or (2) cancelling your current surety 
bond and securing a new $50,000 surety bond.  (Obtaining a separate (insert the amount the 
surety paid) surety bond is impermissible.)  In either case, the effective date of the additional 
coverage must be on or before the date that you submit the additional coverage to the 
contractor. 
 
If the contractor does not receive the additional bond coverage within this 30-day period, it shall 
revoke the DMEPOS suppliers Medicare enrollment under  424.535(a)(1) in accordance with 
existing procedures.  (The effective date of revocation shall be the date on which the DME MAC 
received payment from the surety.)  It is important that the contractor (1) monitor the suppliers 
surety bond status upon receiving a copy of the DME MACs letter to the supplier and (2) take 
prompt action against the supplier (consistent with existing procedures) if the supplier does not 
secure and timely submit the required additional coverage. 
 
4.  Successful Appeal 
 
If the DMEPOS supplier successfully appeals the CMP or assessment and the surety has already 
made payment, CMS will  within 30 days of receiving notice of the successful appeal - notify 
the surety via letter of the successful appeal and repay the surety. 
 
D.  Reporting Requirements 
 
1.  Contents 
 
DME MACs shall compile a report on a quarterly basis in the format prescribed in existing CMS 
directives. The report will capture the following elements: 
  a.  Number of account receivables (debts) reviewed for possible surety bond letter development  
 
b.  Number of debts sent to the surety for recovery  
 
c.  Amounts recovered directly from sureties (1) during the quarter in question, and (2) since 
March 3, 2009 (that is, the total/cumulative amount collected since the beginning of the surety 
bond collection process)  
 
d.  Amounts paid by suppliers after the debt was referred to the surety for collection. The report 
shall include the (1) amount for the quarter in question and (2) total/cumulative amount since 
March 3, 2009.  
 
e.  Names of suppliers and billing numbers for which letters were sent to the surety and/or surety 
bond recoveries were received  
 
f.  Names of suppliers on whose surety bond(s) the surety made payment in the last quarter and 
to whom the DME MAC consequently sent notice to the supplier that it must obtain additional 
surety bond coverage to reach the $50,000 threshold.  
 
g.  Names and addresses of sureties that have failed to make payment within the quarterly period. 
For each instance of non-payment, the report shall identify (a) the amount that was requested, (b) 
the amount that was paid (if any), (3) the name and tax identification number of the supplier in 
question, and (4) the reason the surety did not pay (to the extent this can be determined).  
 
2.  Timing 
 
The quarterly reports shall encompass the following time periods: January through March, April 
through June, July through August, and September through December. Reports shall be 
submitted to PEOG (with a copy to the DME MAC COR) --- via the following e-mail address: 
XXXXXXXX@cms.hhs.gov --- by the 10th day of the month following the end of the reporting 
quarter. Information on surety collections shall be reported once for each demand letter. That 
action shall be reported only when the collection process has been fully completed for that 
specific identified overpayment, which may be comprised of multiple claims. For example, 
suppose the surety was sent a letter in December but its payment was not received until January. 
That action would be documented in the report encompassing the months of January, February, 
and March. 
 
10.2.5.4  Indian Health Services (IHS) Facilities Enrollment as DMEPOS 
Suppliers 
(Rev. 11682; Issued: 11-04-2022; Effective:1 2-05-2022; Implementation:12-05-2022) 
 
A.  Background 
 
The contractor shall enroll IHS facilities as DMEPOS suppliers in accordance with: (a) the 
general enrollment procedures cited in chapter 10; (b) the statement of work contained in the 
contractors contract with Medicare; and (c) the special procedures cited in this section. 
  For enrollment purposes, Medicare recognizes two types of IHS facilities: (1) facilities wholly 
owned and operated by the HIS; and (2) facilities owned by the IHS but tribally operated or 
totally owned and operated by a tribe.  CMS will provide the contractor with a list of IHS 
facilities that distinguishes between these two types. 
 
On the list, the contractor shall use the column entitled, FAC OPERATED BY, for this 
purpose. 
 
B.   Enrollment 
 
The supplier shall complete the Form CMS-855S in accordance with the instructions shown 
therein. 
 
Facilities that are: 
 
  Totally owned and operated by the IHS are considered governmental organizations.  An Area 
Director of the IHS must sign Section 15 of the Form CMS855S, be listed in Section 9 of 
the form, and sign the letter required under Section 8 of the form that attests that the IHS will 
be legally and financially responsible in the event there is any outstanding debt owed to 
CMS. 
 
  Tribally operated are considered tribal organizations. Section 15 of the Form CMS855S 
must be signed by a tribal official who meets the definition of an authorized official under 
42 CFR  424.502.  The individual must also be listed in Section 9 of the form and must sign 
the letter required under Section 8 of the form that attests that the tribe will be legally and 
financially responsible in the event there is any outstanding debt owed to CMS. 
 
C.  Supplier Standards, Exceptions, and Site Visits 
 
All IHS facilities, whether operated by the IHS or a tribe:   
 
1.   Shall meet all required standards, with the exception of the comprehensive liability insurance 
requirements under 42 CFR  424.57(c)(10). 
 
2.   Need not meet the requirement to provide state licenses for their facility/business. For 
example, if the DMEPOS supplier indicates on its application that it will be providing 
hospital beds and is located in a state that requires a bedding license, such licensure is not 
required.  However, if it provides a DMEPOS item that requires a licensed professional in 
order to properly provide the item, it shall provide a copy of the professional license. The 
licensed professional can be licensed in any state or have a federal license (e.g., a pharmacy 
does not need a pharmacy license but shall have a licensed pharmacist). 
 
3.   Shall, like all other DMEPOS suppliers, undergo site visits in accordance with section 
10.6.20(A) and 10.6.20(B) of this chapter.  (This includes all hospitals and pharmacies 
enrolling as DMEPOS suppliers.) 
 
D.  Provider Education for IHS Facilities   
The contractor shall ensure that its web site includes the information contained in this section 
10.2.5.4) that is specific to enrollment of IHS facilities (whether operated by the IHS or a tribe). 
 
E.  Specialty Codes 
 
The contractor shall apply the specialty code A9 (IHS) to all IHS enrollments (whether operated 
by the IHS or a tribe). However, the specialty code A9/A0 shall be applied to facilities that are 
IHS/tribal hospitals. 
 
Other specialty codes should be applied as applicable (e.g., pharmacies). 
 
10.2.5.5  Pharmacy Enrollment as a DMEPOS Supplier - Accreditation 
(Rev. 11682; Issued: 11-04-2022; Effective: 12-05-2022; Implementation: 12-05-2022)  
 
(Refer to section 10.2.2.7 of this chapter for a discussion of pharmacy enrollment via the Form 
CMS-855B (i.e., pharmacy not enrolling as a DMEPOS supplier).) 
 
The contractor shall not require that a pharmacy be accredited as a condition of enrollment 
before January 1, 2011. 
 
The contractor shall determine which enrolled suppliers are pharmacies that are not accredited 
and who will be enrolled for 5 calendar years prior to January 1 of the next calendar year.  The 
contractor shall then send a notice of revocation by January 10, 2011, to all enrolled pharmacies 
that are not accredited and who will not be enrolled for 5 calendar years as of January 1, 2011. 
 
The contractor shall prepare a letter which enables all individually enrolled practice locations of 
pharmacies who have been enrolled for 5 calendar years prior to January 1, 2011, to attest that 
they are exempt from the requirement to be accredited because their total durable medical 
equipment, prosthetics orthotics and supplies (DMEPOS) billings subject to accreditation are less 
than 5 percent of their total pharmacy sales, as determined based upon the total pharmacy sales 
of the pharmacy for the previous 3 calendar or fiscal years.  The letter shall cite that the 
attestation requires the signature of the authorized or delegated official of the entity.  The 
authorized and delegated officials are defined in Section 15, of the Medicare Enrollment 
Application (Form CMS-855S), and as described in the internet enrollment application version 
of PECOS. Before mailing the letters, contractor shall obtain the contractor project officers 
approval of the letter.  The mailing shall be in the form of an endorsement letter with an enclosed 
stamped self-addressed envelope.  The mailing should be performed between October 1, 2010 
and October 31, 2010.  For pharmacies with more than one practice location, the letters shall cite 
the need for each individually enrolled practice location to attest that they are exempt from the 
accreditation requirements.  New locations of enrolled chain pharmacies shall not be considered 
to have been enrolled for 5 calendar years.  Pharmacies that have had a change of ownership in 
the prior 5 years which resulted in a change in their legal business entity, including a change in 
their tax identification number (TIN), shall not qualify for an attestation accreditation exemption 
and therefore shall not be sent the attestation letter. 
  The contractor shall review the attestations received from pharmacies.  Pharmacies that properly 
signed the attestation letter shall be given an accreditation status of exempt.  The contractor shall 
make attempts to assist and follow-up with pharmacy suppliers that have not submitted or 
properly completed their attestations.   The contractor shall send a notice of revocation by 
January 10, 2011, to all enrolled pharmacies who were sent an attestation letter and have not 
properly completed it as of the date of the notice of revocation.  The notice of revocation shall 
cite that the revocation is for a lack of required accreditation. 
 
Between April 1, 2011 and April 30, 2011, the contractor shall compile a sample listing of at 
least 10 percent of the pharmacies that have submitted a contractor-accepted attestation 
exempting them from accreditation.  The contractor shall develop a letter to be sent to 
pharmacies that will be audited to determine if their accreditation exemption attestations are 
correct.  The letter shall request submission of evidence substantiating that the validity of the 
pharmacy suppliers attestation.  At a minimum, requested materials for this evidence shall 
include a certification by an accountant on behalf of the pharmacy or the submission of tax 
returns filed by the pharmacy during the relevant periods.  The contractor shall obtain contractor 
project officer approval of the letter.  Within 45 days after project officer approval of the letter, 
the contractor shall mail a copy of the letter to the random sample of pharmacies that claimed 
exemption through an attestation.  The contractor shall determine the acceptability of the replies 
received in response to the audit verification random sample mailing.  The contractor shall use 
DMEPOS billing data for only products and services requiring accreditation to assist in the 
determination.  The contractor shall make attempts to assist and follow-up with pharmacy 
suppliers that have not submitted or properly completed their audit verifications.  The contractor 
shall consult with the contractor project officer in cases where it is uncertain as to the 
acceptability of the suppliers response to the audit request.  By June 30, 2011, the contractor 
shall send a notice of revocation to all enrolled pharmacies that were sent an audit verification 
letter who did not submit satisfactory evidence that they were compliant with the requirements to 
obtain an accreditation exemption.  The notice of revocation shall cite that the revocation is for a 
lack of required accreditation. 
 
The contractor shall follow the procedures shown above concerning issuance of attestation letters 
and audit survey letters for all succeeding years after they have been performed for the first time. 
 
10.2.6 - Medicare Diabetes Prevention Program (MDPP) Suppliers              
(Rev. 11307; Issued: 03- 25- 2022; Effective: 03-04-22; Implementation: 04-25-22) 
 
A. General Background Information 
 
MDPP is a structured lifestyle intervention that includes dietary coaching, lifestyle intervention, 
and moderate physical activity, all with the goal of preventing the onset of diabetes in individuals 
who are pre-diabetic.  An entity or individual seeking to furnish MDPP services to Medicare 
beneficiaries must enroll as an MDPP supplier via the Form CMS-20134.  Such suppliers must 
meet the following enrollment requirements:  
    Has MDPP preliminary recognition (as defined at 42 CFR  424.205(c)(1)) or full 
recognition as determined by the Center for Disease Control and Preventions (CDC) 
Diabetes Prevention Recognition Program (DPRP) 
  Maintains a valid TIN and NPI at the organizational level 
  Passed screening requirements at a high categorical risk level per  424.518(c) upon 
initial enrollment and revalidate at the moderate categorical risk level per  424.518(b) 
and  
  Complies with the supplier standards 
MDPP supplier applicants do not require any licensure, accreditation, or certificates to be 
eligible to enroll as an MDPP supplier. Rather, the CDC administers the curriculum for the 
MDPP and monitors the organizations fidelity to and success with furnishing the services.  
Thus, organizations with preliminary or full recognition from the CDCs DPRP indicate that they 
are prepared to deliver MDPP services.  
 
As a part of the expanded CMMI model, CMS will only accept in-person MDPP suppliers to 
enroll in Medicare. Though an entity may furnish a select number of virtual MDPP make up 
sessions to a beneficiary (no more than 4 per beneficiary over the entire period of MDPP 
services), they would still be considered in-person MDPP suppliers.  
 
B.  MDPP Supplier Standards 
 
All MDPP suppliers must comply with MDPP supplier standards to obtain and retain Medicare 
billing privileges.  Consistent with 42 CFR  424.205(b)(5) and (d), each MDPP supplier must 
certify on its Form CMS-20134 enrollment application that it meets and will continue to meet the 
following standards (listed in  424.205(d)) and all other requirements: 
 
(1) Must have and maintain MDPP preliminary recognition or full CDC DPRP recognition 
(2) Must not currently have its billing privileges terminated or be excluded by a state Medicaid 
agency 
(3) Must not permit MDPP services to be furnished by or include on its roster any individual 
coach who meets the ineligibility criteria in  424.205(e)(1) 
(4) Must maintain at least one administrative location on an appropriate site. All administrative 
locations, must be reported on their CMS-20134 form and may be subject to site visits.  (See 
 424.205(d)(4) for more information regarding site requirements.) 
(5) Must update the enrollment application within 30 days for any changes of ownership, 
changes to the coach roster, and final adverse legal action history, and update all other 
changes within 90 days 
(6) Must maintain a primary business telephone that is operating at administrative locations or 
directly where services are furnished. The associated telephone number must be listed with 
the name of the business in public view. 
(7) Must not convey or reassign a supplier billing number 
(8) Must not deny an MDPP beneficiary access to MDPP services during the MDPP benefit 
period, including conditioning access to MDPP services on the basis of an MDPP  beneficiarys weight, health status, or achievement of performance goals (with certain 
exceptions described in  424.205(d)(8)(i)) 
(9) Must not---nor may other individuals or entities performing functions or services related to 
MDPP services on the MDPP supplier's behalf---directly or indirectly commit any act or 
omission, or adopt any policy that coerces or otherwise influences an MDPP beneficiarys 
decision to begin accessing MDPP services or change to a different MDPP supplier 
specifically 
(10)  Must offer an MDPP beneficiary no fewer than the services described in  424.205(d)(10) 
(11)  Must disclose detailed information about the MDPP benefit to each beneficiary to whom it 
furnishes MDPP services before the initial core session is furnished, including the set of 
services, eligibility requirements, the once-per-lifetime nature of MDPP services, and the 
standards in  424.205(d) 
(12)  Must answer MDPP beneficiaries questions about MDPP services and respond to MDPP 
related complaints.  An MDPP supplier must implement a complaint resolution protocol 
and maintain documentation of all beneficiary contact regarding such complaints, including 
the name and Medicare Beneficiary Identifier of the beneficiary, a summary of the 
complaint, related correspondences, notes of actions taken, and the names and/or NPIs of 
individuals who took such action on behalf of the MDPP supplier. This information must 
be kept at each administrative location and made available to CMS or its contractors upon 
request   
(13)  Must maintain a crosswalk file which indicates how participant identifications for the 
purposes of CDC performance data correspond to corresponding beneficiary health 
insurance claims numbers or Medicare Beneficiary Identifiers for each MDPP beneficiary.  
The MDPP supplier must submit the crosswalk file to CMS or its contractor 
(14)  Must submit performance data for MDPP beneficiaries who attend ongoing maintenance 
sessions with data elements consistent with the CDCs DPRP standards for data elements 
required for the core benefit 
(15)  Must allow CMS or its agents to conduct onsite inspections or recordkeeping reviews in 
order to ascertain the MDPP suppliers compliance with these standards, as well as the 
documentation requirements outlined  424.205(g) 
 
 
The CMS will notify the contractor when an MDPP supplier within its jurisdiction has moved 
from preliminary or full recognition down to pending and therefore no longer maintains 
eligibility as an MDPP supplier.  
 
For those suppliers that no longer have a valid recognition level to maintain their MDPP supplier 
enrollment, the contractor shall take the necessary steps to revoke the suppliers billing 
privileges. 
 
Violations of the supplier standards are determined as non-compliance and the associated 
enrolment denial and revocation authorities would apply. 
 
10.2.7 - Opioid Treatment Programs                                                                     
(Rev. 11682; Issued: 11-04-2022; Effective: 12-05-2022; Implementation: 12-05-2022) 
 
A.  Legislative and Regulatory Background   
The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for 
Patients and Communities Act (hereafter referenced as the SUPPORT Act) was designed 
to alleviate the nationwide opioid crisis by: (1) reducing the abuse and supply of opioids; (2) 
helping individuals recover from opioid addiction and supporting the families of these 
persons; and (3) establishing innovative and long-term solutions to the crisis.  Section 2005 
of the SUPPORT Act attempted to fulfill these objectives, in part, by establishing a new 
Medicare benefit category for opioid treatment programs (OTPs).   
 
An OTP is currently defined in 42 CFR  8.2 as a program or practitioner engaged in opioid 
treatment of individuals with an opioid agonist treatment medication registered under 21 
U.S.C.  823(g)(1).  There are three overarching (but not exclusive) requirements that an 
OTP must meet in order to bill for OTP services: 
 
1.  Accreditation  
 
The OTP must have a current, valid accreditation by an accrediting body or other entity approved 
by the Substance Abuse and Mental Health Services Administration (SAMHSA), the federal 
agency that oversees OTPs.  The accreditation process includes, but is not limited to, an 
accreditation survey, which involves an onsite review and evaluation of the OTP to determine 
compliance with applicable federal standards.  There are currently six SAMHSA-approved 
accreditation bodies. 
 
2.  Certification 
 
The OTP must have a current, full, valid certification by SAMHSA for such a program.  The 
prerequisites for certification (as well as the certification process itself) are addressed in 42 CFR 
8.11 and include, but are not restricted to, the following:    
 
  Current and valid accreditation (described in subsection (A)(1) above)  
  Adherence to the federal opioid treatment standards described in 42 CFR  8.12  
  Compliance with all pertinent state laws and regulations, as stated in  8.11(f)(1) 
 
Under 42 CFR 8.11(a)(3), certification is generally for a maximum 3-year period, though this 
may be extended by 1 year if an application for accreditation is pending.  SAMHSA may revoke 
or suspend an OTPs certification if any of the applicable grounds identified in 42 CFR  8.14(a) 
or (b), respectively, exist.   
 
3.  Enrollment 
 
The SUPPORT Act also required that an OTP be enrolled in the Medicare program under section 
1866(j) of the Act in order to bill and receive payment from Medicare for opioid use disorder 
treatment services. 
 
In the Calendar Year (CY) 2020 Physician Fee Schedule final rule (published in the Federal 
Register on November 15, 2019 (84 FR 62567)), CMS established a new 42 CFR  424.67 
containing requirements that OTPs must meet and continually adhere to in order to enroll (and  remain enrolled) in Medicare effective January 1, 2020.  Since this latter date, OTPs have 
enrolled in Medicare consistent with 42 CFR  424.67 and the general provider enrollment 
requirements of 42 CFR Part 424, subpart P (42 CFR  424.500-570).  This section 10.2.7 
outlines the specific enrollment policies associated with OTP enrollment. 
 
B.   OTP Enrollment Process 
 
The instructions in this section 10.2.7(B) are in addition to, and not in lieu of, those in CMS Pub. 
100-08, Program Integrity Manual (PIM), chapter 10.  To the extent there are conflicting 
instructions, the policies in this section 10.2.7 shall take precedence.    
 
1.  Applicable Form CMS-855 
 
a.  General Requirements 
 
As of November 16, 2020, OTPs may enroll (and remain enrolled) via the Form CMS-855B or 
the Form CMS-855A, but not both.  Some OTPs currently enrolled via the Form CMS-855B 
may accordingly seek to change their enrollment to a Form CMS-855A.  To ensure that the OTP 
is at no time enrolled under both Form CMS-855 application types, the contractor shall do the 
following: 
 
  Upon receipt of an initial Form CMS-855A or Form CMS 855B from an OTP, the 
contractor shall confirm that the OTP is not currently enrolled as such via another Form 
CMS-855 application type.  (For example, if the contractor receives an initial Form 
CMS-855A from an OTP, the contractor shall verify that the OTP is not already enrolled 
via the Form CMS-855B.)  
 
  If the contractor determines that the OTP is not already enrolled as such, the contractor 
shall process the application normally. 
 
  If, however, the contractor determines that the OTP is already enrolled as such via a 
different Form CMS-855 application type, the contractor shall verify with an authorized 
or delegated official of the OTP (by telephone or e-mail) that the OTP is changing its 
enrollment from a Form CMS-855B to a Form CMS-855A (or vice versa).  The OTP in 
this situation is not required to submit a Form CMS-855 application to voluntarily 
terminate its prior enrollment. 
 
The Form CMS-855B has been updated to add Opioid Treatment Program as a listed provider 
type.  (For the Form CMS-855A (at least until that form is updated), the OTP shall check the 
Other box in Section 2 and state Opioid Treatment Program.) 
 
An entity that is enrolling or is already enrolled in Medicare as another provider or supplier type 
may also seek enrollment as an OTP.  It must, however, submit a separate Form CMS-855 
application to do so; it cannot enroll or be enrolled as an OTP and another provider/supplier type 
via the same enrollment. 
  Note that the policies in this section 10.2.7 regarding an OTPs transition from a Form CMS-
855B enrollment to a Form CMS-855A enrollment (or vice versa) only apply if the OTP is doing 
so in the same state in which it is currently enrolled as an OTP.  If an OTP is enrolling under a 
different Form CMS-855 in a state different from that in which it is currently enrolled (e.g., a 
Form CMS-855B enrolled OTP in State X is enrolling via the Form CMS-855A in State Y), it is 
considered a brand new enrollment (and not merely a switch in OTP enrollment type); this 
would thus require, for instance, moderate or high-level screening as opposed to limited 
screening (as discussed further in section 10.2.7(B)(3) below).  
 
2.  Applicable Fee  
 
An OTP is an institutional provider under 42 CFR  424.502 and thus is required to pay an 
application fee pursuant to 42 CFR  424.514.  The contractor shall follow the application fee 
procedures outlined in chapter 10 of the PIM.  A fee is required even when the OTP is changing 
its enrollment from a Form CMS-855B to a Form CMS-855A, or vice versa.   
 
3.  Categorical Screening 
 
Consistent with 42 CFR  424.518, the contractor shall categorically screen OTP applications as 
follows: 
 
a.  Newly enrolling OTPs that are not changing their enrollment from a Form CMS-855B to 
a Form CMS-855A, or vice versa -  
   
  If the OTP has not been fully and continuously certified by SAMHSA since October 24, 
2018, the contractor shall conduct high-risk level categorical screening. 
 
  If the OTP has been fully and continuously certified by SAMHSA since October 24, 
2018, the contractor shall conduct moderate-risk level categorical screening. 
 
b.  Newly enrolling OTPs that are changing their enrollment from a Form CMS-855B to a 
Form CMS-855A, or vice versa - The contractor shall conduct limited-risk level 
categorical screening if the OTP had previously completed, as applicable, the moderate or 
high-risk level screening as part of its initial enrollment.  Otherwise, moderate or high-
risk level screening (as applicable under  424.518) shall be conducted. 
 
c.  Revalidating OTPs  The contractor shall conduct moderate-risk level categorical 
screening. 
 
d.  Practice Location Addition  The contractor shall conduct moderate-risk level categorical 
screening (i.e., site visit of the new location consistent with the procedures outlined in 
this chapter 10). 
 
4.  Confirmation of Certification  
  When processing OTP initial applications (including those involving a change in Form CMS-855 
application type) and revalidation applications, the contractor shall confirm and record in 
PECOS the OTPs SAMHSA certification status as follows: 
 
a.  Review the OTP directory at https://dpt2.samhsa.gov/treatment/directory.aspx.  The OTPs 
certification must be full, current, and valid.  (Provisional certification status is not 
acceptable.)  The OTPs SAMHSA certificate (and the OTPs identification in the SAMHSA 
directory) need not be have the exact same legal business name as that on the OTPs IRS 
document, though the contractor shall develop for clarification if it has questions as to 
whether the OTP on the application and in the directory are truly the same. 
 
b.  Verify that each location listed on the Form CMS-855 is separately and uniquely certified. 
 
c.  Enter into PECOS the OTPs relevant certification data obtained from the aforementioned 
OTP directory.  This includes: (1) the OTP number; and (2) the certification effective date 
(which can be obtained from the OTPs renewal letter).  The certification effective date is the 
date on which SAMHSA acknowledged notification from the accrediting organization and 
can be verified by reviewing the OTPs renewal letter information in the database.  (The 
contractor need not obtain a copy of the letter from the OTP.)   
 
The expiration date must be obtained via the SAMHSA operating certificate for the location in 
question; the OTP should submit said certificate with its application. 
 
Irrespective of whether the OTP reported the data described in (4)(c) on the Form CMS-855, the 
contractor shall use the information in the OTP directory for purposes of data entry.  
 
5.  OTP Managing Employees 
 
As with all enrolling providers and suppliers, the OTP must disclose all of its managing 
employees in Section 6 of the Form CMS-855.  Such managing employees must include the 
OTPs medical director and program sponsor, which the OTP must have pursuant to 42 CFR  
8.12(b) and  424.67(b)(5). The contractor shall verify that the medical director is a validly 
licensed physician or psychiatrist; he/she must be licensed by the state in which the OTPs 
primary practice location is situated.  The contractor may develop with the OTP for any 
information it needs (and via any manner it chooses) to verify the persons licensure.  If the 
contractor determines that the individual is not appropriately licensed, it shall contact its PEOG 
BFL for guidance. 
 
The OTP must submit a copy of the organizational diagram required under Section 5 of the Form 
CMS-855 even if it merely changing its enrollment type from a Form CMS-855B to a Form 
CMS-855A (or vice versa).   
 
6.  OTP Personnel  
 
i.  Regulatory Background 
 
Section 424.67 contains several important provisions concerning OTP personnel.  These include: 
    Completion of Attachment/Supplement ( 424.67(b)(1)(i)) - Requires the OTP to 
maintain and submit to CMS (via the applicable Form CMS-855 supplement or 
attachment) a list of all physicians, other eligible professionals, and pharmacists 
(regardless of whether the individual is a W-2 employee of the OTP) who are legally 
authorized to prescribe, order, or dispense controlled substances on the OTPs behalf.  
The list must include the individuals (1) first and last name and middle initial, (2) social 
security number, (3) NPI, and (4) license number (if applicable). 
 
  Felony Convictions ( 424.67(b)(6)(i)(A)) - The OTP must not employ or contract with a 
prescribing or ordering physician or eligible professional or with any individual legally 
authorized to dispense narcotics who, within the preceding 10 years, has been convicted 
of a federal or state felony that CMS deems detrimental to the best interests of the 
Medicare program and its beneficiaries.  The applicable felonies are based on the same 
categories of detrimental felonies (as well as case-by-case detrimental determinations) 
found at  424.535(a)(3).  (It is immaterial whether the individual is (1) currently 
dispensing narcotics at or on behalf of the OTP or (2) a W-2 employee of the OTP.) 
 
  Revoked/Preclusion List ( 424.67(b)(6)(ii)) - The OTP must not employ or contract with 
any personnel (regardless of whether the individual is a W-2 employee of the OTP) who 
is (1) revoked from Medicare under  424.535 or any other applicable section in Title 42 
or (2) on the preclusion list. 
 
  State Board Action ( 424.67(b)(6)(iii)) - The OTP must not employ or contract with any 
personnel (W-2 or otherwise) who has a prior adverse action by a state oversight board 
(including, but not limited to, a reprimand, fine, or restriction) for a case involving patient 
harm that CMS deems detrimental to the best interests of the Medicare program and its 
beneficiaries. 
 
ii.  Attachment and Verification 
 
Attachment 3 of the Form CMS-855B collects information on the individuals described in  
424.67(b)(1)(i) above.  (The Form CMS-855A will eventually be updated to include a similar 
attachment, after which OTPs completing that form will have to submit the attachment.)  OTPs 
submitting the Form CMS-855B (either the current/revised/new 07/20 version or the prior 07/11 
version) must complete this attachment as described in (and subject to) (ii)(A) below and, once 
enrolled, report any changes to the information thereon (e.g., new or deleted prescribers) 
consistent with 42 CFR  424.516(e).   
 
Irrespective of the type of transaction involved (e.g., initial, revalidation, change of information), 
the contractor shall accept from the OTP: 
 
  The revised version of the Form CMS-855B (which includes the aforementioned OTP 
attachment) beginning January 4, 2021.  
  
  The prior (07/11) version of the Form CMS-855B through March 31, 2021. (Any such 
application received by the contractor after March 31, 2021 shall be returned to the OTP 
consistent with the instructions in this chapter and other applicable CMS guidance.)   
Pursuant to the foregoing, the contractor shall adhere to the following policies and instructions in 
this section (6)(ii). 
 
(A)  When to Submit Attachment  
 
(1)  General Principles 
 
The OTP need only submit the attachment for the first time as part of (i) an initial Form CMS-
855B enrollment, (ii) a Form CMS-855B revalidation (periodic or off-cycle), or (iii) a change 
from a Form CMS-855A enrollment to a Form CMS-855B enrollment.  (For purposes of this 
requirement, the term Form CMS-855B includes the 07/20 version and the 07/11 version (the 
latter only through March 31, 2021, however).)  The OTP is not required to complete it for the 
first time as part of a change of information request.  Consider the following examples: 
 
Example 1 - Smith OTP enrolled in Medicare via the Form CMS-855B in June 2020, prior to the 
Form CMS-855B being revised to include the attachment.  Smith submits a change request in 
June 2021 to add a new billing agency.  Smith need not complete the attachment at this time 
because Smiths application does not fall within any of the three categories in (A)(i) through (iii) 
above. 
 
Example 2 - Using Example 1, suppose Smith submitted a Form CMS-855B revalidation 
application (rather than a change of information) in June 2021.  Smith would have to complete 
the attachment at that time. 
 
Example 3 - Again using Example 1, suppose Smith submitted a Form CMS-855A in March 
2021 to change its enrollment from a Form CMS-855B.  No attachment need be completed 
because the Form CMS-855A lacks an attachment and because no category in (A)(i) through (iii) 
above applies. 
 
Example 4 - Again using Example 1, assume Smith in August 2020 hired two pharmacists to 
dispense controlled substances on its behalf.  Smith would neither have to report these persons 
on the attachment nor complete the attachment in full, for no category in (A)(i) through (iii) 
above applies. 
 
Example 5  Suppose Jones OTP submits an initial enrollment application on March 1, 2021 
using the 07/11 version of the Form CMS-855B.  The contractor may accept the application, but 
the latter must include the information on the attachment.  (If a paper application is used, the 
OTP must take the attachment from the 07/20 version, complete it, and submit it with its 07/11 
application.)  If the OTP in this scenario fails to include the attachment, the contractor shall 
develop for it using the instructions in this chapter.   
 
Example 6  Using Example 5, suppose Jones enrolled as an OTP in September 2020.  It submits 
a change of information using the 07/11 version of the Form CMS-855B on February 15, 2021.  
Jones need not submit the OTP attachment with its change request because no category in (A)(i) 
through (iii) above applies. 
  Example 7  Using Example 6, assume Jones submitted its change request on April 15, 2021 
rather than February 15.  The contractor shall return the application because the 07/11 version is 
no longer in use; however, Jones need not submit the OTP attachment at that time because no 
category in (A)(i) through (iii) above applies.  
 
(2) Submission When Not Required 
 
Instances could occur where the OTP submits the Form CMS-855B attachment for the first time 
when it was not required to do so (i.e., no category in (6)(A)(i) through (iii) applies).  The two 
most likely scenarios would involve: (a) a Form CMS-855A OTP application submission (e.g., 
initial, change request); or (b) a Form CMS-855B-enrolled OTP submitting a change request.    
 
In the case of (a), the contractor shall not process the attachment and may either keep it in the 
provider file or return it to the OTP via the general procedures in this chapter for returning 
applications.  Regardless of which of the latter two approaches the contractor takes, the 
contractor shall: (i) notify the OTP that the attachment was not processed; (ii) explain why; and 
(iii) state that the attachment will need to be submitted at a later time as determined by CMS.  If 
the contractor elects to retain the attachment, the notification in (i)/(ii)/(iii) above may be given 
in any matter the contractor chooses.   
 
For (b), the contractor shall process the attachment consistent with the instructions in this section 
(6)(ii).    
 
(B) Owning/Managing Individuals - Notwithstanding (6)(ii)(A) above, any person otherwise 
required to be reported on the attachment must also be disclosed in Section 6 of the Form CMS-
855B if he or she qualifies as a 5 percent or greater owner, managing employee, partner, etc.  To 
illustrate, assume Dr. Jones prescribes controlled substances on the OTPs behalf.  He is also a 
managing employee of the OTP.  The OTP is initially enrolling in Medicare via the Form CMS-
855B.  Jones would have to be listed in Section 6 and on the attachment.  If Jones left the OTP 
altogether, the OTP would have to report this in both Section 6 and the attachment; if Jones no 
longer prescribes drugs for the OTP but remains a managing employee, this would have to be 
reported via the attachment but not in Section 6. 
 
(C) Timeframe for Changes - Additions/deletions/changes to the information in the attachment 
must be reported within 90 days of the change per 42 CFR  424.516(e)(2).   
 
(D) Missing Data - In general, the contractor shall develop (using the procedures outlined in this 
chapter) for any data that is missing or unverifiable on the attachment.  (This includes individuals 
who the contractor learns (via any means) should be listed on the attachment but were not.)  
However, and with the exception of names and social security numbers, the contractor may forgo 
such development if the missing/unverifiable information can be located and validated via other 
means.  This could include, for example: (i) the NPI of the individual (who is also a managing 
employee) is listed in Section 6 of the Form CMS-855B; or (ii) the persons license number can 
be obtained through PECOS.   
   
Note that the specific processing exception addressed in (D) applies only to OTPs.  Other 
processing exceptions applicable to other provider and supplier types (as well as to OTPs) can be 
found elsewhere in this chapter.   
(E) Validation of Individuals on Attachment - The contractor shall review all individuals listed 
on the attachment against the MED and the SAM.  (The contractor may combine this step with 
its check of the same individual if the latter is also listed in Section 6 of the form; it need not 
perform two separate reviews.)  The contractor shall contact its PEOG BFL for further guidance 
if the contractor determines or learns during its screening that the individual:  
 
  Is OIG excluded;  
  Is debarred (per the SAM);  
  Is on the preclusion list; 
  Has one of the actions described in  424.67(b)(6)(i)(A), 424.67(b)(6)(ii);  
  or  424.67(b)(6)(iii) above; or   
  Does not meet applicable requirements to prescribe, order, or dispense  
   controlled substances on the OTPs behalf.   
 
In reviewing all individuals listed on the attachment (and absent a CMS directive to the 
contrary), the contractor is not required to perform any validation activities beyond those which 
it would ordinarily perform for persons listed in Section 6.  (For example, the contractor need not 
research each person to determine (i) whether he/she is licensed, (2) what his/her license number 
is, or (3) whether he/she has ever had a fine imposed against him/her related to patient harm.)   
 
(F) Multiple Locations and Off-Site  All persons who meet the requirements of  
424.67(b)(1)(i) must be listed on the OTPs attachment regardless of where the individual is 
located (e.g., the primary practice location, one of the OTPs multiple locations, his/her home, 
etc.)  The central issue is whether the individual is authorized to act on the OTPs behalf, not 
his/her location. 
 
(G) Appropriate Attachment Sections 
 
As there is no section on the Form CMS-855B attachment specific to prescribers, such persons 
should be listed in the Ordering Personnel Identification section rather than the Dispensing 
Personnel Information section.  However, if the contractor determines that the prescriber was 
inadvertently listed in the Dispensing section, it need not require the OTP to move him/her to 
the Ordering section.  In addition: 
 
  If the person qualifies as both an ordering and dispensing individual but is only listed in 
one of the two sections of the attachment, the contractor need not require the OTP to list 
him/her in both.   
  If the person qualifies as either an ordering or dispensing individual but is listed in the 
incorrect section (e.g., a dispenser is listed in the ordering section), the contractor need 
not require the OTP to move him/her to the other section.     
 
iii. Person With Adverse Action But Need Not Be Listed on Attachment or in Section 6 
 
There may be instances where the contractor learns (via any means) that an individual described 
in  424.67(b)(6)(i)(A), 424.67(b)(6)(ii), or  424.67(b)(6)(iii) has one of the actions described  within those regulatory sections but was not required to be listed on the OTPs application (either 
on the attachment or elsewhere on the application).  Examples could include the following: 
 
  A W-2 nurse has restrictions on her license due to a patient harm case 
  A non-prescribing/non-ordering physician under contract is currently on the preclusion 
list 
  A physician assistant employee is currently revoked from Medicare. 
 
These individuals may not have met the criteria under  424.67(b)(1)(i) to be reported on the 
attachment or the OTP may not have yet been required to submit the attachment (e.g., the OTP is 
enrolled via the Form CMS-855A.)  Regardless, if the contractor becomes aware of such an 
individual, it shall contact its PEOG BFL for guidance. 
 
7.  Provider Agreement 
 
i.  Basic Requirement 
 
To enroll (and remain enrolled) in Medicare as an OTP, the OTP (including provider-based 
OTPs, as discussed in subsection (B)(9) below) must sign and adhere to the terms of the Form 
CMS-1561 Provider Agreement.  (This is the same agreement signed by certified providers such 
as hospitals, hospices, and home health agencies.  See 42 CFR Part 489, Subparts A through E 
(as well as CMS Pub. 100-07, State Operational Manual) for general information on provider 
agreements.)  Given this, the contractor shall verify that the OTP submitted a signed and dated 
Form CMS-1561 with its initial enrollment package. The provider agreement must be signed by 
an authorized or delegated official (as those terms are defined in  424.502) of the OTP; the 
signature can be handwritten or digital. This form may be accepted via mail, fax, email, or 
document upload.  The legal business name on the Form CMS-1561 must match that on the 
Form CMS-855. 
  
If the OTP failed to submit the Form CMS-1561 as described in the previous paragraph, the 
contractor shall develop for the document (or any missing or inconsistent data thereon) 
consistent with the procedures outlined in chapter 10 of the PIM. 
 
ii.   Criteria for Inapplicability 
 
The requirement to submit, sign, and date a new Form CMS-1561 does not apply if the OTP 
meets all of the following requirements: (1) the OTP is already enrolled as such in Medicare; (2) 
the OTP already has a valid Form CMS-1561 agreement in effect; and (3) the OTP is newly 
enrolling solely to change its existing Form CMS-855B enrollment to a Form CMS-855A, or 
vice versa.    
 
8.  Locations  
 
An OTP may have multiple practice locations under a single enrollment so long as they all have 
the same legal business name and employer identification number.  However, it may not split its 
locations between a Form CMS-855A enrollment and a Form CMS-855B enrollment.  All 
locations must be under one enrollment.  To illustrate, suppose an OTP is currently enrolled via  the Form CMS-855B.  It has four locations - W, X, Y, and Z.  The OTP cannot keep W and X 
under its Form CMS-855B enrollment and switch Y and Z to a Form CMS-855A enrollment.  It 
must retain all locations under the Form CMS-855B enrollment or move them all to a Form 
CMS-855A enrollment.   
 
Instances might arise where an OTP lists multiple locations on its enrollment application, and 
one or more locations do not meet full status while one or more do.  (For purposes of this 
situation, full status means that the location is separately and uniquely certified.  See sections 
10.2.7(a)(2) and (B)(4)(b) for more information.)  Here, the contractor, in lieu of denying the 
entire application, may develop with the OTP to either: (1) update the locations status (if full 
status for it has since been obtained); or (2) remove the location from the enrollment application.  
Any such development---while encouraged, is not required---shall be performed consistent with 
the procedures and timeframes outlined in this chapter.  The OTPs failure to fully and timely 
comply with the development request shall result in applications rejection. If the OTP does 
comply, the contractor can proceed as normal.   
 
9.  Provider-Based 
 
As indicated in section 10.3.1.1.13(F)(1) of this chapter, an unenrolled OTP that wishes to 
become provider-based to a hospital cannot do so via the hospitals submission of a change of 
information application that adds the OTP as a practice location.  The OTP must first enroll as an 
OTP via an initial enrollment, sign a provider agreement, undergo screening, etc.  Once the OTP 
is enrolled, the hospital may add the OTP as a practice location on its enrollment.  The situation 
is akin to that described in section 10.3.1.1.3(F)(1) regarding provider-based HHAs; section 
10.3.1.1.3(F)(1) emphasizes that the HHA must separately enroll as such.    
 
If a hospital submits an application to add-- 
 
(i) An unenrolled OTP as a practice location, the contractor shall return the change request on the 
basis of  424.526(a)(7); the OTP must submit an initial enrollment application. 
 
(ii) An enrolled OTP as a practice location, the contractor shall process the application consistent 
with the instructions in this chapter.  A separate PECOS record for the OTP site (in its capacity 
as a hospital practice location) need not be created.  Moreover: 
 
  The enrolled OTP need not sign a new/additional provider agreement 
  The hospital need not complete the attachment regarding ordering, prescribing, and 
dispensing personnel, for the attachment is only completed by OTPs.  However, if the OTPs 
addition as a provider-based location results in a change to any of the individually enrolled 
OTPs existing attachment information (e.g., new prescribers), the OTP must submit a 
change of information consistent with 42 CFR  424.516(e)(2).  Likewise, any other change 
to the OTPs individual enrollment stemming from its provider-based status (e.g., new 
ownership, change in managing employees) must be reported consistent with this chapters 
instructions as well as 42 CFR Part 424, subpart P,  424.67, and any other applicable 
regulations. 
  The contractor need not confirm that the OTP location is still SAMHSA-certified 
  The hospital must pay an application fee since it is adding a new location    The application shall be screened at the limited screening level per 42 CFR  424.518 
  Notwithstanding any other instruction to the contrary in this chapter, the contractor shall 
follow the basic process in subsection (C)(2)(a) below with respect to referring the practice 
location addition to PEOG so that a CCN can be assigned to the OTP practice location (e.g., 
include in the e-mail the hospitals and OTPs respective names, the hospitals CCN and NPI, 
and the individually enrolled OTPs CCN and NPI) 
 
C.  Approval 
 
1.  No State Agency or CMS Survey & Operations Group (SOG) Location Involvement 
 
Unlike with many entities that complete the Form CMS-855A, there is no state agency or SOG 
Location involvement with OTP Form CMS-855A enrollments.  Accordingly, no 
recommendations for approval or other type of referral need be made to the state or SOG 
Location nor will the SOG Location send any tie-in notice to the contractor.  Except as otherwise 
stated in this section 10.2.7, the application will be reviewed and handled entirely at the 
contractor level 
 
2.  Process of Approval 
 
If the contractor determines that the OTPs application should be approved, it shall undertake the 
following: 
 
a.    For Form CMS-855A applications only, request via PEMACReports@cms.hhs.gov that 
CMS assign a Form CMS-855A CCN to the enrollment.  (This task is required even if the OTP 
is merely changing its existing enrollment from a Form CMS-855B to a Form CMS-855A.)   
 
b.  As applicable (and except as stated in section (B)(7)(ii) above), send the Form CMS-1561 to 
PEMACReports@cms.hhs.gov for CMS to execute the signature on behalf of the Secretary. 
CMS will return the executed provider agreement within 3 business days.  (The tasks in 2(a) and 
2(b) can be completed via the same e-mail.) 
 
c.  As applicable, send a copy of the executed provider agreement to the OTP along with the 
enrollment approval letter.  (The contractor shall retain the original provider agreement.)   
 
3.  Effective Date of Billing 
 
For newly enrolling OTPs that are not changing their enrollment from a Form CMS-855B to a 
Form CMS-855A (or vice versa), the contractor shall apply the effective date policies outlined in 
42 CFR  424.520(d) and 424.521(a) and explained in chapter 10 of the PIM.    
 
For newly enrolling OTPs that are changing their enrollment from a Form CMS-855B to a Form 
CMS-855A (or vice versa), the contractor shall apply to the new/changed enrollment the same 
effective date of billing that was applied to the OTPs initial/former enrollment.  (See 42 CFR  
424.67(c)(2).)  To illustrate, suppose an OTP initially enrolled via the Form CMS-855B in 2020. 
The effective date of billing was April 1, 2020.  Wishing to submit an 837I claim form for the 
services it has provided since April 1, 2020 the OTP elects to end its Form CMS-855B  enrollment and enroll via the Form CMS-855A pursuant.  It successfully does the latter in March 
2021.  Under  424.67(c)(2), the billing effective date of the Form CMS-855A enrollment would 
be retroactive to April 1, 2020 (though the time limits for filing claims found in  424.44 would 
continue to apply).   
 
4.   In cases where the OTP is changing its Form CMS-855 enrollment type, the contractor shall 
do the following:  
 
a.  End-date/deactivate the prior enrollment effective: (1) the date following that on which the 
OTP submitted its last claim under its prior enrollment; or (2) the prior enrollments effective 
date of billing if no claims were submitted under the prior enrollment.  The PECOS L & T basis 
shall be Voluntary Termination.  The deactivation reason shall be Voluntary withdrawal: 
Applicant voluntarily withdrew from Medicare program. 
 
b.  Notify the OTP in the approval letter that the OTPs prior enrollment has been end-
dated/deactivated and specify said end-date.   
 
 
10.2.8 - Providers/Suppliers Not Eligible to Enroll 
(Rev. 11307; Issued: 03- 25-2022; Effective: 03-04-22; Implementation: 04-25-22) 
 
Below is a list of individuals and entities that frequently attempt to enroll in Medicare but are not 
eligible to do so. (This list is not all-inclusive, however.).  If the contractor receives an 
enrollment application from any of these individuals or entities, the contractor shall deny the 
application -- with the exception of entities eligible to enroll using the Form CMS-20134, which 
is specific to the furnishing of MDPP services.  An assisted living facility, for example, that also 
provides the DPP and is eligible to enroll as an MDPP supplier may enroll through the CMS-
20134; however, this enrollment only pertains to the rendering of MDPP services.   
 
  Acupuncturist 
  Assisted Living Facility 
  Birthing Center 
  Certified Alcohol and Drug Counselor 
  Certified Social Worker 
  Drug and Alcohol Rehabilitation Counselor 
  Hearing Aid Center/Dealer 
  Intern (Graduate Medical Education) 
  Licensed Alcoholic and Drug Counselor 
  Licensed Massage Therapist  
  Licensed Practical Nurse  
  Licensed Professional Counselor 
  Marriage Family Therapist  
  Master of Social Work 
  Medicare Beneficiaries 
  Mental Health Counselor 
  National Certified Counselor    Naturopath 
  Occupational Therapist Assistant 
  Physical Therapist Assistant 
  Registered Nurse 
  Speech and Hearing Center 
  State Medicaid Agency (SMA)(SMAs do not have an NPI and are not eligible to enroll in the 
Medicare program.  If an SMA is enrolled or seeks enrollment as a provider or supplier in the 
Medicare program, the contractor shall deny or revoke its Medicare billing privileges using, 
respectively,  424.530(a)(5)(ii) (denials) and  424.535(a)(5)(ii) (revocations) as the basis.) 
  Substance Abuse Facility 
 
10.3  Medicare Enrollment Forms  Information, Processing, and PECOS 
2.0  
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
Sections 10.3, 10.3.1, 10.3.2 and 10.3.3 of this chapter provide guidance and information 
regarding the processing of provider enrollment forms.  They also include new verification and 
operational instructions pertaining to the implementation of PECOS 2.0.  Upon the 
implementation of PECOS 2.0 (and except as stated otherwise), said instructions in sections 10.3 
through 10.3.3 take precedence over all other contrary guidance in this chapter.  For more 
detailed information concerning the contractors logistical navigation of the PECOS 2.0 system, 
the contractor can consult the PECOS 2.0 Knowledge Base (available within PECOS) and 
other technical direction. 
 
Section 10.3 discusses the basic processes, capabilities, and policies associated with PECOS 2.0.  
The contractor shall adhere to the instructions in 10.3 when processing the applications described 
in sections 10.3.1 through 10.3.3. 
 
A.  PECOS 2.0 General Process 
 
Except as otherwise specified by CMS, PECOS 2.0 automatically processes all web-based 
applications upon submission as well as all paper applications after the contractor performs 
intake actions (e.g., entering the paper-submitted data into PECOS).  (This includes all CMS-
855, CMS-20134, CMS-588, and CMS-460 forms, and irrespective of the type of enrollment 
transaction involved (e.g., initial applications, change requests.)  In general, PECOS 2.0 will only 
halt the automated process: (a) for more complex application situations (e.g., changes of 
ownership); or (b) if the contractor must manually perform certain verification activities (e.g., 
review of adverse action documentation).  Upon this stoppage: 
 
(i)  The application exits the automatic process and requires the contractor to manually intervene.   
 
(ii) PECOS 2.0 creates a list that outlines the verifications/checks performed and when they 
occurred.   
 
For web-based applications, providers and suppliers must upload all required documentation, 
submit all signatures, and pay an application fee or submit a hardship request before submitting  the application.  PECOS requires the application (including the Form CMS-588 and Form CMS-
460) to be 100% complete before the provider/supplier submits it.  This reduces the amount of 
development the contractor must undertake.  In addition, PECOS notifies the contractor of any 
change in the status of an application, which helps expedite processing.    
 
(Note that PECOS 2.0 will also conduct certain validations/checks for paper applications after 
the contractor completes its data entry of the providers or suppliers application information.) 
 
B.  Important Aspects of PECOS 2.0  
  
This subsection (B) discusses various aspects of PECOS 2.0s capabilities and other concepts 
and instructions related thereto.  (For purposes of the remainder of section 10.3 and of section 
10.3.1, the term PECOS means PECOS 2.0 (although PECOS 2.0 will still occasionally be 
used) and the term PECOS applications means web-based applications.)  
 
1.  Verification  
 
Some of the Form CMS-855/20134 application data elements and other enrollment functions that 
will be part of PECOSs verification/operational capabilities are:  
  
(i) Validation of Social Security Numbers (SSN) (though PECOS will not verify employer 
identification numbers (EIN) with the IRS) 
 
(ii) Validation of National Provider Identifiers (NPI) 
 
(iii) Performing Delivery Point Verification  
 
(iv) Review of the Death Master File (DMF)  
 
(v) Reviewing for Office of Inspector General (OIG) exclusions per the Medicare Exclusions 
Database (MED) (Note that if the System for Award Management (SAM) is not part of PECOSs 
or APSs verifications, the contractor must perform SAM reviews manually.) 
 
(vi) Checking whether an active reenrollment bar exists.  (PECOS maintains the reenrollment bar 
list.  For each individual or entity added to an application, PECOS will perform a processing 
check.)) 
 
(vii) Inclusion of high-risk screening list and all other CMS generated lists (e.g., overpayments, 
affiliations, Medicaid terminations) 
 
(viii) Facilitation and verification of application fee payment 
 
(ix) Ordering site visit and fingerprinting 
 
(x) Reviewing licensure status via APS.  (Note that the contractor may rely on APS licensure 
verification in limited scenarios, including revalidation and some changes of information. See  subsection (B)(8) below for more information on licensure.)  However, the contractor must still 
manually check for certifications, such as for non-physician practitioners.   
 
(xi) Criminal background (e.g., the contractor need not click into APS)   
 
(xii) Complete automated processing of revalidation applications that do not include any changed 
information and the application is e-signed 
 
(xiii) Excluding CMS Certification Numbers (CCNs) for certified providers/suppliers, generation 
and management of provider transaction access numbers (PTANs) as needed.  (PECOS can 
allocate locality information as well as determine how many PTANs are required for the 
enrollment situation in question and the associated effective date(s).  The contractor can make 
edits as warranted and consistent with CMS policy.)    
 
Except as otherwise specified in current or future CMS guidance, the contractor must manually 
handle all other validation and processing activities not referenced in (i) through (xiii) above.  As 
previously indicated, and after performing validations, PECOS will identify for the contractor 
those data elements requiring manual intervention because the data element (e.g., EIN, certain 
adverse actions, legal business name, certifications) is not one that PECOS checks.  Moreover, 
automatic processing only occurs with applications for which PECOS has not identified errors 
(e.g., additional screening needed, unverified addresses, etc.).  If errors exist and/or the 
application cannot otherwise be automatically processed further, PECOS reverts to manual 
processing and notifies the contractor thereof.    
 
If the contractor manually corrects a data element that PECOS could not validate, PECOS 
attempts to reverify said data; the contractor need not manually perform this task.  
 
2.  Documentation 
 
a.   Basic Principle  
 
As a general rule (and for both web and paper applications), the provider/supplier need not 
submit documentation unless either of the following instances applies: 
 
i.  All other means the contractor is authorized to use (per this chapter) for validating the 
information have been exhausted (e.g., licensure web sites, state board web sites, APS, etc.) 
AND the supplier has not previously submitted said documentation in PECOS 1.0 or 2.0 (e.g., as 
part of a prior revalidation); OR 
 
ii. The provider/supplier is furnishing or changing data for which this chapter specifically and 
unequivocally requires the submission of documentation to validate (e.g., adverse legal action  documentation per section 10.6.6) AND the supplier has not previously submitted said 
documentation in PECOS 1.0 or 2.0.   
 
The above principle applies to all application types and transactions and notwithstanding any 
other instruction to the contrary in this chapter.   
 
Note that documents that have been uploaded into PECOS 1.0 will be migrated to PECOS 2.0. 
 
b.  Operational Procedures When Documentation Is Required 
 
i.  PECOS Applications  As mentioned earlier, providers/suppliers must upload required 
documentation before submitting the application.  However, because PECOS cannot read 
documents or verify their exact contents, the contractor shall manually review and confirm the 
type and contents of the submitted document.  Once this confirmation occurs, the contractor need 
not reverify the document when subsequent applications are submitted unless information 
relative to that document has changed.  
 
Except as stated in subsection (2)(a) above, a provider/supplier submitting a web application 
need not upload required documentation if it has previously submitted that document.  The 
provider/supplier will be able to see the document in question in its PECOS record and select and 
apply that document to its current application.   
 
ii.  Paper Applications - The provider/supplier shall mail, fax, or e-mail such documentation with 
its application.   The contractor shall upload received documentation into PECOS when 
processing the application; each document, however, must be separately uploaded (e.g., the Form 
CMS-855 CHOW application must be uploaded separately from the sales agreement).   For 
paper applications (including initial enrollments), if the provider failed to submit required 
documentation, the contractor shall review the provider/suppliers enrollment record to see if the 
provider/supplier previously submitted the document with a prior application.  If it was 
previously submitted, the contractor shall apply the document to the current application without 
developing for it with the provider/supplier.  If it was not previously submitted, the contractor 
shall develop for it.    
 
iii.  Documentation Classification  
 
When documentation is uploaded into PECOS by the provider/supplier (PECOS applications) or 
the contractor (paper applications), the contractor shall ensure that, as applicable: 
 
  Each document is uploaded in the application section with which it is most closely associated 
(e.g., criminal conviction documentation in the final adverse action section; IDTF technician 
certifications in the IDTF section).  
 
  If the provider/supplier submits one file containing different document types (e.g., a CP-575, 
an ownership chart), each document type within said file is separated and uploaded in its 
appropriate application section (per the prior bullet).    
  If the provider/supplier does not submit its documents consistent with the practices in the two 
above bullets, the contractor shall remedy the issue itself without requesting the 
provider/supplier to do so.   
 
Note that each page within a multi-page document need not be separately and individually 
uploaded in its own file.  The document and all of the pages therein can be uploaded as a single, 
combined file.   
 
3.  Correspondence and Coordination  PECOS Applications Only  
 
a.  General Concept  
 
Except as otherwise permitted or specified in sections 10.3.1 through 10.3.3, the contractor shall 
send written enrollment-related correspondence to the provider/supplier via PECOS (hereafter 
sometimes referenced as the PECOS Communication Vehicle (PCV)). This includes most types 
of provider-contractor correspondence, such as emails, revalidation requests, development 
requests, approval letters, etc.  PECOS will store all such correspondence.  Certain written 
communications, however, cannot be made through the PCV at this point; in such situations, the 
contractor shall: (1) follow current procedures for sending/receiving such communications; and 
(2) manually upload a copy of the written correspondence to the related application in PECOS.   
 
b.  Telephonic Communications  
 
It is emphasized that nothing in sections 10.3 through 10.3.3 precludes the use of telephonic 
communication/development (including for web applications) with the provider/supplier if it is 
otherwise permitted under these sections. However, the contractor shall document such 
telephonic communications in PECOS Application Timeline with the same data elements as 
those required under section 10.6.19(L) of this chapter. 
 
4.  Party Relationships  
 
a.  Consolidated Applications and National Entity Profiles  
  
In PECOS 2.0, individuals and organizations will have National Entity Profiles (hereafter 
Profile(s) or National Profile(s)) that are unique by legal name, tax identification number, 
and ownership. (This is similar to the associate profile in legacy PECOS, the difference being 
that an entitys ownership information and other data unique to that organization is shared at the 
National Profile level in PECOS 2.0.)  A partys National Profile will show Medicare enrollment 
record(s) for each of their provider/supplier types (e.g., ABC, Inc. will have one National Profile 
that includes 3 separate Medicare enrollment records: one for its clinic/group, one for its durable 
medical equipment (DME) enrollment, and one for its IDTF enrollment).  All such records will 
be grouped by provider/supplier type due to differences in data collection and/or processing 
requirements.   
  
Under PECOS 2.0, a provider/supplier can submit one consolidated application per 
provider/supplier type; said application will be split such that it results in the submission of one  application to each contractor jurisdiction per provider/supplier type group.  Consider the 
following examples: 
  
EXAMPLE A: A group practice exists in Nebraska, Iowa, and Missouri, all of which are in the 
same contractor jurisdiction.  Here: (1) only one application is submitted to the contractor as 
opposed to three (one for each state); and (2) for inventory purposes, this will constitute only one 
application (not three).  (Note that the contractor need only send one determination letter 
(approval, denial, etc.) to the group practice even though three states are involved.  This is 
because only one application was submitted.) 
  
EXAMPLE B: A group practice exists in Ohio, Pennsylvania, and West Virginia, each of which 
are in separate contractor jurisdictions.  Here, the group may submit a consolidated application 
for all three enrollments, which PECOS would then split into three separate applications because 
there are three separate contractor jurisdictions.  (In this example, the fact that there are three 
separate states involved is largely irrelevant for application submission purposes.  The central 
consideration is the number of contractor jurisdictions.) 
 
EXAMPLE C: An organization has a group practice and an IDTF in one contractor jurisdiction.  
The entity must submit two applications because the clinic and IDTF are two distinct 
provider/supplier types and the enrollments are therefore grouped separately.  
 
(Regarding Example C, note that a physician/practitioner can change a specialty within its broad 
supplier type category via PECOS 2.0 (e.g., changing from a nurse practitioner to a physician 
assistant).  However (and as with the aforementioned group-IDTF scenario), a physician cannot 
change his/her enrollment to that of an NPP, or vice versa, by this means absent a new 
enrollment.)    
 
National Profile (or global) data is only screened when changed.  This means that global 
information is not rescreened each time the provider/supplier submits an application pertaining to 
an enrollment record under/within that National Profile.  In a similar vein, though, changes to 
National Profile information (e.g., legal business names (LBN), ownership) made on a single 
application are applied to all of the provider/suppliers enrollments.  That is, an authorized or 
delegated official can make changes to National Profile information for numerous and associated 
providers/suppliers at one time, whereas data changes that are specific to a unique enrollment 
only apply to that enrollment.  An illustration follows: 
 
EXAMPLE D: Suppose 20 separately enrolled IDTFs have four common owners: W, X, Y, and 
Z. W sells its 25 percent interest to V.  Under PECOS, this change can be reported via a 
single/consolidated application submission.  Twenty separate submissions are unnecessary.  Now 
assume that two of these group practices are changing their respective addresses.  Here, the 
entity must submit an application that indicates the two separate change requests because the 
practice location data is unique to each enrollment  
 
Once the consolidated application has been processed and finalized, PECOS creates/updates all 
applicable individual enrollment records as though a single application had been submitted for 
each. 
  Though providers/suppliers may submit consolidated applications that update multiple 
enrollments of the same provider/supplier type or grouping, they still remain free to submit 
separate/individual applications for each enrollment.  
 
When the provider/supplier is making a National Profile level change and that profile has 
multiple enrollments, the provider/supplier must check the box in PECOS confirming that it 
understands that this change: (1) is related to the National Profile for (XYY) with (TIN 123); and 
(2) will accordingly update all of the providers/suppliers other active Medicare enrollments 
within PECOS, regardless of what is shown on this particular application.  (This is sometimes 
labeled an indirect enrollment record update (IERU).  With a National Profile level change that 
revises an enrollment record, PECOS may notify the provider/supplier (typically the contact 
person or the correspondence address) of the IERU. 
 
b.  Consolidated Application Exceptions 
 
(i)  Providers/suppliers may only submit one type of provider enrollment transaction in a 
consolidated application (e.g., the provider cannot submit a consolidated application to reactivate 
the billing privileges of three of its enrolled suppliers and to report a CHOW involving two of its 
enrolled providers).    
 
(ii) Initial enrollments for certain provider/supplier types (e.g., certified providers) cannot be 
submitted via a consolidated application.   
 
(iii) DMEPOS suppliers may be limited in the number of individual enrollments than can be 
included in a consolidated application.   
 
(iv) Consolidated applications are only for PECOS applications, not paper applications; that is, 
consolidated applications cannot be submitted via paper 
 
c.  Associations 
 
Certain types of relationships (excluding ownership and management relationships) between 
enrolled persons and organizations in PECOS are labeled associations.  (This is not to be 
confused with the definition of affiliation in  424.502 for purposes of  424.519.)  These 
associations/relationships frequently involve: (1) reassignors and reassignees; (2) IDTFs and 
supervising physicians; and (3) CAH II relationships.  In all cases, both parties in the relationship 
must be enrolled for the affiliation to exist.  The purpose of the association designation is to 
give a formal label to certain types of relationships for PECOS purposes. 
 
d.   Signatures  
 
i.   General Policy - If an application is submitted that will create multiple enrollments or 
enrollment records and the signer is authorized to sign all enrollments, the applications signature 
will be automatically applied to the other enrollments. 
 
ii.  Authorized Officials 
  In a consolidated application with multiple enrollments, an authorized official can only sign for 
those enrollments for which he/she is on record as an authorized official.  To illustrate, suppose a 
consolidated application contains enrollments in Pennsylvania and Ohio.  Ms. Smith is listed as 
an authorized official for the Pennsylvania enrollment but not the Ohio enrollment.  Ms. Smith 
therefore cannot serve as an authorized official for the latter.    
 
e.  Multiple Contractor Involvement  
 
As already referenced, situations will arise where a submitted consolidated application that 
changes National Profile information impacts multiple contractors.  (To illustrate, a provider that 
is enrolled in three contractor jurisdictions (X, Y, Z) might submit a consolidated application to 
change its DBA name.)  The contractor shall observe that: 
 
(i)  Each contractor is responsible for processing the application it receives.  It cannot rely on one 
of the other affected contractors to process all of the applications.  Using our above 
illustration, X must process the application it received that is unique to its jurisdiction, Y 
must process the application specific to its jurisdiction, and so forth.   
(ii)  The term processing in (i) above includes, but it not limited to, verifying data, developing 
for clarifying information, approving/denying the application, etc.  Thus, for example, 
Contractor X cannot rely exclusively on Contractor Ys verifications without attempting to 
validate the same data concerning the Contractor X application.  Nor can Contractor Y use 
Contractor Xs development letter to solicit the same data.  Each application in this situation 
stands alone on its own merits and must be handled separately (e.g., each contractor must: (a) 
make its own determination (approval, denial, etc.) regarding the application it is processing; 
(b) send its own approval/denial/rejection letter; (c) develop for clarifying data pertaining to 
its application; and (d) process its application consistent with applicable timeliness 
requirements).   
  
5.  Letter Generation  
 
i.  Automation 
 
Except as stated in subsection (5)(ii) below and as otherwise stated in this section 10.3, PECOS 
generates and sends to the provider/supplier all required letters (e.g., approval letters under 
section 10.7 et seq. of this chapter), though the contractor must manually select which letter must 
be sent.  Note that each letter will have an issue date that signifies both (1) the date of the letter 
and (2) the date it is sent.  The contractor shall treat this issue date as the date of letter and  date sent for purposes of establishing applicable effective dates, the conclusion of development 
periods, and other timeframes that are based on the letter date or sent date.  
 
ii.  Exceptions to Automated Letter Process 
 
There may be isolated instances when the contractor has to produce and/or send letters outside of 
PECOS.  This could include, for example: 
 
   PECOS can produce most letters requiring certified mail, but the contractor must manually 
print and send them 
   The letter type is not available in PECOS 
 
(Note that the contractor can always override a particular automated letter creation and 
upload/use a different letter.)  
 
For letters the contractor must prepare and/or send outside of PECOS, the contractor shall ensure 
that: (1) the letter has an issue date consistent with subsection (5)(i) above; and (2) it uploads a 
copy of the letter to PECOS.  Except for certified letters (which must be mailed via hard-copy), 
the contractor may send the letter via mail, e-mail, fax, or the PCV, although the PCV is very 
highly preferred if the printed letter can be uploaded into PECOS and sent via this means. 
 
The date of the letter is the date on which the letter was created.  The issue date is the date 
on which the letter was sent.  For letters that PECOS sends (see subsection (5)(i) above), the 
letter and issue dates will be the same.  For the letters discussed in subsection (5)(ii), however, 
they may be different (i.e., the contractor may send the letter the day after it is created).    
 
6.  Site Visits and Application Fees 
 
a.  Site Visits (SVs) -  
 
i.   General Principle 
 
All SVs are ordered via PECOS, and all SV results (with photos) are entered/uploaded into said 
system.  The National SV Contractor(s): (i) completes SV requests directly in PECOS; or (ii) 
receives the request from PECOS and sends the full SV record back to PECOS from its system 
when complete.  They either are ordered for and attached to the relevant application or they 
occur ad-hoc.  However, the contractor must still review the site visit results and indicate 
pass/fail, consistent with existing instructions. 
 
PECOS can identify a completed/passed site visit within the previous 12 months so that a new 
site visit is unnecessary. 
 
ii.  Ordering 
 
  PECOS Applications  PECOS will automatically order a site visit (if one is required) only 
in the following situations: 
  (A) An initial application (excluding HHAs) 
(B) Excluding certified providers/suppliers, a change of information or revalidation 
application if the provider/supplier is currently in the high or moderate screening level 
and the practice location in question has not passed a site visit within the previous 12 
months. 
 
Notwithstanding the foregoing, the contractor can manually intervene to postpone or cancel this 
site visit if warranted under the circumstances (and consistent with the instructions in this 
chapter). 
 
For all other situations not referenced in subsection (ii)(A) and (B) above, the contractor must 
manually order the site visit. 
 
  Paper Applications  The contractor must manually order the site visit if one is required. 
b.  Application Fees 
 
 
Application fees can be combined if multiple enrollment records are implicated by the 
submission (e.g., consolidated application), but each application still requires a separate fee.  To 
illustrate, suppose an entity is enrolling 5 different IDTFs, and the fee amount is $631 per IDTF.  
The provider can submit separate $631 fees or can combine them into a single $3,155 payment. 
In the case of hardship waivers, however, 5 separate hardship waivers  one for each enrollment 
 must be submitted; they cannot be combined into one waiver request. 
   
In addition:  
 
  If the provider/supplier is submitting an application requiring a fee, PECOS will 
automatically indicate the appropriate fee amount.   
  For consolidated applications in which multiple fees are required, the provider/supplier can 
remove an enrollment record from its submission (e.g., the provider wishes to rescind its 
prospective enrollment because the fee amount is excessive), PECOS will correspondingly 
reduce the required total fee amount.  If the provider/supplier does this after it has paid the 
fee, it can request a refund via the instructions in this chapter.   
  If the provider/supplier makes an out of bound fee payment (that is, a payment outside of 
the application submission), the provider/supplier can apply the fee(s) to its application by 
entering Pay.gov tracking IDs. 
  Providers/suppliers can request hardship waivers directly via PECOS. 
  Fee refunds shall continue to be processed consistent with existing instructions. 
 
7.  Application Re-Routing and Returns 
 
For web applications incorrectly sent to the contractor, the latter can re-route the application to 
the correct contractor via PECOS.  For paper applications incorrectly sent to the contractor (and 
unless otherwise stated in this chapter or in another CMS directive), the contractor may return 
the application per 42 CFR  424.526 without completing application intake.    
  PECOS cannot independently determine whether an application should be returned (e.g., initial 
Form CMS-855A application submitted more than 180 days prior to the effective date).  The 
contractor must make this assessment. 
 
8.  Licensure 
 
As already mentioned, APS will present to the contractor its review of the provider/suppliers 
licensure status.  In some cases, however, the contractor will have to also manually verify the 
provider/suppliers licensure using an original source, such as a state licensing board website.  In 
this regard, the contractor shall adhere to the following: 
 
  Applications Other Than Initial Enrollments and Reactivations  The contractor need not 
review licensure original sources if all three of the following requirements are met: (1) all of 
the licensure information on the application (regardless of the datas materiality) matches that 
shown in APS (e.g., same name, active status); (2) the license contains no restrictions or 
qualifiers insofar as the contractor can determine from the application and the APS review; 
and (3) it is otherwise clear to the contractor that the provider/supplier is appropriately 
licensed. 
  Applications Other Than Initial Enrollments and Reactivations -- If any of the three criteria 
in the previous bullet are not met OR the contractor is in any way uncertain as to whether the 
provider/supplier is appropriately licensed, the contractor shall review an original source. 
(Note that the data match between APS and that on the application must be 100%, regardless 
of the materiality of the data or the extent of the discrepancy.  Even if there is a slight 
difference in the individuals name, an original source must be reviewed.)   
  Initial Enrollment Applications and Reactivations  The contractor shall use an original 
source to verify licensure notwithstanding the APS results. 
 
In all cases, the contractor shall ensure that all licensure reviews required under this chapter are 
performed.  If licensure is not required for the provider/supplier, the contractor shall treat this in 
PECOS as a situation where the provider/supplier passed the licensure review. 
 
APS will display all licensure information relevant to the enrollment that the contractor is 
processing.  It is possible, though, that licensure data may appear involving enrollments and 
parties other than those under review.  The contractor need only take action based on licenses 
related to the specific enrollment being processed.   
 
C.  Impact on Application Transaction Types and Formats 
 
This subsection (C) addresses certain PECOS functions, capabilities, and policies regarding 
specific enrollment-related transactions, application types, and application formats (e.g., web, 
paper), including associated signature requirements.   
 
1.   Revalidations  
  
Except as otherwise described in this chapter, PECOS automatically handles revalidation 
requests, tracking, and correspondence.  It also prevents the submission of web applications 
outside of the revalidation window. PECOS establishes timeframes and then queues mailings  based on revalidation history and enrollment dates, although CMS can modify timeframes and 
request off-cycle revalidations at any time.  Failure to respond to a revalidation request would 
result in, as applicable to the situation, an automatic pend, deactivation, etc.   
 
2.  Form CMS-588/Electronic Funds Transfer (EFT)/Multi-Carrier System (MCS)/Special 
Payment Addresses 
 
Under PECOS: 
 
a.  All EFT information (including bank account data) must be entered, processed, and stored in 
PECOS.  The contractor shall no longer use the shared system to enter bank information. 
 
b.  All MCS transactions related to provider enrollment shall be entered into and updated through 
PECOS.  This includes provider codes, options, do not forward (DNF), effective periods, 
linkages to PTANs, banking, etc. 
 
c.  The contractor shall continue to follow the instructions in section 10.6.23 of this chapter 10. 
 
d.  Notwithstanding any other instruction in this subsection (C)(2), the contractor need not 
undertake pre-notification review of an EFT account if the latter already exists under the 
provider/suppliers TIN and the provider/supplier is merely adding it to a new enrollment under 
that same TIN.  
 
3.  Reassignments  
 
a.  General Principle 
 
As stated earlier, PECOS automatically processes reassignments received online; this includes 
preventing a supplier from reassigning benefits to an ineligible party. 
 
b.  Location Group Assignment  When establishing a reassignment for PECOS applications, the 
provider/supplier must determine and select which Locations Groups of the clinic/group at 
which the provider/supplier will be performing services (i.e., billing from); this will help support 
proper PTAN assignment.  For paper applications, however, the contractor must make the 
aforementioned determination based strictly on the information submitted (i.e., without 
development on this specific issue); such data could include, for instance, the reported primary 
and secondary practice locations and information that the group submitted.  
 
4.  Form CMS-855O and Form CMS-855I Conversions and Terminations 
 
If a supplier who is enrolled via the Form CMS-855I or Form CMS-855O submits, respectively, 
a web Form CMS-855O or a web Form CMS-855I to change his/her enrollment, the supplier 
need not terminate his/her prior enrollment.  PECOS 2.0 performs this function.  (This only 
applies to web applications.)   
 
5.  Certified Provider/Supplier Application  State Involvement  
  The contractor cannot send/email documents, approval recommendation packages, etc., to the 
states, accrediting organizations (AO), and SOG Locations via PECOS.  Said materials shall 
continue to be sent via the Box system consistent with existing policy. (States, AOs, and the 
SOG Locations do not have access to PECOS.)  However, certain other components of the 
survey/certification process are handled/managed through PECOS.  This includes, but is not 
limited to: (1) tracking applications sent to the state; and (2) storing and/or generating approval 
letters to and from the state. 
 
6.  Appeals and Rebuttals 
 
Appeals and rebuttals are stored in PECOS.  The contractor can process the appeal/rebuttal via 
PECOS and, as applicable, revise the enrollment record based on the appeal/rebuttal decision. 
 
If the contractor receives an appeal that should have instead been sent to CMS, the contractor 
shall enter the appeals data into PECOS and forward the appeal to CMS consistent with existing 
instructions.  
 
The provider cannot submit appeals and rebuttals via PECOS. 
 
7.  Web vs. Paper Applications 
 
a.  Paper Applications  
The contractor shall: (i) enter into PECOS the basic information about a received application (a 
process called intake) such that PECOS can send a confirmation correspondence and, if 
applicable, associate the application with an existing enrollment; and (ii) upload into PECOS any 
images of the paper application and/or all supporting documentation.  Note that these tasks do 
not constitute the creation of a web-based application.  Providers/suppliers submitting paper 
applications: 
  Must use fillable versions thereof, meaning the information cannot be handwritten.  (This 
includes situations where the provider/supplier is submitting an application page pursuant to 
a development request; the page must be from a fillable application.  If the provider/supplier 
submits a handwritten application or page, the contractor shall develop for a fillable one 
rather than return the application, though intake shall still be completed.)  Note that this 
requirement applies: 
  To all CMS applications for which a fillable version thereof is available (e.g., CMS-588), 
o
including situations where the provider must submit corrected/revised pages of the 
application pursuant to a development request 
  Only to CMS form applications and not to (i) supporting documentation or (ii) responses 
o
to development requests not involving the submission of corrected/revised application 
pages (e.g., supporting documentation need not be in a fillable format). 
  Must submit the application via mail 
  Will receive correspondence via the PCV.  (However, the provider/supplier must still submit 
any additional materials related to its application (e.g., application pages, supporting 
documents) via paper.)  One hundred percent (100%) of paper applications and appeals/rebuttals/CAPs (regardless of 
type (A/B/I) or transaction (initial/change of information)) must be entered into PECOS within 
two business days of receipt.  This includes uploading all hard copies of received 
applications/appeals/rebuttals and attachments into PECOS.   
 
The minimum data elements that must be part of the contractors intake are: 
 
  Type of document (application or supporting document) 
  Date of Receipt 
  Method of receipt (mail, email, fax, upload) 
  Application type 
  Submission reason (initial, change, revalidation) 
  State 
  Name 
  TIN 
  DCN 
 
(Regarding the intake of attachments and supporting documentation, the contractor need not 
separate the documents (or pages of documents) within the 2-business day period if they are 
submitted in bulk.  Only the bulk document need be uploaded.)  
 
b.  Signatures  
 
For paper applications, handwritten (wet) signatures in ink and digital/electronic signatures 
(digital or electronic signatures such as those created by digital signature options, such as Adobe) 
are acceptable.  For web applications, electronic signatures are required. 
 
Given the advent of PECOS 2.0, certain previous certification statement instructions pertaining 
to Internet-based PECOS applications are no longer applicable (e.g., the ability to submit paper 
certification statements after submission).  In addition, because certification statements must be 
signed before the application is submitted, there will be much less need for the contractor to 
develop for them.  Nevertheless, the contractor must still verify signatures consistent with the 
instructions in this chapter.) 
 
c.  Web and Paper Usage  
 
A provider/supplier that submits a web application is not prohibited from submitting future 
enrollment applications via paper.  Likewise, a provider/supplier that submitted its initial 
application via paper may always submit future applications via web.  In each scenario, the 
contractor shall follow the instructions in this section 10.3 et seq. that are applicable to the type 
of application (PECOS vs. paper) that was submitted.  For instance, suppose a provider 
previously submitted its initial application via web and now submits a paper change of 
information request.  The contractor shall upload the submission into PECOS, develop for any  missing or unsigned/undated certification statement, avail itself of any processing alternatives 
that are applicable to paper applications, etc. 
 
Notwithstanding the above, when the provider/supplier submits a web application, any updates to 
the application---such as, for example, pursuant to a development request or the submission of 
additional documentation---before the application is processed to conclusion (e.g., approved, 
denied, rejected) must be via PECOS.  The provider/supplier cannot submit its update via paper. 
 
d.  Documents Received Outside of Application Submissions 
 
The contractor may receive documents unrelated to a particular application submission, appeal, 
or rebuttal.  This could include, for example, a W-9, a new CLIA certificate, an updated license, 
a surety bond cancellation notice, an FDA certification, a CMS-460, insurance documents, etc.  
These documents must be uploaded into PECOS consistent with the instructions in this section 
10.3 et al. and the timeframe described in section 10.3(C)(7)(a). 
 
8.  Business and Practice Location Names/Assignments 
 
The DBA name and Other name data fields are not required in PECOS.  If the 
provider/supplier nevertheless submits this data, the other name/DBA name should be at the 
organization level while the name at the practice location level should be, in effect, the name on 
the locations front door. 
 
In reassignment situations, providers/suppliers can assign in PECOS multiple primary practice 
locations (PPLs), one PPL, or none at all.  If the provider/supplier wishes to add, change, or 
remove a PPL designation, no signature is necessary.   
 
9.  Contact Persons/Parties for PECOS Applications 
 
(The instructions in this subsection (C)(9) supersede those in section 10.6.9 of this chapter with 
respect to PECOS applications.) 
 
For PECOS applications only, there are three types of contacts: 
 
a.  Enrollment Contacts (EC): These are persons whom the provider/supplier may designate in 
its PECOS application submission as having the authority to contact the contractor about the 
provider/suppliers enrollment once the provider/supplier is enrolled.  ECs will not be contacted 
by CMS (except in response to an ECs inquiry) either by mail, e-mail, telephone, the PCV, etc., 
and their contact information will not be part of the official application or be shown on the 
PECOS screens.  Moreover, the provider/supplier need not have any ECs if it so chooses. 
 
b.  Application Contacts (AC): These individuals are somewhat akin to the longstanding 
category of contact persons.  They are: (1) optional for the provider/supplier; (2) valid contacts 
only for the application in question; and (3) neither added to the formal enrollment record nor 
contacted by CMS on any matter other than the application.  If the provider/supplier chooses to 
list ACs, it must also designate a Primary AC from this list; this person will receive any 
physical letters the contractor sends while the other ACs will receive e-mails.    
  c.  Correspondence Address  This is the same address that has long been used for provider 
enrollment applications.  Its meaning and use will not change with the advent of PECOS 2.0. 
 
Except as otherwise stated in subsections 9(a) through (c) above, the contractor shall: 
 
  Continue to use the correspondence address as normal 
  Use ACs (as opposed to ECs) for communications regarding the application in question 
  Respond to any EC questions if they are related to a matter outside of the contractors 
current processing of an application.  (If the question is not related to the present 
application, the contractor shall notify the EC that it cannot respond to the query.) 
 
D.  Chapter 10 Applicability 
 
1.  Except as otherwise noted, the PECOS instructions in section 10.3 et seq. take precedence 
over all others in this chapter pertaining to the same issue or operational procedure.    
 
2.  Certain existing instructions in chapter 10 (including those in section 10.3 et seq.) require (or, 
in a few cases, do not require) particular data elements on the application to be completed.  The 
contractor shall observe that PECOS may or may not mandate that the provider complete 
particular data fields before proceeding to succeeding fields.  This might render moot some of 
the processing alternatives and exemptions discussed in this chapter.  The contractor may 
therefore disregard those alternatives/exemptions that are immaterial to the situation. 
 
3.  Certain existing data elements on the applications and which are listed in this chapter 10 may 
not be reflected in PECOS. In such cases, the contractor may disregard the instructions in this 
chapter pertaining thereto. 
 
4.  Except as otherwise stated, the term PECOS in this chapter refers to PECOS 2.0 and 
incorporates the phrase Internet-based PECOS. 
 
5.  All instances in section 10.3 et seq. in which the contractor must now document a data 
element verification or a telephonic communication in PECOS rather than in the provider file 
shall include the applicable information required under section 10.6.19(L).  Note that the 
contractor may document such communications in PECOS even for paper applications. 
 
6.  In cases where use of the PCV is not required but permissible, the contractor is very strongly 
encouraged to utilize that mechanism. 
 
7.  All clock stoppages otherwise permitted under this chapter can be applied with respect to the 
policies in this section 10.3. 
 
10.3.1 - CMS-855 Series Enrollment Forms: Information and Processing 
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
Each CMS-855 Series form is used to enroll a specific provider or supplier type for a specific 
purpose.  This section 10.3.1 et seq, discusses various data elements on the Form CMS-855 
applications.  Not every data element on the forms is discussed in section 10.3.1 et seq.; only  those elements that warrant additional instructions are mentioned.  Except as stated otherwise, 
the instructions in 10.3.1 et seq.: (1) support and do not supplant the instructions and information 
within the applications themselves; and (2) do not supersede federal regulations concerning 
Medicare provider screening and enrollment.  
 
Regardless of whether the data element in question is discussed in this section, the contractor 
shall adhere to all instructions in this chapter 10 in terms of the collection, processing, and 
verification of all data elements on the Form CMS-855 applications, unless stated otherwise in 
this chapter or in another CMS directive.  (This includes processing alternatives and clock 
stoppages.)  CMS reiterates, however, that in the event of any inconsistency or conflicting 
direction between an instruction in section 10.3.1 et seq. and an instruction in section 10.3, the 
latter takes precedence; this includes, for example, guidance pertaining to: (1) enrollment data 
submission, acquisition, development, processing, and validation; and (2) communicating with 
the provider/supplier). 
 
For purposes of these sections, and unless otherwise indicated, the term approval includes 
recommendations for approval.  
 
In addition: 
 
  The contractor is advised that the Form CMS-855 section numbers outlined in this section 
10.3 et seq. may not be reflected (or may be different) in PECOS 2.0.  However, the 
instructions for each denoted application section in 10.3 et seq. apply to the concomitant 
enrollment information in PECOS 2.0.  For instance, if certain practice location information 
in Section 4 of the current Form CMS-855B is captured in a different section of PECOS 2.0, 
the contractor shall still follow the Section 4 practice location instructions.  Chapter 10 will 
eventually be restructured to more closely align with the process of a provider/suppliers 
completion of a PECOS application. 
  In situations where the contractor may capture or develop for information via several means, 
one of which is the PCV, the contractor is strongly encouraged to use the latter as its 
information acquisition or development vehicle.   
 
If the contractor needs additional information concerning the forms or the processing thereof, it 
may contact its PEOG BFL.   
 
 10.3.1.1  Form CMS-855A  Medicare Enrollment Application for 
Institutional Providers  
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
Institutional providers (e.g., hospitals) that will furnish Medicare Part A services to beneficiaries 
must complete the Form CMS-855A.  For purposes of this section 10.3.1.1 et seq. (and except as 
otherwise stated), the term provider includes certified suppliers that must complete the Form 
CMS-855B. 
 
 
  10.3.1.1.1  Section 1 (Basic Information) - Form CMS-855A   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
  
In Section 1, the provider indicates the reason for submittal of the application.  Unless otherwise 
stated in this chapter or in another CMS directive, or as permitted by PECOS, the provider can 
only check one reason for submittal.   
 
With the exception of (1) the voluntary termination checkbox and (2) the effective date of 
termination---and except as stated in section 10.6.1.3 of this chapter---any blank data/checkboxes 
in the Basic Information section can be verified through any means (e.g., e-mail, the PCV, 
telephone, fax). 
 
10.3.1.1.2  Section 2 (Identifying Information) - Form CMS-855A   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Licenses, Certification, and Accreditation Information 
 
The extent to which the provider must furnish licensure, certification, or accreditation 
information in Section 2 depends upon the provider type involved.  Requirements vary by 
provider type and by location; for instance, some states may require a particular provider to be 
certified but not licensed, or vice versa.   
 
The only licenses the provider must submit with the application are those required by Medicare 
or the state to function as the provider type in question.  Licenses and permits that are not of a 
medical nature are not required.  If the contractor knows that a particular state does not require 
licensure/certification and the Not Applicable boxes in the Identifying Information section of 
the Form CMS-855A are not checked, no further development is needed.   
 
Regarding accreditation under the Identifying Information section of the Form CMS-855A, if the 
provider checks Yes, the contractor shall ensure that the listed accrediting body is one that 
CMS recognizes in lieu of a state survey or other certification for the provider type in question.  
If CMS does not recognize the accrediting body, the contractor shall advise the provider 
accordingly.  (Note, however, that the provider may not intend to use the listed accreditation in 
lieu of the state survey; it may have merely furnished the accrediting body in response to the 
question.)   
 
Documents that are attainable only after state surveys or accreditation need not be included as 
part of the application, and the provider need not furnish the data requested in the Identifying 
Information section of the Form CMS-855A.  However, the provider shall furnish those 
documents it can submit prior to the survey/accreditation.  The contractor shall include all 
submitted licenses, certifications, and accreditations in the enrollment package it sends to the 
state. 
 
(See section 10.3.1.1.14 of this chapter for information about processing alternatives involving 
licensure submissions.)   
 
B.  Correspondence Address and Telephone Number   
The correspondence address must be one at which the contractor can directly contact the 
provider to resolve any issues once the provider is enrolled in Medicare.  It cannot be the address 
of a billing agency, management services organization, chain home office, or the providers 
representative (e.g., attorney, financial advisor); however, it can be a P.O. Box.  The contractor 
need not verify the correspondence address. 
 
The provider may list any telephone number it wishes as the correspondence phone number.  The 
number need not link to the listed correspondence address.  If the provider fails to list a 
correspondence telephone number and it is required for the application submission, the 
contractor shall develop for this information via the procedures outlined in this chapter (e.g., the 
PCV for PECOS applications).  The contractor shall accept a particular phone number if it has no 
reason to suspect that it does not belong to or is not somehow associated with the provider. The 
contractor is not required to verify the telephone number. 
 
Unless CMS specifies otherwise, any change in the providers phone number or address that the 
provider did not cause (i.e., area code change, municipality renames the providers street) must 
still be updated via the Form CMS-855A. 
 
C.  E-mail Addresses 
 
Regarding the correspondence e-mail address in the Correspondence Address and Telephone 
Number Section of the Form CMS-855A, this e-mail address can be a generic one.  It need not 
be that of a specific individual.  The contractor may accept a particular e-mail address if it has no 
reason to suspect that it does not belong to or is not somehow associated with the provider. 
 
D.  Other Identifying Information 
 
Other than the tax identification number (TIN) and legal business name (LBN), the contractor 
may capture all information in the Correspondence Address and Telephone Number Section of 
the Form CMS-855A by telephone, the PCV (if applicable), e-mail, fax, or a review of the 
providers web site. 
 
10.3.1.1.3  Section 3 (Final Adverse Legal Actions/Convictions) - Form CMS-
855A   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
See section 10.6.6 of this chapter for information regarding final adverse actions.  Except as 
otherwise stated, the PECOS policies in section 10.3 supersede those in section 10.6.6 (e.g., 
communicating with the provider via the PCV).    
 
10.3.1.1.4  Section 4 (Practice Location Information) - Form CMS-855A   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  General Background 
  Unless CMS specifies otherwise, any change in the providers phone number or address that the 
provider did not cause (i.e., area code change, municipality renames the providers street) must 
still be updated via the Form CMS-855. 
 
Any provider submitting a Form CMS-855A application must submit the 9-digit ZIP Code for 
each practice location listed. 
 
(For paper applications only - If a practice location (e.g., hospital unit) has a CMS Certification 
Number (CCN) that is in any way different from that of the main provider, the contractor shall 
create a separate enrollment record in PECOS for that location.  (This does not apply, however, 
to home health agency (HHA) branches, outpatient physical therapy/outpatient speech pathology 
(OPT/OSP) extension sites, and transplant centers.))   
 
The contractor shall verify that the practice locations listed on the application actually exist and 
are valid addresses with the United States Postal Service (USPS). PECOS includes a USPS 
Address Matching System Application Program Interface (API), which validates address 
information entered and flags the address if it is determined to be invalid, unknown, 
undeliverable, vacant, unlikely to deliver mail (No-Stat), a CMRA (i.e., UPS Store, mailboxes, 
etc.), or a known invalid address false positive.  These address types are not permitted in PECOS 
and are flagged upon entry.  
 
For both PECOS and paper applications, the contractor need not verify that the reported 
telephone number is operational and connects to the practice location/business listed on the 
application.  Moreover, the contractor need not contact every location for applicants that are 
enrolling multiple locations; the contractor can verify each locations telephone number with the 
contact person listed on the application and document the verification in PECOS.  (The 
telephone number must be one at which patients and/or customers can reach the provider to ask 
questions or register complaints.)  The contractor may also match the provider's telephone 
number with known, in-service telephone numbers - via, for instance, the Yellow Pages or the 
Internet - to correlate telephone numbers with addresses.  If the contractor cannot verify the 
telephone number, it shall request clarifying information from the provider; the inability to 
confirm a telephone number may indicate that an onsite visit is necessary.  In some instances, a 
1-800 number or out-of-state number may be acceptable if the provider's business location is in 
another state but its practice locations are within the contractors jurisdiction. 
 
If the contractor cannot verify the providers address and/or telephone number, the contractor 
shall request clarifying information from the provider.  If the provider states that the facility and 
its phone number are not yet operational, the contractor may continue processing the application.  
However, it shall indicate in its recommendation letter that the address and telephone number of 
the facility could not be verified.  For purposes of PECOS entry, the contractor can temporarily 
use the date the certification statement was signed as the effective date.  
 
(For paper applications only: In Section 4A of the Form CMS-855A, if the type of practice 
location checkbox is blank, the contractor can confirm the information via the PCV, e-mail, or 
fax.)  
 
B.  Do Not Forward (DNF) 
  Unless instructed otherwise in another CMS directive, the contractor shall follow the DNF 
initiative instructions in Pub. 100-04, chapter 1, section 80.5.  Returned paper checks, remittance 
notices, or EFT payments shall be flagged if returned from the post office or banking institution, 
respectively, as this may indicate that the providers special payment address (in the Practice 
Location Information section of the Form CMS-855A) or EFT information has changed.  The 
provider should submit a Form CMS-855A to change this address; if the provider does not have 
an established enrollment record in PECOS, it must complete an entire Form CMS-855A and 
Form CMS-588. 
 
If the provider is closing its business and has a termination date, the contractor will likely need to 
make payments for prior services rendered.  Since the practice location has been terminated, the 
contractor may encounter a DNF message.  If so, the contractor should request the provider to 
complete the special payment address section of the Form CMS-855A and to sign the 
certification statement.  The contractor, however, shall not collect any other information unless 
there is a need to do so or unless an instruction in this chapter states otherwise.  (See section 
10.6.1.3(C)(5) of this chapter for additional information.) 
 
C. Remittance Notices/Special Payments 
 
For new enrollees, all payments must be made via EFT.  The contractor shall thus ensure that the 
provider has completed and signed the Form CMS-588 and shall verify that the bank account 
complies with Pub. 100-04, chapter 1, section 30.2. 
 
If an enrolled provider that currently receives paper checks submits a Form CMS-855A change 
request (no matter what the change involves), the provider must also submit a Form CMS-588 
that switches its payment mechanism to EFT.  (The change request cannot be processed until the 
Form CMS-588 is submitted.)  All future payments (excluding special payments) must be made 
via EFT; once a provider changes its method of payment from paper checks to EFT, it must 
continue using EFT.  A provider cannot switch from EFT to paper checks.  The contractor shall 
verify that the bank account complies with Pub. 100-04, chapter 1, section 30.2. 
 
The special payment address may only be one of the following: 
 
(i)  One of the providers practice locations 
 
(ii)  A P.O. Box 
 
(iii)  The providers billing agent.  (The contractor shall request additional information if it has 
any reason to suspect that the arrangement  at least with respect to any special payments that 
might be made  may violate the Payment to Agent rules in Pub. 100-04, chapter 1, section 
30.2.) 
 
(iv)  The chain home office address.  Per Pub.100-04, chapter 1, section 30.2, a chain 
organization may have payments to its providers sent to the chain home office.  The provider 
must list the chain home offices LBN on the Form CMS-588.  The TIN on the Form CMS-588 
should be that of the provider. 
 
(v) Correspondence address   
(vi)  A lockbox. (The contractor shall request additional information if it has any reason to 
suspect that the arrangement, at least with respect to any special payments that might be made, 
may violate the Payment to Agent rules in Pub. 100-04, chapter 1, section 30.2.) 
 
D.  Out-of-State Practice Locations 
 
If a provider is adding a practice location in another state that is within the contractors 
jurisdiction -- and, for PECOS applications, to the extent PECOS permits it --- a separate, initial 
Form CMS-855A enrollment application is not required if all of the following conditions are 
met: 
 
(i)  The location is not part of a separate organization (e.g., a separate corporation, partnership); 
 
(ii)  The location does not have a separate TIN and LBN;  
 
(iii) The state in which the new location is being added does not require the location to be 
surveyed;  
 
(iv)  Neither the new location nor its owner is required to sign a separate provider agreement; 
and  
 
(v)  The provider type in question is not required to separately enroll each of its practice 
locations. (For example, a federally qualified health center (FQHC) would not meet this criterion 
because FQHCs must separately enroll each location.)    
 
Consider the following examples: 
 
EXAMPLE 1 - The contractors jurisdiction consists of States X, Y and Z.  Jones Health Care 
Facility (JHCF), Inc. is enrolled in State X with 3 sites.  It wants to add a fourth site in State Y.  
The new site will be under JHCF, Inc.  JHCF will not be establishing a separate corporation, 
LBN, or TIN for the site, and - per the state and CMS policy - a separate survey and provider 
agreement are not necessary; moreover, CMS policy does not require this provider type to 
separately enroll each of its practice locations.  Since all 5 conditions above are met, JHCF, Inc. 
can add the fourth location via a change of information request, rather than an initial application.  
The change request must include all information relevant to the new location (e.g., licensure, 
new managing employees).  (For paper applications only---and to the extent required---the 
contractor shall create a separate PECOS enrollment record for the State Y location.)  
 
EXAMPLE 2 - The contractors jurisdiction consists of States X, Y and Z.  JHCF, Inc., is 
enrolled in State X with 3 locations.  It wants to add a fourth location in State Y but under a 
newly created, separate legal entity - JHCF, LP.  The fourth location must be enrolled via a 
separate, initial Form CMS-855A. 
 
EXAMPLE 3 - The contractors jurisdiction consists of States X, Y and Z.  Jones Health 
Services (JHS), Inc., is enrolled in State X with 1 location.  It wants to add a second location in 
State Z under JHS, Inc.  However, it has been determined that a separate survey and certification  of the new location are required.  A separate, initial Form CMS-855A for the new location is 
required. 
 
E.  Additional Practice Location Information 
 
1.  Special Payments 
 
In the Practice Location Information/Where Do You Want Remittance Notices or Special 
Payments Sent section, if neither box is checked and no address is furnished, the contractor can 
contact the provider by telephone, e-mail, the PCV, or fax to confirm the providers intentions.  
If the provider replies that the special payments address is the same as the practice location, no 
further development is needed.  If, however, the provider wants payments sent to a different 
address, the provider must furnish this address in the Where Do You Want Remittance Notices 
or Special Payments Sent section of the Form CMS-855A. 
 
Note that the provider/supplier can only have one special payment address per enrollment for 
both PECOS and paper applications.  See section 10.3(C)(2)(b) for more information. 
 
2.  Base of Operations 
 
In the Practice Location Information/Base of Operations section, if the Check here box is not 
checked and no address is furnished, the contractor can contact the provider by telephone, e-
mail, the PCV, or fax to confirm the providers intentions.  If the provider replies that the base of 
operations address is the same as the practice location, no further development is needed.  If the 
provider indicates that the base of operations is at a different location, the provider must furnish 
this address in the Base of Operations section of the Form CMS-855A. 
 
3.  Vehicle Information 
 
In the Practice Location Information/Vehicle Information section, if the vehicle certificates are 
furnished but the applicable Form CMS-855A sections are blank, the contractor can verify via 
telephone, the PCV, e-mail, or fax that said vehicles are the only ones the provider has. 
 
10.3.1.1.5  Sections 5 and 6 (Ownership Interest and/or Managing Control 
Information) - Form CMS-855A   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
See section 10.6.7 et seq. of this chapter for information concerning owning and managing 
individuals and organizations.   
 
Except as otherwise stated, the PECOS policies in section 10.3 supersede those in section 10.6.7 
(e.g., communicating with the provider via the PCV).    
 
10.3.1.1.6  Section 7 (Chain Home Office Information) - Form CMS-855A   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
  If the provider is part of a chain organization, it must complete the Chain Home Office 
Information section of the Form CMS-855A with information about the chain home office.  
Under 42 CFR  421.404, a home office is the entity that provides centralized management 
and administrative services to the providers or suppliers under common ownership and common 
control, such as centralized accounting, purchasing, personnel services, management direction 
and control, and other similar services.  Other definitions relevant to chain organizations (and 
which are in  421.404) include: 
 
   Chain provider - A group of two or more providers under common ownership or control.  
 
   Common control - Exists when an individual, a group of individuals, or an organization has 
the power, directly or indirectly, to significantly influence or direct the actions or policies of the 
group of suppliers or eligible providers.  
 
   Common ownership  Exists when an individual, a group of individuals, or an organization 
possesses significant equity in the group of suppliers or eligible providers.  
 
The contractor shall not delay its processing of the providers application while awaiting the 
issuance of a chain home office number (i.e., a determination as to whether a set of entities 
qualifies as a chain organization).  Such an issuance/determination is not required for a 
recommendation for approval.  
 
If all of the Chain Home Office Information section is blank (including the check box in this 
section), no additional development is necessary.  If the provider indicates that it is part of a 
chain but the checkboxes in the Chain Home Office Information section are blank, the contractor 
can verify the type of transaction involved via the PCV, e-mail, or fax. 
 
If a chain organization listed in Section 7 also serves as the providers billing agent, the chain 
must also be reported in the Billing Agency section of the Form CMS-855A. 
 
The chain home office administrator (CHOA) must be listed as an owning and/or managing 
individual in Section 6 and all final adverse action data must be disclosed.  (For purposes of 
provider enrollment, a CHOA is deemed to have managing control over the provider.)  If the 
CHOA reported in Section 7 is listed with complete information in Section 6 (e.g., the 
individuals Social Security Number (SSN) is disclosed in Section 6), only the individuals first 
and last name need be listed in Section 7.   
 
A chain home office must be listed as an owning and/or managing organization in Section 5 and 
all final adverse action data must be disclosed.  (For purposes of provider enrollment, a chain 
home office automatically qualifies as an owning/managing organization.)  If the entity is 
reported with complete information in Section 5, its legal business name is the only data element 
that must be reported in Section 7.  (If blank, the contractor may develop for the cost report date, 
the home offices contractor, and the chain number by telephone, e-mail, the PCV, or fax.)   
 
Note that an NPI is typically not required for a chain home office. 
  If blank, the following data elements can be collected by telephone, e-mail, the PCV, or fax: (i) 
Type of Action this Provider is Reporting; (ii) Type of Business Structure of the Chain Home 
Office; and (iii) the Providers Affiliation to the Chain Home Office). 
 
For more information on chain organizations, refer to: 
 
  Pub. 100-04, chapter 1, sections 20.3 through 20.3.6 
 
  42 CFR  421.404 
 
  CMS change request 5720 
 
10.3.1.1.7  Section 8 (Billing Agency Information) - Form CMS-855A   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
(Regarding the Billing Agency Information section of the Form CMS-855A, see section 10.6.8 
of this chapter.  Except as otherwise stated, the PECOS policies in section 10.3 supersede those 
in section 10.6.8.)   
 
If the chain organization listed in Section 7 of the Form CMS-855A also serves as the providers 
billing agent, the chain must be listed in Section 8 as well. 
 
If the telephone number is blank, the contractor may verify it with the provider via telephone, the 
PCV, e-mail, or fax.   
 
If all of the Billing Agency Information section is blank (including the check box), no additional 
development is necessary. 
 
10.3.1.1.8  Section 12 (Special Requirements for Home Health Agencies) - 
Form CMS-855A   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
(Regarding the Special Requirements for Home Health Agencies section of the Form CMS-
855A, see section 10.2.1.6(F) of this chapter.  Except as otherwise stated, the PECOS policies in 
section 10.3 supersede those in section 10.2.1.6(F).)   
 
If it is obvious that the entity is not enrolling as an HHA, the checkbox above this section can be 
left blank. 
 
If the entity is an HHA: 
 
(i)  If the Special Requirements for Home Health Agencies/Type of Home Health Agency or 
Financial Documentation sections is/are blank, the contractor can verify the data with the 
provider via telephone, e-mail, the PCV, or fax. 
 
(ii) If the telephone number in the Special Requirements for Home Health Agencies section is 
blank, the contractor can verify the data with the provider via telephone, e-mail, the PCV, or fax.   
10.3.1.1.9  Sections 13 and 14 (Contact Person and Penalties for Falsifying 
Information) - Form CMS-855A   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Contact Person (Section 13) 
 
(Regarding the Contact Person section of the Form CMS-855A, see section 10.6.9 of this 
chapter.  Except as otherwise stated, the PECOS policies in section 10.3 supersede those in 
section 10.6.9.) 
 
If this section is completely blank, the contractor need not develop for this information and can 
simply contact an authorized or delegated official. 
 
If neither box is checked but the contact person information is incomplete (e.g., no telephone 
number listed), the contractor may either (1) develop for this information by telephone, e-mail, 
the PCV, or fax, or (2) contact an authorized or delegated official. 
 
There is no existing option on the Form CMS-855A to delete a contact person.  The contractor 
shall therefore accept a contact persons end-date via telephone, e-mail, the PCV, fax, or mail 
from the individual provider, an authorized/delegated official, or a current contact person on file.  
The contractor shall document in PECOS who requested the termination, how the request 
originated (e-mail, the PCV, phone, or fax), and when the request occurred.  However, the 
provider must still report all contact person additions via the Form CMS-855A. 
 
B.  Penalties for Falsifying Information (Section 14) 
 
Please refer to the Penalties for Falsifying Information section of the Form CMS-855A for an 
explanation of penalties for deliberately furnishing false information on this application to gain 
or maintain Medicare enrollment.   
 
10.3.1.1.10  Certification Statement - Form CMS-855A   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Certification Statement  General Policies 
 
(Unless otherwise specified, the instructions in this section 10.3.1.1.10(A) apply to: (1) 
signatures on the paper Form CMS-855A; and (2) electronic signatures for web applications.)  
 
For paper applications, handwritten (wet) signatures in ink and digital/electronic signatures 
(digital or electronic signatures such as those created by digital signature options created in 
software, such as Adobe) are acceptable.  For web applications, electronic signatures are 
required; the contractor may contact its PEOG BFL for questions regarding electronic signatures. 
 
B.  Paper Submissions 
  A signed certification statement shall accompany the paper Form CMS-855A application.  If the 
provider submits an invalid certification statement or no certification statement at all, the 
contractor shall still process the application. The contractor shall solicit an appropriate 
certification statement as part of the development process  preferably via the PCV, e-mail or 
fax.  This includes certification statements that are: (a) unsigned; (b) undated; (c) signed (as 
reflected by the date of signature) more than 120 days prior to the date on which the contractor 
received the application); (d) missing; or (e) stamped.  The contractor shall send one 
development request to include a list of all of the missing required data/documentation, including 
the certification statement. The contractor may reject the providers application if the provider 
fails to furnish the missing information on the enrollment application - including all necessary 
documentation - within 30 calendar days from the date the contractor requested the missing 
information or documentation.   
 
Unless stated otherwise in this chapter or in another CMS directive: 
 
(i) The contractor shall begin processing the application upon receipt and shall develop for 
missing certification statements and all other missing information (including an application fee) 
upon review. 
 
(ii) The contractor may return a certification statement via scanned email or fax. 
 
(iii) Signature dates cannot be more than 120 days prior to the receipt date of the application. 
 
(iv) For paper applications that require development, the dated signature of at least one of the 
providers authorized or delegated officials must be on the certification statement that must be 
sent in within 30 days.  Obtaining the signatures of the other authorized and delegated officials is 
not required.    
 
(v) For paper changes of information (as the term changes of information is defined in section 
10.4.4 of this chapter), if the certification statement is signed by an individual not on file with the 
contractor as an authorized or delegated official of the provider, the contractor may accept the 
certification statement.  However, it shall develop for information on the person consistent with 
the procedures in this chapter.  
 
(vi) The contractor need not compare the signature on the Form CMS-855A with the same 
authorized or delegated officials signature on file to ensure that it is the same person.  
 
(vii) The contractor shall not request the submission of a drivers license or passport to verify a 
persons signature or identity. 
 
C.  PECOS Submissions 
 
Unless stated otherwise in this chapter or in another CMS directive: 
 
(i)  The contractor shall (a) begin processing the application upon receipt via PECOS; (b) perform 
all required manual validations; and (c) develop for any needed clarifying or missing information  or documentation consistent with section 10.3 above and all other applicable instructions in this 
chapter.  
 
(ii) If the provider submits an invalid certification statement, the contractor shall treat this as 
missing information and develop for a correct certification statement  preferably via the PCV, 
e-mail, or fax.  (This includes certification statements that are signed by a person unauthorized to 
do so under 42 CFR Part 424, subpart P.)  The contractor shall send one development request to 
include a list of all of the data/documentation to be furnished or clarified, including, as 
applicable, the certification statement. The contractor may reject the providers application if the 
provider fails to furnish said data/documentation within 30 calendar days from the date of the 
contractors request.  
 
(iii) For PECOS applications that require development, at least one of the providers authorized 
or delegated officials must sign any certification statement that must accompany the providers 
response. Obtaining the signatures of the other authorized and delegated officials is not required.   
 
(iv) For PECOS changes of information, if the certification statement is signed by an individual 
who is not on file with the contractor as an authorized or delegated official of the provider, the 
contractor may accept the certification statement.  However, it shall develop for information on 
the person in question consistent with the procedures in this chapter.   
 
(v)  The contractor need not compare the signature thereon with the same authorized or 
delegated officials signature on file to ensure that it is the same person.  
 
(vi) The contractor shall not request the submission of a drivers license or passport to verify a 
persons signature or identity. 
 
D.  Certification Statement Development 
 
If, as already mentioned, the provider submits an invalid certification statement (as described in 
subsections (B) and (C) above), the contractor shall develop for a correct certification statement 
and send a development letter to the provider.  The provider must submit the requested 
certification statement as follows:  
 
(i) Paper applications -- Via scanned email, fax, or mail.  Only the actual signature page is 
required; the provider need not submit the additional page containing the certification terms. 
(This also applies to the providers initial submission of a certification statement.  Such instances 
require the submission of only the signature page and not the certification terms.) 
 
(ii)  Web applications  Via electronic signature.    
(iii)  
10.3.1.1.11  Section 15 (Authorized Officials) - Form CMS-855A   
(Rev. 11168; Issued:12-22-21; Effective:12-31-21; Implementation:01-24-22 ) 
 
A.  General Requirements 
  An authorized official must be a 5 percent direct owner, chairman of the board, etc., of the 
enrolling provider with the authority to bind the provider, both legally and financially, to the 
requirements set forth in 42 CFR  424.510.  This person must also have an ownership or control 
interest in the provider--- such as the general partner, chairman of the board, chief financial 
officer, chief executive officer, president, or someone holding a position of similar status and 
authority within the provider organization.  One cannot use his/her status as the chief executive 
officer, chief financial officer, etc., of the providers parent company, management company, or 
chain home office as a basis for his/her role as the providers authorized official.  
 
Section 424.502 specifically defines an authorized official as an appointed official (for example, 
chief executive officer, chief financial officer, general partner, chairman of the board, or direct 
owner) to whom the organization has granted the legal authority to enroll it in the Medicare 
program, to make changes or updates to the organizations status in the Medicare program, and 
to commit the organization to fully abide by the statutes, regulations, and program instructions of 
the Medicare program.  Note that an authorized official is not restricted to the examples of the 
titles outlined above but can be a person of equivalent status who is an appointed official to 
whom the organization has granted the legal authority to act on the organizations behalf.  These 
additional titles could include, but are not limited to, executive director, administrator, president, 
and vice-president.  The contractor shall consider the individuals title as well as the authority 
granted by the organization when determining whether an individual qualifies as an authorized 
official.  If the contractor is unsure of an authorized officials qualifications or authority, it shall 
contact its PEOG BFL for guidance. In addition, the contractor shall obtain PEOG BFL approval 
if the only role of the listed authorized official is Contracted Managing Employee 
notwithstanding his/her title or other qualifications; the PEOG BFL will confirm authority.   
 
If the person is not listed as a Contracted Managing Employee in the Individual Ownership 
Interest and/or Managing Control Information section and the contractor has no reason to suspect 
that the person does not qualify as an authorized official, no further investigation is required.  
Should the contractor have doubts that the individual qualifies as an authorized official, it shall 
contact the official or the applicant's contact person to obtain more information about the 
official's job title and/or authority to bind.  If the contractor remains unconvinced that the 
individual qualifies as an authorized official, it shall notify the provider that the person cannot be 
an authorized official.  If that person is the only authorized official listed and the provider refuses 
to use a different authorized official, the contractor shall deny the application. 
 
B.  Number of Authorized Officials 
 
The provider can have an unlimited number of authorized officials, so long as each meets the 
definition of an authorized official.  However, the provider must complete the Individual 
Ownership and/or Managing Control section of the Form CMS-855A for each authorized 
official. 
 
C.  Deletion of Authorized Official 
 
For authorized official deletions, the contractor need not obtain (1) that officials signature, or (2) 
documentation verifying that the person is no longer an authorized official. 
 
D.  Change in Authorized Officials   
A change in authorized officials does not impact the authority of existing delegated officials to 
report changes and/or updates to the provider's enrollment data or to sign revalidation 
applications. 
 
E.  Authorized Official Not on File 
 
If the provider submits a change request (e.g., change of address) and the authorized official 
signing it is not on file, the contractor shall ensure that: (1) the person meets the definition of an 
authorized official; and (2) the Individual Ownership Interest and/or Managing Control 
Information section of the Form CMS-855 is completed for him/her.  The signature of an 
existing authorized official is not needed to add a new authorized official.  Note that the original 
change request and the addition of the new official shall be treated as a single change request 
(i.e., one change request encompassing two different actions) for purposes of enrollment 
processing and reporting. 
 
F.  Effective Date  
 
The effective date in PECOS for an authorized official should be the date of signature. 
 
G.  Social Security Number 
 
To be an authorized official, the person must have and submit his/her SSN.  He/she may not use 
an Individual Taxpayer Identification Number (ITIN) in lieu of an SSN in this regard.   
 
H.  Identifying the Provider 
 
As stated earlier, an authorized official must be an authorized official of the provider, not of an 
owning organization, parent company, chain home office, or management company.  Identifying 
the provider is not - for purposes of determining an authorized officials qualifications - 
determined solely by the providers tax identification number (TIN).  Rather, the organizational 
structure is the central factor.  For instance, suppose that a chain drug store, Company X, wants 
to enroll 100 of its pharmacies with the contractor.  Each pharmacy has a separate TIN and must 
therefore enroll separately.  Yet all of the pharmacies are part of a single corporate entity  
Company X.  In other words, there are not 100 separate corporations in our scenario, but merely 
one corporation whose individual locations have different TINs.  Here, an authorized official for 
Pharmacy #76, can be someone at Xs headquarters (assuming that the definition of authorized 
official is otherwise met), even though this main office might be operating under a TIN that is 
different from that of #76.  This is because headquarters and Pharmacy #76 are part of the same 
organization/corporation.  Conversely, if #76 was a corporation that was separate and distinct 
from Company X, only individuals that were part of #76 could be authorized officials. 
 
I.  Signatory Requirements 
 
1. Valid Signatures  See section 10.3.1.1.10(A) of this chapter for information on the types of 
acceptable signatures. If the contractor receives a digital signature that differs from those 
described in section 10.3.1.1.10(A), the contractor shall contact its PEOG BFL for guidance. 
  2.  Form CMS-855A Initial Applications  For these transactions, an authorized official must 
sign and date the certification statement.   
 
3.  Change Requests and Revalidations - For these transactions, an authorized or delegated 
official may sign the certification statement.  This applies to: (1) signatures on the paper Form 
CMS-855; (2) signatures on the certification statement for Internet-based provider enrollment; 
and (3) electronic signatures. 
 
4.  The authorized officials telephone number can be left blank.  No further development 
 
is needed.
 
10.3.1.1.12  Section 16 (Delegated Officials) - Form CMS-855A   
(Rev. 11168; Issued:12-22-21; Effective:12-31-21; Implementation:01-24-22 ) 
 
A.  General Requirements 
 
A delegated official is an individual to whom an authorized official listed in the Certification 
Statement section of the Form CMS-855A delegates the authority to report changes and updates 
to the providers enrollment record or to sign revalidation applications.  The delegated officials 
signature binds the organization both legally and financially, as if the signature were that of the 
authorized official.  Before the delegation of authority is established, the only acceptable 
signature on the enrollment application to report updates or changes to the enrollment 
information is that of an authorized official currently on file with Medicare.  The delegated 
official must be an individual with an ownership or control interest in (as that term is defined 
in  1124(a)(3) of the Social Security Act), or be a W-2 managing employee of the provider. 
 
Section 1124(a)(3) defines an individual with an ownership or control interest as: 
 
  A five percent direct or indirect owner of the provider, 
 
  An officer or director of the provider (if the provider is a corporation), or 
 
  Someone with a partnership interest in the provider if the provider is a partnership 
 
The delegated official must be a delegated official of the provider, not of an owning 
organization, parent company, chain home office, or management company.  One cannot use 
his/her status as a W-2 managing employee of the providers parent company, management 
company, or chain home office as a basis for his/her role as the providers delegated official. 
 
The provider must complete the Ownership Interest and Managing Control Information for 
Individuals section of the Form CMS-855A for all delegated officials.  
 
A delegated official has no authority to sign an initial application.  However, the delegated 
official may (i) sign a revalidation application and (ii) sign off on changes/updates submitted in 
response to a contractors request to clarify or submit information needed to continue processing 
the provider's initial application. 
  Delegated officials may not delegate their authority to any other individual.  Only an authorized 
official may delegate the authority to make changes and/or updates to the provider's Medicare 
data or to sign revalidation applications. 
 
For purposes of the Delegated Officials information captured in the Delegated Official section 
only, the term "managing employee" means any individual (including a general manager, 
business manager, or administrator) who exercises operational or managerial control over the 
provider, or who conducts the day-to-day operations of the provider.  However, this does not 
include persons who, either under contract or through some other arrangement, manage the day-
to-day operations of the provider but who are not actual W-2 employees.  For instance, suppose 
the provider hires Joe Smith as an independent contractor to run its day-to-day-operations.  
Under the definition of "managing employee" in the Ownership Interest and Managing Control 
Information for Individuals section of the Form CMS-855A, Smith would have to be listed in 
that section.  Yet under the Delegated Officials section definition (as described above), Smith 
cannot be a delegated official because he is not an actual W-2 employee of the provider.  
Independent contractors are not considered "managing employees" under the Delegated Officials 
section of the Form CMS-855A. 
 
B.  W-2 Form 
 
Unless the contractor requests it to do so, the provider need not submit a copy of the 
owning/managing individuals W-2 to verify an employment relationship. 
 
C.  Number of Delegated Officials 
 
The provider can have as many delegated officials as it chooses.  It also need not have any 
delegated officials at all.  If the provider lists no delegated officials, however, the authorized 
official(s) remains the only individual(s) who can report changes and/or updates to the provider's 
enrollment data. 
 
D.   Effective Date 
 
The effective date in PECOS for a delegated official should be the date of signature. 
 
E.  SSN 
 
To be a delegated official, the person must have and submit his/her SSN.  He/she may not use an 
ITIN in lieu of an SSN in this regard. 
 
F.  Deletion of a Delegated Official 
 
For delegated official deletions, documentation verifying that the person no longer is or qualifies 
as a delegated official is not required.  In addition, the delegated officials signature is 
unnecessary. 
 
G.  Delegated Official Not on File 
  If the provider submits a change of information (e.g., change of address) and the delegated 
official signing the form is not on file, the contractor shall ensure that: 
 
(i) The person meets the definition of a delegated official,  
(ii) The provider completes the Individual Ownership and/or Managing Control section of the 
Form CMS-855A for that person, and  
(iii) An authorized official signs off on the addition of the delegated official.   
 
(NOTE: The original change request and the addition of the new official constitute a single 
change request (i.e., one change request encompassing two different actions) for purpose of 
enrollment processing and reporting)). 
 
H.  Signature on Paper Application  
 
If the provider submits a paper Form CMS-855A change request, the contractor may accept a 
delegated officials signature in the Certification Statement or Delegated Official section of the 
Form CMS-855A. 
 
I.  Telephone Number 
 
The delegated officials telephone number can be left blank. No further development is needed. 
 
10.3.1.1.13  Additional Form CMS-855A Processing Information   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Supporting Documents Section 
 
See the Supporting Documents section of the Form CMS-855A as well as section 10.3 of this 
chapter for information concerning supporting documents. 
 
B.  Unsolicited Additional Information 
 
If the provider submits additional/missing/clarifying data or documentation on its own volition 
(i.e., not pursuant to a contractor request), the contractor shall include this additional 
data/documentation in its overall application review. Any new or changed information that a 
provider submits prior to the date the contractor finishes processing a previously submitted 
change request constitutes a separate change request rather than an update to the original change 
request.  The contractor may process both changes simultaneously; however, the contractor shall 
process the first submitted change to completion before processing the second one to completion. 
 
C.  Non-Enrollment Functions 
 
In some instances, the contractor cannot forward an application to the state until it performs 
certain non-enrollment functions pertaining to the application (e.g., the reimbursement unit needs 
to examine patient listing data).  The PECOS status may be changed to approval recommended 
prior to the conclusion of the non-enrollment activity if: (1) the contractor has completed all  required enrollment actions; and (2) the non-enrollment action is the only remaining 
unperformed activity.   
 
D.  Multiple Providers under a Single TIN 
 
It is important for contractors to remember that multiple providers and suppliers --- even those of 
different types --- may have the same TIN; for instance, a CORF, an HHA, and a hospice might 
have a similar TIN.  However, each provider must submit a separate Form CMS-855A 
application.  They cannot all be reported via one enrollment, though, for PECOS submissions, 
consolidated applications may be permitted.  (See section 10.3(B)(4) for more information.) 
 
(For paper applications only, the contractor must create a separate enrollment record for each 
provider under the same TIN). 
 
E.  Future Effective Dates 
 
If the contractor cannot enter an effective date into PECOS because the provider, practice 
location, etc., is not yet established, the contractor may use the authorized officials date of 
signature as the temporary effective date.  Once the actual effective date is established, the 
effective date in PECOS can be changed. 
 
F.  Provider-Based Entities 
 
The contractor shall adhere to the following regarding the enrollment of provider-based entities: 
 
1.  Certified Provider or Certified Supplier Initially Enrolling  Suppose an HHA or other 
certified provider or certified supplier wishes to enroll and become provider-based to a hospital.  
The provider/supplier must enroll with the contractor as a separate entity.  It cannot be listed as a 
practice location on the hospitals Form CMS-855A. 
 
2.  Certified Provider or Certified Supplier Changing its Provider-Based Status  If a 
certified provider or certified supplier is changing its status from provider-based to freestanding 
or vice versa, it need not submit any updates to its Form CMS-855A enrollment. 
 
3.  Group Practice Initially Enrolling  If a group practice is enrolling in Medicare and will 
become provider-based to a hospital, the group generally must enroll via the Form CMS-855B if 
it wants to bill for practitioner services.  The group would also need to be listed or added as a 
practice location on the hospitals Form CMS-855A. 
 
4.  Group Practice Changing from Provider-Based to Freestanding  In this situation, the 
hospital should submit a Form CMS-855A change request that deletes the clinic as a practice 
location.  The group may also need to change the type of clinic it is enrolled as; this may require 
a new Form CMS-855B. 
 
5.  Group Practice Changing from Freestanding to Provider-Based  Here, the hospital must 
submit a Form CMS-855A change request adding the group as a practice location.  The group 
may also need to change the type of clinic it is enrolled as; this may require a new Form CMS-
855B.   
Unless CMS instructs otherwise, the contractor shall not delay its processing of any practice 
location addition application pending receipt of a provider-based attestation or CMS approval of 
provider-based status. 
 
10.3.1.1.14  Form CMS-855A Processing Alternatives   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
The processing alternatives in this section 10.3.1.1.14 are in addition to, and not in lieu of, any 
other processing alternatives described in this chapter or another CMS directive.  These 
processing alternatives also apply notwithstanding any instruction in this chapter to the contrary.  
As stated in section 10.3, however, some of the application data elements and verification 
procedures that have previously been subject to a processing exception/alternative may no longer 
be so or are moot under PECOS 2.0.  (See section 10.3 for a discussion of such data and 
procedures.)  In such situations, the contractor shall disregard the exception/alternative and 
follow the instructions in sections 10.3 through 10.3.1.1.10. 
 
A.  General Principle 
 
(Subject to the exceptions listed below as well as the instructions in section 10.3, the following 
principle applies to all Form CMS-855A sections.) 
 
If a data element on the providers Form CMS-855A application is missing but the information is 
disclosed (1) elsewhere on the application or (2) in the supporting documentation submitted with 
the application, the contractor need not obtain the missing data via an updated Form CMS-855A 
page and a newly-signed certification statement; no further development  not even by telephone 
 is required.  The following information, however, must be furnished in the appropriate 
section(s) of the Form CMS-855A, even if the data is identified elsewhere on the form or in the 
supporting documentation: 
 
(i)  All organizational and individual ownership and managing control information on the Form 
CMS-855A 
 
(ii)  Except as otherwise stated in section 10.6.6 of this chapter, any final adverse action data 
requested in the Final Adverse Legal Actions/Convictions section and the final adverse legal 
action history for any organization or individual listed in the Ownership Interest and/or 
Managing Control Information sections of the Form CMS-855A 
 
(iii)  All legal business names (LBNs) (e.g., provider, chain home office) (NOTE:  If an 
application is submitted with a valid NPI and CCN combination but (1) the LBN field is blank, 
(2) an incomplete or inaccurate LBN is submitted, or (3) the applicant includes a DBA name in 
the Practice Location Information section of the Form CMS-855A and the contractor can 
confirm the correct LBN based on the NPI-CCN combination provided, the contractor need not 
develop.) 
 
(iv)  All tax identification numbers (TINs) (e.g., provider, owning organization) 
  (v)  NPI-legacy number combinations in the Practice Location Information section of the Form 
CMS-855A (NOTE: The contractor may use the shared systems, PECOS, or its provider files as 
a resource to determine the PTAN or NPI before developing with the provider.) 
 
(vi) Provider type  
 
(vii)  The following data in the Change of Ownership (CHOW), Acquisitions/Mergers or 
Consolidations sections of the Form CMS-855A: 
 
  DBA name 
  Effective dates of sale/transfer/consolidation 
  Checkbox in the Identifying Information (CHOW Information) section indicating whether 
buyer will accept assets/liabilities 
  Names of units with separate legacy numbers/NPIs 
  All NPIs and legacy numbers (NOTE: The contractor may use the shared systems, PECOS, 
or its provider files as a resource to determine the CCN or NPI before developing with the 
provider).   
 
B.   Supporting Documentation Resubmission 
 
If supporting documentation currently exists in the providers file, the provider need not submit 
that documentation again during the enrollment process. The contractor shall utilize the existing 
documentation for verification.  In short, documentation submitted with a previously submitted 
enrollment application (or documentation currently uploaded in PECOS) qualifies as a 
processing alternative (unless stated otherwise in this chapter or any CMS directive).  
 
C.  City, State, and ZIP Code  
 
If an address in any section of the Form CMS-855A (e.g., correspondence address, practice 
location) lacks a city, state, or zip + four, the contractor can verify the missing data in any 
manner it chooses.  In addition, the contractor can obtain the zip + four from either the U.S. 
Postal Service or the Delivery Point Validation in PECOS. 
 
D.  Licenses  
 
In situations where the provider is required to submit a copy of a particular professional or 
business license, certification, or registration but fails to do so, the contractor need not obtain 
such documentation from the provider if the contractor can verify the information independently.  
The contractor can do this by: (1) reviewing and printing confirmation pages from the applicable 
state web site; (2) requesting and receiving from the appropriate state body written confirmation 
of the providers status therewith; and (3) using any other third-party verification source.  In 
addition, if the provider submits a copy of the applicable license, certification, or registration but 
fails to complete the appropriate section of the form, the section need not be completed if the 
data in question can be verified on the license/certification itself or via any of the three 
mechanisms above.  The contractor shall, however, note the following: 
  (i)  The above-referenced written confirmation from a state body of the providers status can be 
in the form of a letter, fax, or e-mail, but it must be in writing.  Documentation of a verbal 
conversation between the contractor and the body in question does not qualify as appropriate 
confirmation. 
 
(ii) The aforementioned licensure exception only applies to those documents that traditionally 
fall within the category of licenses, registrations, or certifications.  It is inapplicable to materials 
such as adverse action documentation, bills of sale, etc.  Furthermore, the exception is moot in 
cases where: (a) the state does not require a particular license/certification; or (b) the 
license/certification has not been obtained because a state survey has not yet been performed.  
 
E.  Documentation of Missing Information Elsewhere 
 
The contractor shall document in PECOS that the missing information covered under this section 
10.3.1.1.14 was found elsewhere in the enrollment package.  However, this excludes information 
that must be verified at the current point in time (i.e., a license without a primary source 
verification method).  
 
F.  Relationship to Opt-Out 
 
The contractor shall not utilize information submitted with opt-out applications for enrollment 
application processing or vice-versa. 
 
10.3.1.2  Form CMS-855B Medicare Enrollment Application for Clinics, 
Group Practices, and Certain Other Suppliers  
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
  
This application should be completed by supplier organizations (e.g., ambulance companies) that 
will bill Medicare for Part B services furnished to Medicare beneficiaries. It is not used to enroll 
individuals. 
 
The policies in this section 10.3.1.2 et seq. apply exclusively to the Form CMS-855B (except as 
otherwise noted).   
 
10.3.1.2.1  Section 1 (Basic Information) - Form CMS-855B   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
In this section, the supplier indicates the reason for submittal of the application.  Unless 
otherwise stated in this chapter, in another CMS directive, or as permitted by PECOS, the 
supplier may only check one reason for submittal.  For example, suppose a supplier is changing 
its tax identification number via the Form CMS-855B.  The supplier must submit two 
applications: (1) an initial Form CMS-855B as a new supplier; and (2) a Form CMS-855B 
voluntary termination.  Both transactions cannot be reported on the same application. 
 
With the exception of (1) the voluntary termination checkbox and (2) the effective date of 
termination data in the Basic Information section of the Form CMS-855B---and except as stated  in section 10.6.1.3 of this chapter---any blank data/checkboxes in this section can be verified 
through any means chosen by the contractor (e.g., e-mail, the PCV, telephone, fax). 
 
10.3.1.2.2  Section 2 (Identifying Information) - Form CMS-855B   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  License, Certification, and Accreditation Information 
 
1.  Background 
 
Regarding licensure information in the Identifying Information Section of the Form CMS-855B, 
the extent to which the applicant must furnish licensure, certification, or accreditation data 
depends upon the supplier type involved.  Requirements will vary by supplier type and by 
location; for instance, some states may require a particular supplier to be certified but not 
licensed (or vice versa).   
 
The only licenses that the supplier must submit with the application are those that Medicare 
and/or the state requires to function as the supplier type in question.  Licenses and permits not of 
a medical nature are not required.  In some instances, licensure may not be required in a 
particular state at all, though the contractor in this case shall still ensure that the supplier meets 
all applicable state and Medicare requirements. 
 
If the contractor knows that a particular state does not require licensure/certification and the Not 
Applicable boxes are not checked in the Identifying Information Section of the Form CMS-
855B, no further development is needed. 
 
2.  Jurisdictions and Practice Locations 
 
Except as otherwise stated in this chapter or in another CMS directive, the contractor shall verify 
that the supplier is licensed and/or certified to furnish services in: 
 
(i)  The state where the supplier is enrolling; and 
 
(ii)  Any other state within the contractors jurisdiction in which the supplier (per the Practice 
Location Information section of the Form CMS-855B) will maintain a practice location 
 
3.  Permissible Independent Verification 
 
In situations where the supplier is required to submit a copy of a particular professional or 
business license, certification, or registration but fails to do so, the contractor need not obtain 
such documentation from the supplier if the contractor can verify the information independently.  
The contractor can do this by: (1) reviewing and printing confirmation pages from the applicable 
state web site; (2) requesting and receiving from the appropriate state body written confirmation 
of the suppliers status therewith; and (3) using any other third-party verification source.  In 
addition, if the supplier submits a copy of the applicable license, certification, or registration but 
fails to complete the appropriate section of the form, the section need not be completed if the  data in question can be verified on the license/certification itself or via any of the three 
mechanisms above.  The contractor shall, however, note the following: 
 
(i) The above-referenced written confirmation from a state body of the suppliers status can be in 
the form of a letter, fax, or e-mail, but it must be in writing.  Documentation of a verbal 
conversation between the contractor and the body in question does not qualify as appropriate 
confirmation. 
 
(ii) The aforementioned licensure exception only applies to those documents that traditionally 
fall within the category of licenses, registrations, or certifications.  It is inapplicable to materials 
such as adverse action documentation, bills of sale, paramedic intercept agreements, etc.  
Furthermore, the exception is moot in cases where: (a) the state does not require a particular 
license/certification; or (b) the license/certification has not been obtained because a state survey 
has not yet been performed.  
 
4.  Additional Policies 
 
a.  License Reinstatement - If the applicant had a previously revoked or suspended license 
reinstated (and unless CMS states otherwise in this chapter or elsewhere), the applicant must 
submit a copy of the reinstatement notice with the application. 
 
b.  License expiration/revocation dates for non-certified suppliers - For expired licenses, the 
contractor shall enter into PECOS the date after the expiration as the expiration date.  For 
revoked and suspended licenses, the contractor shall enter into PECOS the revocation date (not 
the day after) as the expiration date.  
 
B.  Clinical Laboratory Improvement Act (CLIA) and Drug Enforcement Agency (DEA) 
 
CLIA and DEA certificates are not required. If the applicable CLIA and DEA certificates are not 
furnished or the applicable Form CMS-855B sections are blank, no further development is 
needed. 
 
See section 10.6.19 et seq. of this chapter for special instructions regarding periodic license 
reviews. 
 
C.  Supplier Identification Information  Business Information 
 
Unless otherwise stated in this chapter or in another CMS directive, the contractor may capture 
all information in the Identifying Information Section (with the exception of the TIN and LBN) 
by telephone, fax, e-mail, the PCV, or a review of the suppliers web site. 
 
D.  Physical Therapy/Occupational Therapy Groups 
 
A PT/OT group must complete the questionnaire in the Identifying Information Section for 
PT/OT groups. In doing so:  
  (i)  If the group indicates that it renders services in patients homes, the contractor shall verify 
that the group has an established private practice where it can be contacted directly and where it 
maintains patients' records.  
 
(ii)  If the group answers yes to question 2, 3, 4, or 5, the contractor shall request a copy of the 
lease agreement giving the group exclusive use of the facilities for PT/OT services only if it has 
reason to question the accuracy of the groups response. If the contractor makes this request and 
the supplier cannot furnish a copy of the lease, the contractor shall deny the application.  
 
E.  State Surveys 
 
Documents that can only be obtained after state surveys or accreditation need not be included as 
part of the application.  (This typically occurs with ASCs and portable x-ray suppliers.)  The 
supplier must, however, furnish those documents that can be submitted prior to the 
survey/accreditation. 
 
The contractor shall include any licenses, certifications, and accreditations submitted by 
suppliers in the enrollment package that is forwarded to the state. 
 
Once the contractor receives the approval recommendation notice from the state, the contractor is 
encouraged (but not required) to contact the state or the supplier for the applicable licensing 
and/or certification data and to enter it into PECOS. 
 
F.  Notarization 
 
If the applicant submits a license that is not notarized or "certified true," the contractor shall 
verify the license with the appropriate state agency. (A notarized copy of an original document 
has a stamp that says "official seal," along with the name of the notary public, the state, the 
county, and the date the notary's commission expires.  A certified "true copy" of an original 
document has a raised seal that identifies the state and county in which it originated or is stored.) 
 
G.  Correspondence Address and Telephone Number 
 
The correspondence address in the Correspondence Address and Telephone Number Section of 
the Form CMS-855B must be one at which the contractor can directly contact the applicant to 
resolve any issues once the supplier is enrolled in Medicare.  It cannot be the address of a billing 
agency, management services organization, chain home office, or the providers representative 
(e.g., attorney, financial advisor).  It can, however, be a P.O. Box.  The contractor need not 
verify the correspondence address.   
 
The supplier may list any telephone number it wishes as the correspondence phone number.  The 
number need not link to the listed correspondence address.  If the supplier fails to list a 
correspondence telephone number and it is required for the application submission, the 
contractor shall develop for this information  preferably via the PCV, e-mail, or fax.  The 
contractor shall accept a particular phone number if it has no reason to suspect that it does not 
belong to or is not somehow associated with the supplier. The contractor is not required to verify 
the telephone number. 
  H.  E-mail Addresses 
 
An e-mail address listed on the application can be a generic e-mail address.  It need not be that of 
a specific individual.  The contractor may accept a particular e-mail address if it has no reason to 
suspect that it does not belong to or is not somehow associated with the supplier. 
 
10.3.1.2.3  Section 3 (Final Adverse Legal Actions/Convictions) - Form CMS-
855B   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
See section 10.6.6 of this chapter for information regarding final adverse actions.  Except as 
otherwise stated, the PECOS policies in section 10.3 above supersede those in section 10.6.6 
(e.g., communicating with the provider via the PCV).    
 
10.3.1.2.4  Section 4 (Practice Location Information)  Form CMS-855B   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Reporting and Verification Policies 
 
1.  ZIP Code  The supplier must submit the 9-digit ZIP Code for each practice location listed. 
 
2.  Practice Location Name - For suppliers paid via the Multi-Carrier System (MCS), the practice 
location name entered into PECOS shall be the legal business name. 
 
3.  Practice Location Verification  Except as stated otherwise in this chapter or in another CMS 
directive, the contractor shall verify that the practice locations listed on the application actually 
exist and are valid addresses with the United States Postal Service (USPS).  PECOS includes a 
USPS Address Matching System Application Program Interface (API), which validates address 
information entered and flags the address if it is determined to be invalid, unknown, 
undeliverable, vacant, unlikely to deliver mail (No-Stat), a CMRA (i.e., UPS Store, mailboxes, 
etc.), or a known invalid address false positive.  These address types are not permitted in PECOS 
and are flagged upon entry.  
 
4.  Phone Number Verification - The contractor shall verify that the reported telephone number is 
operational and connects to the practice location/business listed on the application.  However, the 
contractor need not contact every location for applicants that are enrolling multiple locations; the 
contractor can verify each locations telephone number with the contact person listed on the 
application and note the verification in PECOS.  (The telephone number must be one at which 
patients and/or customers can reach the applicant to ask questions or register complaints.)  The 
contractor may also match the applicant's telephone number with known, in-service telephone 
numbers - via, for instance, the Yellow Pages or the Internet - to correlate telephone numbers 
with addresses. If the applicant uses his/her/its cell phone for their business, the contractor shall 
verify that this is a telephone connected directly to the business.  If the contractor cannot verify 
the telephone number, it shall request clarifying information from the applicant; the inability to 
confirm a telephone number may indicate that an onsite visit is necessary.  In some instances, a 
1-800 number or out-of-state number may be acceptable if the applicant's business location is in 
another state but his/her/its practice locations are within the contractors jurisdiction.   
5.  Special Certified Supplier Instructions (ASCs and Portable X-Ray Suppliers (PXRS)) - If the 
suppliers address and/or telephone number cannot be verified, the contractor shall request 
clarifying information from the supplier.  If the supplier states that the facility and its phone 
number are not yet operational, the contractor may continue processing the application.  
However, it shall indicate in its recommendation letter that the address and telephone number of 
the facility could not be verified.  For purposes of PECOS, the contractor can temporarily use the 
date the certification statement was signed as the effective date.  
 
6.  Specific Section 4 Subsection Policies   
 
a.  Practice Location Type - In Section 4A, if the type of practice location checkbox is blank, 
the contractor can confirm the information via the PCV, e-mail, or fax. 
 
b.  Section 4B - If neither box is checked and no address is provided, the contractor can contact 
the supplier by telephone, the PCV, e-mail, or fax to confirm the suppliers intentions.  If the 
special payments address is indeed the same as the practice location, no further development is 
needed.  If, however, the supplier wants payments to be sent to a different address, the address in 
Section 4B must be completed via the Form CMS-855B.  
 
c.  Updated Questionnaire - If the supplier (1) is adding a practice location and (2) is normally 
required to complete a questionnaire in the Form CMS-855B specific to its supplier type (i.e.: 
physical or occupational therapist groups), the entity must submit an updated questionnaire to 
incorporate services rendered at the new location.  
 
d.  Section 4E  If the Check here box in Section 4E is not checked and no address is provided, 
the contractor can contact the supplier by telephone, the PCV, e-mail, or fax to confirm the 
suppliers intentions. If the base of operations address is the same as the practice location, no 
further development is needed.  If the supplier indicates that the base of operations is at a 
different location, the address in Section 4E must be furnished via the Form CMS-855B.  
 
e.  Section 4F - If the vehicle certificates are furnished but the applicable Form CMS-855B 
sections are blank, the contractor can verify via telephone, the PCV, e-mail, or fax that said 
vehicles are the only ones the supplier has.  
 
B.  Do Not Forward (DNF) 
 
Unless instructed otherwise in another CMS directive, the contractor shall follow the DNF 
initiative instructions in Pub. 100-04, chapter 1, section 80.5.  Returned paper checks, remittance 
notices, or EFT payments shall be flagged if returned from the post office or banking institution, 
respectively, as this may indicate that the suppliers special payment address (the Practice 
Location Information section of the Form CMS-855B) or EFT information has changed.  The 
supplier should submit a Form CMS-855B to change this address; if the supplier does not have 
an established enrollment record in PECOS, it must complete an entire Form CMS-855B.  (For 
DMEPOS suppliers, the DME MAC is responsible for obtaining, updating, and processing Form 
CMS-588 changes.) 
  If a supplier is closing his/her/its business and has a termination date (e.g., he/she is retiring), the 
contractor will likely need to make payments for prior services rendered.  Since the practice 
location has been terminated, the contractor may encounter a DNF message.  If so, the contractor 
should request the supplier to complete the special payment address section of the Form CMS-
855B and to sign the certification statement.  The contractor, however, shall not collect any other 
information unless there is a need to do so. 
 
C. Remittance Notices/Special Payments 
 
For new enrollees, all payments must be made via EFT.  The contractor shall thus ensure that the 
supplier has completed and signed the Form CMS-588 and shall verify that the bank account 
complies with Pub. 100-04, chapter 1, section 30.2. 
 
If an enrolled supplier that currently receives paper checks submits a Form CMS-855 change 
request  no matter what the change involves  the supplier must also submit: 
 
    A Form CMS-588 that switches its payment mechanism to EFT.  (The change request cannot 
be processed until the Form CMS-588 is submitted.)  All future payments (excluding special 
payments) must be made via EFT.  
 
    The contractor shall also verify that the bank account complies with Pub. 100-04, chapter 1, 
section 30.2. 
 
(Once a supplier changes its method of payment from paper checks to EFT, it must continue 
using EFT.  A supplier cannot switch from EFT to paper checks.)  
 
The special payment address may only be one of the following: 
 
  One of the suppliers practice locations 
 
  A P.O. Box 
 
  The suppliers billing agent.  The contractor shall request additional information if it has any 
reason to suspect that the arrangement  at least with respect to any special payments that might 
be made  may violate the Payment to Agent rules in Pub. 100-04, chapter 1, section 30.2. 
 
  Correspondence address 
 
  A lockbox. The contractor shall request additional information if it has any reason to suspect 
that the arrangement - at least with respect to any special payments that might be made - may 
violate the Payment to Agent rules in Pub. 100-04, chapter 1, section 30.2. 
 
D.  Out-of-State Practice Locations 
 
(The policies in this section 10.3.1.2.4(D) apply unless CMS instructs otherwise in this chapter 
or in another directive.) 
  If a supplier is adding a practice location in another state that is within the contractors 
jurisdiction, a separate, initial Form CMS-855B enrollment application is not required if the 
following 5 conditions are met: 
 
(i) The location is not part of a separate organization (e.g., a separate corporation, partnership); 
 
(ii) The location does not have a separate TIN and LBN;  
 
(iii) The state in which the new location is being added does not require the location to be 
surveyed;  
 
(iv) Neither the new location nor its owner is required to sign a separate certified supplier 
agreement; and  
 
(v) The location is not an IDTF, ASC, or other supplier type that must individually and 
separately enroll each of its locations. 
 
Consider the following scenarios: 
 
EXAMPLE 1 - The contractors jurisdiction consists of States X, Y and Z.  Jones Group Practice 
(JGP), Inc., is enrolled in State X with 3 locations.  It wants to add a fourth location in State Y.  
The new location will be under JGP, Inc.  JGP will not be establishing a separate corporation, 
LBN, or TIN for the fourth location.  Since there is no state agency or SOG Location 
involvement with group practices, all five conditions are met.  JGP can add the fourth location 
via a change of information request, rather than an initial application.  The change request must 
include all information relevant to the new location (e.g., licensure, new managing employees).  
(For paper applications only---and to the extent required---the contractor shall create a separate 
PECOS enrollment record for the State Y location.)  
 
EXAMPLE 2 - The contractors jurisdiction consists of States X, Y and Z.  Jones Group Practice 
(JGP), Inc., is enrolled in State X with 3 locations.   It wants to add a fourth location in State Y 
but under a newly created, separate entity - Jones Group Practice, LP.  The fourth location must 
be enrolled via a separate, initial Form CMS-855B. 
 
EXAMPLE 3 - The contractors jurisdiction consists of States X, Y and Z.  Jones Group Practice 
(JGP), Inc., is enrolled in State X with 3 locations.  It wants to add a fourth location in State Q.  
Since State Q is not within the contractors jurisdiction, a separate initial enrollment for the 
fourth location is necessary. 
 
E.  Unavoidable Phone Number or Address Changes - Unless CMS specifies otherwise, any 
change in the suppliers phone number or address that the supplier did not cause (e.g., area code 
change, municipality renames the suppliers street) must still be updated via the Form CMS-
855B. 
   
10.3.1.2.5  Sections 5 and 6 (Ownership Interest and/or Managing Control 
Information) - Form CMS-855B   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
See section 10.6.7 et seq. of this chapter for information concerning owning and managing 
individuals and organizations.  Except as otherwise stated, the PECOS policies in section 10.3 
supersede those in section 10.6.7 (e.g., communicating with the supplier via the PCV).   
 
10.3.1.2.6  Sections 8, 13, and 14 (Billing Agencies, Contact Persons, and 
Penalties for Falsifying Information) - Form CMS-855B   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
Except as otherwise stated, the PECOS policies in section 10.3 supersede those in sections 10.6.8 
and 10.6.9 of this chapter.   
 
A.  Billing Agency Information (Section 8) 
 
(Regarding the Billing Agency Information section of the Form CMS-855B, see section 10.6.8 of 
this chapter.) 
 
If the telephone number is blank, the contractor may verify it with the supplier via telephone, the 
PCV, e-mail, or fax.   
 
If all of the Billing Agency Information section is blank (including the check box), no additional 
development is necessary. 
 
B.  Contact Person (Section 13) 
 
(Regarding the Contact Person section of the Form CMS-855B, see section 10.6.9 of this 
chapter.) 
 
If this section is completely blank, the contractor need not develop for this information and can 
simply contact an authorized or delegated official. 
 
If neither box is checked but the contact person information is incomplete (e.g., no telephone 
number listed), the contractor may either (1) develop for this information by telephone, the PCV, 
e-mail, or fax, or (2) contact an authorized or delegated official. 
 
There is no existing option on the Form CMS-855B to delete a contact person.  The contractor 
shall therefore accept a contact persons end-date via telephone, the PCV, e-mail, fax, or mail 
from the individual supplier, an authorized/delegated official, or a current contact person on file.  
The contractor shall document in PECOS who requested the termination, how the request 
originated (e-mail, phone, or fax), and when the request occurred.  However, the provider must 
still report all contact person additions via the Form CMS-855B. 
 
C.  Penalties for Falsifying Information (Section 14)   
Please refer to the Penalties for Falsifying Information section of the Form CMS-855B for an 
explanation of penalties for deliberately furnishing false information on this application to gain 
or maintain Medicare enrollment.   
 
10.3.1.2.7  Certification Statement - Form CMS-855B   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
(Unless otherwise specified in this chapter or in another CMS directive, the instructions in this 
section 10.3.1.2.7 apply to (1) signatures on the paper Form CMS-855B; and (2) electronic 
signatures for web applications.) 
 
For paper applications, handwritten (wet) signatures in ink and digital/electronic signatures 
(digital or electronic signatures such as those created by digital signature options created in 
software, such as Adobe) are acceptable.  For web applications, electronic signatures are 
required; the contractor may contact its PEOG BFL for questions regarding electronic signatures. 
 
A.  Paper Submissions 
 
A signed certification statement shall accompany the paper Form CMS-855B application.  If the 
supplier submits an invalid certification statement or no certification statement at all, the 
contractor shall still process the application. The contractor shall solicit an appropriate 
certification statement as part of the development process  preferably via the PCV, e-mail, or 
fax. This includes certification statements that are: (a) unsigned; (b) undated; (c) signed (as 
reflected by the date of signature) more than 120 days prior to the date on which the contractor 
received the application); (d) missing; or (e) stamped.  The contractor shall send one 
development request that includes a list of all of the missing required data/documentation, 
including the certification statement. The contractor may reject the suppliers application if the 
supplier fails to furnish the missing information on the enrollment application - including all 
necessary documentation - within 30 calendar days from the date the contractor requested the 
missing information or documentation.   
 
Unless stated otherwise in this chapter or in another CMS directive: 
 
(i) The contractor shall begin processing the application upon receipt and shall develop for 
missing certification statements and all other missing information (including, if applicable, an 
application fee) upon review. 
 
(ii) The contractor may return a certification statement via scanned email or fax. 
 
(iii) Signature dates cannot be more than 120 days prior to the receipt date of the application. 
 
(iv) For paper applications that require development, the dated signature of at least one of the 
suppliers authorized or delegated officials must be on the certification statement that must be 
sent in within 30 days.  Obtaining the signatures of the other authorized and delegated officials is 
not required. 
         (v) For paper changes of information (as the term changes of information is defined in section 
10.4.4 of this chapter), if the certification statement is signed by an individual not on file with the 
contractor as an authorized or delegated official of the supplier, the contractor may accept the 
certification statement.  However, it shall develop for information on the person in question 
consistent with the procedures in this chapter.  
 
(vi)  The contractor need not compare the signature on the Form CMS-855B with the same 
authorized or delegated officials signature on file to ensure that it is the same person.  
 
(vii)  The contractor shall not request the submission of a drivers license or passport to verify a 
persons signature or identity. 
 
B.  PECOS Submissions 
 
Unless stated otherwise in this chapter or in another CMS directive: 
 
(i)  The contractor shall (a) begin processing the application upon receipt via PECOS; (b) 
perform all required manual validations; and (c) develop for any needed clarifying or missing 
information or documentation consistent with section 10.3 and all other applicable instructions in 
this chapter.   
 
(ii) If the supplier submits an invalid certification statement, the contractor shall treat this as 
missing information and develop for a correct certification statement  preferably via email or 
fax.  (This includes certification statements that are signed by a person unauthorized to do so 
under 42 CFR Part 424, subpart P.)  The contractor shall send one development request that 
includes a list of all of the data/documentation to be furnished or clarified, including, as 
applicable, the certification statement. The contractor may reject the suppliers application if the 
supplier fails to furnish said data/documentation within 30 calendar days from the date of the 
contractors request.  
 
(iii) For PECOS applications that require development, at least one of the suppliers authorized 
or delegated officials must sign any certification statement that must accompany the suppliers 
response.   Obtaining the signatures of the other authorized and delegated officials is not 
required.  
 
(iv) For PECOS changes of information (as the term changes of information is defined in 
section 10.4.4 of this chapter), if the certification statement is signed by an individual who is not 
on file with the contractor as an authorized or delegated official of the supplier, the contractor 
may accept the certification statement.  However, it shall develop for information on the person 
in question consistent with the procedures in this chapter.   
 
(v) The contractor is not required to compare the signature thereon with the same supplier, 
authorized or delegated officials signature on file to ensure that it is the same person.  
 
(vi) The contractor shall not request the submission of a drivers license or passport to verify a 
persons signature or identity. 
  C.  Certification Statement Development 
 
If, as already mentioned, the supplier submits an invalid certification statement (as described in 
subsections (A) and (B) above), the contractor shall (using the procedures outlined in this 
chapter) develop for a correct certification statement and send a development letter to the 
supplier  preferably via the PCV, e-mail, or fax.  The supplier must submit the requested 
certification statement as follows:  
 
(i) Paper applications -- Via scanned e-mail, fax, or mail.  Only the actual signature page is 
required; the additional page containing the certification terms need not be submitted. (This also 
applies to the suppliers initial submission of a certification statement; such instances require the 
submission of only the signature page and not the certification terms.) 
 
(ii) Web applications  Via electronic signature.  
 
10.3.1.2.8  Section 15 (Authorized Officials) - Form CMS-855B   
(Rev. 11168; Issued:12-22-21; Effective:12-31-21; Implementation:01-24-22 ) 
 
A.  General Requirements 
 
An authorized official must be a 5 percent direct owner, chairman of the board, etc., of the 
enrolling supplier with the authority to bind the supplier, both legally and financially, to the 
requirements set forth in 42 CFR 424.510.  This person must also have an ownership or control 
interest in the supplier--- such as the general partner, chairman of the board, chief financial 
officer, chief executive officer, president, or someone holding a position of similar status and 
authority within the provider organization.  One cannot use his/her status as the chief executive 
officer, chief financial officer, etc., of the suppliers parent company, management company, or 
chain home office as a basis for his/her role as the providers authorized official.  
 
Section 424.502 specifically defines an authorized official as an appointed official (for example, 
chief executive officer, chief financial officer, general partner, chairman of the board, or direct 
owner) to whom the organization has granted the legal authority to enroll it in the Medicare 
program, to make changes or updates to the organizations status in the Medicare program, and 
to commit the organization to fully abide by the statutes, regulations, and program instructions of 
the Medicare program.  Note that an authorized official is not restricted to the examples of the 
titles outlined above but can be a person of equivalent status who is an appointed official to 
whom the organization has granted the legal authority to act on the organizations behalf.  These 
additional titles could include, but are not limited to, executive director, administrator, president, 
and vice-president.  The contractor shall consider the individuals title as well as the authority 
granted by the organization when determining whether an individual qualifies as an authorized 
official.  If the contractor is unsure of an authorized officials qualifications or authority, it shall 
contact its PEOG BFL for guidance. In addition, the contractor shall obtain PEOG BFL approval 
if the only role of the listed authorized official is Contracted Managing Employee 
notwithstanding his/her title or other qualifications; the PEOG BFL will confirm authority.   
 
If the person is not listed as a Contracted Managing Employee in the Individual Ownership 
Interest and/or Managing Control Information section and the contractor has no reason to suspect  that the person does not qualify as an authorized official, no further investigation is required.  
Should the contractor have doubts that the individual qualifies as an authorized official, it shall 
contact the official or the applicant's contact person to obtain more information about the 
official's job title and/or authority to bind.  If the contractor remains unconvinced that the 
individual qualifies as an authorized official, it shall notify the supplier that the person cannot be 
an authorized official.  If that person is the only authorized official listed and the supplier refuses 
to use a different authorized official, the contractor shall deny the application. 
 
B.  Number of Authorized Officials 
 
The supplier can have an unlimited number of authorized officials, so long as each meets the 
definition of an authorized official.  However, the supplier must complete the Individual 
Ownership and/or Managing Control section of the Form CMS-855B for each authorized 
official. 
 
C.  Deletion of Authorized Official 
 
For authorized official deletions, the contractor need not obtain (1) that officials signature, or (2) 
documentation verifying that the person is no longer an authorized official. 
 
D.  Change in Authorized Officials 
 
A change in authorized officials does not impact the authority of existing delegated officials to 
report changes and/or updates to the supplier's enrollment data or to sign revalidation 
applications. 
 
E.  Authorized Official Not on File 
 
If the supplier submits a change request (e.g., change of address) and the authorized official 
signing it is not on file, the contractor shall ensure that: (1) the person meets the definition of an 
authorized official; and (2) the Individual Ownership Interest and/or Managing Control 
Information section of the Form CMS-855B is completed for him/her.  The signature of an 
existing authorized official is not needed to add a new authorized official.  Note that the original 
change request and the addition of the new official shall be treated as a single change request 
(i.e., one change request encompassing two different actions) for purposes of enrollment 
processing and reporting. 
 
F.  Effective Date  
 
The effective date in PECOS for an authorized official should be the date of signature. 
 
G.  Social Security Number 
 
To be an authorized official, the person must have and submit his/her SSN.  He/she may not use 
an Individual Taxpayer Identification Number (ITIN) in lieu of an SSN in this regard.   
 
H.  Identifying the Supplier 
  As stated earlier, an authorized official must be an authorized official of the supplier, not of an 
owning organization, parent company, chain home office, or management company.  Identifying 
the supplier is not - for purposes of determining an authorized officials qualifications - 
determined solely by the suppliers tax identification number (TIN).  Rather, the organizational 
structure is the central factor.  For instance, suppose that a chain drug store, Company X, wants 
to enroll 100 of its pharmacies with the contractor.  Each pharmacy has a separate TIN and must 
therefore enroll separately.  Yet all of the pharmacies are part of a single corporate entity  
Company X.  In other words, there are not 100 separate corporations in our scenario, but merely 
one corporation whose individual locations have different TINs.  Here, an authorized official for 
Pharmacy #76, can be someone at Xs headquarters (assuming that the definition of authorized 
official is otherwise met), even though this main office might be operating under a TIN that is 
different from that of #76.  This is because headquarters and Pharmacy #76 are part of the same 
organization/corporation.  Conversely, if #76 was a corporation that was separate and distinct 
from Company X, only individuals that were part of #76 could be authorized officials. 
 
I.  Signatory Requirements 
 
1. Valid Signatures  See section 10.3.1.2.7(A) of this chapter for information on the types of 
acceptable signatures. If the contractor receives a digital signature that differs from those 
described in section 10.3.1.2.7(A), the contractor shall contact its PEOG BFL for guidance. 
 
2.  Form CMS-855B Initial Applications  For these transactions, an authorized official must 
sign and date the certification statement.   
 
3.  Change Requests and Revalidations - For these transactions, an authorized or delegated 
official may sign the certification statement.  This applies to: (1) signatures on the paper Form 
CMS-855B; (2) signatures on the certification statement for Internet-based provider enrollment; 
and (3) electronic signatures. 
 
4.  The authorized officials telephone number can be left blank.  No further development 
 
is needed.
 
10.3.1.2.9  Section 16 (Delegated Officials) - Form CMS-855B   
(Rev. 11168; Issued:12-22-21; Effective:12-31-21; Implementation:01-24-22 ) 
 
A.  General Requirements 
 
A delegated official is an individual to whom an authorized official listed in the Certification 
Statement section of the Form CMS-855B delegates the authority to report changes and updates 
to the suppliers enrollment record or to sign revalidation applications.  The delegated officials 
signature binds the organization both legally and financially, as if the signature were that of the 
authorized official.  Before the delegation of authority is established, the only acceptable 
signature on the enrollment application to report updates or changes to the enrollment 
information is that of an authorized official currently on file with Medicare.  The delegated 
official must be an individual with an ownership or control interest in (as that term is defined 
in  1124(a)(3) of the Social Security Act), or be a W-2 managing employee of the supplier. 
  Section 1124(a)(3) defines an individual with an ownership or control interest as: 
 
  A five percent direct or indirect owner of the supplier, 
 
  An officer or director of the supplier (if the supplier is a corporation), or 
 
  Someone with a partnership interest in the supplier if the supplier is a partnership 
 
The delegated official must be a delegated official of the supplier, not of an owning organization, 
parent company, chain home office, or management company.  One cannot use his/her status as a 
W-2 managing employee of the suppliers parent company, management company, or chain 
home office as a basis for his/her role as the suppliers delegated official. 
 
The supplier must complete the Ownership Interest and Managing Control Information for 
Individuals section of the Form CMS-855B for all delegated officials.  
 
A delegated official has no authority to sign an initial application.  However, the delegated 
official may (i) sign a revalidation application and (ii) sign off on changes/updates submitted in 
response to a contractors request to clarify or submit information needed to continue processing 
the supplier's initial application. 
 
Delegated officials may not delegate their authority to any other individual.  Only an authorized 
official may delegate the authority to make changes and/or updates to the supplier's Medicare 
data or to sign revalidation applications. 
 
For purposes of the Delegated Officials information captured in the Delegated Official section 
only, the term "managing employee" means any individual (including a general manager, 
business manager, or administrator) who exercises operational or managerial control over the 
provider, or who conducts the day-to-day operations of the supplier.  However, this does not 
include persons who, either under contract or through some other arrangement, manage the day-
to-day operations of the supplier but who are not actual W-2 employees.  For instance, suppose 
the provider hires Joe Smith as an independent contractor to run its day-to-day-operations.  
Under the definition of "managing employee" in the Ownership Interest and Managing Control 
Information for Individuals section of the Form CMS-855B, Smith would have to be listed in 
that section.  Yet under the Delegated Officials section definition (as described above), Smith 
cannot be a delegated official because he is not an actual W-2 employee of the provider.  
Independent contractors are not considered "managing employees" under the Delegated Officials 
section of the Form CMS-855B. 
 
B.  W-2 Form 
 
Unless the contractor requests it to do so, the supplier need not submit a copy of the 
owning/managing individuals W-2 to verify an employment relationship. 
 
C.  Number of Delegated Officials 
  The supplier can have as many delegated officials as it chooses.  It also need not have any 
delegated officials at all.  If the supplier lists no delegated officials, however, the authorized 
official(s) remains the only individual(s) who can report changes and/or updates to the supplier's 
enrollment data. 
 
D.  Effective Date 
 
The effective date in PECOS for a delegated official should be the date of signature. 
 
E.  SSN 
 
To be a delegated official, the person must have and submit his/her SSN.  He/she may not use an 
ITIN in lieu of an SSN in this regard. 
 
F.  Deletion of a Delegated Official 
 
For delegated official deletions, documentation verifying that the person no longer is or qualifies 
as a delegated official is not required.  In addition, the delegated officials signature is 
unnecessary. 
 
G.  Delegated Official Not on File 
 
If the supplier submits a change of information (e.g., change of address) and the delegated 
official signing the form is not on file, the contractor shall ensure that: 
 
(i) The person meets the definition of a delegated official,  
(ii) The supplier completes the Individual Ownership and/or Managing Control section of the 
Form CMS-855B for that person, and  
(iii) An authorized official signs off on the addition of the delegated official.   
 
(NOTE: The original change request and the addition of the new official constitute a single 
change request (i.e., one change request encompassing two different actions) for purpose of 
enrollment processing and reporting)). 
 
H.  Signature on Paper Application  
 
If the provider submits a paper Form CMS-855B change request, the contractor may accept a 
delegated officials signature in the Certification Statement or Delegated Official section of the 
Form CMS-855B. 
 
I.  Telephone Number 
 
The delegated officials telephone number can be left blank. No further development is needed. 
 
10.3.1.2.10  Additional Form CMS-855B Processing Information   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
  The processing alternatives in section 10.3.1.2.10(E) are in addition to, and not in lieu of, any 
other processing alternatives described in this chapter or another CMS directive.  These 
processing alternatives also apply notwithstanding any instruction in this chapter to the contrary.  
As stated in section 10.3, however, some of the application data elements and verification 
procedures that have previously been subject to a processing exception/alternative may no longer 
be so or are moot under PECOS 2.0.  (See section 10.3 for a discussion of such data and 
procedures.)  In such situations, the contractor shall disregard the exception/alternative and 
follow the instructions in section 10.3 and section 10.3.1.2 through 10.3.1.2.9. 
 
A.  Supporting Documents (Section 17) 
 
See the Supporting Documents Section of the Form CMS-855B as well as section 10.3 for 
information concerning supporting documents. 
 
B.  Attachment 1 for Ambulance Service Suppliers 
 
In section D of Attachment 1 of the Form CMS-855B, the Land, Air, and Marine boxes 
need not be checked (or developed) if the type of vehicle involved is clear.  In addition, the 
contractor need not develop for the written statement signed by the President, Chief Executive 
Officer, or Chief Operating Officer of the airport from where the aircraft is hangared that 
furnishes the name and address of the facility. 
 
See section 10.2.2.10 of this chapter for more detailed processing instructions on Attachment 1. 
 
C.  Attachment 2 for Independent Diagnostic Testing Facilities 
 
See section 10.2.2.4 of this chapter for more detailed processing instructions on Attachment 2. 
 
D.  Attachment 3 for Opioid Treatment Programs 
 
See section 10.2.7 of this chapter for more detailed processing instructions on Attachment 3. 
 
E.  Provider-Based Entities 
 
The contractor shall adhere to the following regarding the enrollment of provider-based entities: 
 
  Group Practice Initially Enrolling  If a group practice is enrolling in Medicare and will 
become provider-based to a hospital, the group generally must enroll via the Form CMS-855B if 
it wants to bill for practitioner services.  The group would also need to be listed or added as a 
practice location on the hospitals Form CMS-855A. 
  Group Practice Changing from Provider-Based to Freestanding  In this situation, the 
hospital should submit a Form CMS-855A change request that deletes the clinic as a practice 
location.  The group may also need to change the type of clinic it is enrolled as; this may require 
a new Form CMS-855B. 
  Group Practice Changing from Freestanding to Provider-Based  Here, the hospital must 
submit a Form CMS-855A change request adding the group as a practice location.  The group  may also need to change the type of clinic it is enrolled as; this may require a new Form CMS-
855B. 
 
Unless CMS instructs otherwise, the contractor shall not delay the processing of any practice 
location addition applications pending receipt of provider-based attestations or CMS approval of 
provider-based status. 
 
F.  Additional Processing Information and Alternatives 
 
1.   Unsolicited Additional Information 
 
If the supplier submits additional/missing/clarifying data or documentation on its own volition 
(i.e., without being contacted by the contractor), the contractor shall include this additional 
data/documentation in its overall application review. Any new or changed information that a 
supplier submits prior to the date the contractor finishes processing a previously submitted 
change request constitutes a separate change request rather than an update to the original change 
request.  The contractor may process both changes simultaneously; however, the contractor shall 
process the first submitted change to completion before processing the second one to completion. 
 
2.  Information Disclosed Elsewhere 
 
If a data element on the suppliers Form CMS-855B application is missing but the information is 
disclosed (1) elsewhere on the application or (2) in the supporting documentation submitted with 
the application, the contractor need not obtain the missing data via an updated Form CMS-855B 
page and a newly-signed certification statement; no further development  not even by telephone 
 is required.  The following information, however, must be furnished in the appropriate 
section(s) of the Form CMS-855B, even if the data is identified elsewhere on the form or in the 
supporting documentation: 
 
  All ownership and managing control information in the Organizational or Individual 
Ownership and/or Managing Control sections of the Form CMS-855B 
 
  Except as otherwise stated in section 10.6.6 of this chapter, any final adverse action data 
requested in the Final Adverse Legal Actions/Convictions Section and the Organizational and 
Individual Ownership and/or Managing Control/Final Adverse Legal Action History sections of 
the Form CMS-855B 
 
  All legal business names (LBN) or legal names (NOTE: If an application is submitted with a 
valid NPI-PTAN combination but (1) the LBN field is blank, (2) an incomplete or inaccurate 
LBN is submitted, or (3) the applicant includes a DBA name in the Practice Location 
Information section of the Form CMS-855B -- and the contractor is able to confirm the correct 
LBN based on the NPI-PTAN combination provided, the contractor need not develop.)  
 
  All tax identification numbers (TIN)  
    NPI-legacy number combinations in the Practice Location Information section of the Form 
CMS-855B (NOTE: The contractor may use the shared systems, PECOS, or its provider files as 
a resource to determine the PTAN or NPI before developing with the supplier.) 
 
  Supplier type in the Identifying Information section of the Form CMS-855B  
 
3.  Supporting Documentation Resubmission 
 
If the supporting documentation currently exists in the suppliers file, the supplier need not 
submit that documentation again during the enrollment process. The contractor shall utilize the 
existing documentation for verification. Documentation submitted with a previously submitted 
enrollment application (or documentation currently uploaded in PECOS) qualifies as a 
processing alternative, unless stated otherwise in this chapter or another CMS directive. Also, per 
section 10.6.19(H) of this chapter, the contractor shall document in PECOS that the missing 
information was found elsewhere in the enrollment package. (This excludes information that 
must be verified at the current point in time (i.e., a license without a primary source verification 
method.)  In addition, the contractor shall not utilize information submitted along with opt-out 
applications for enrollment application processing or vice-versa. 
 
4.  City, State, and ZIP Code  
 
If an address (e.g., correspondence address, practice location) lacks a city, state or zip + four, the 
contractor can verify the missing data in any manner it chooses. In addition, the contractor can 
obtain the zip + four from either the U.S. Postal Service or the Delivery Point Validation in 
PECOS. 
 
5.  Inapplicable Questions 
 
The supplier need not check no for questions that obviously do not apply to its supplier type.   
 
6. Authorized/Delegated Official Telephone Number 
 
The telephone numbers in these sections can be left blank. No further development is needed. 
 
10.3.1.3  Form CMS-855I  Medicare Enrollment Application for Physicians 
and Non-Physician Practitioners  
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
This application should be completed by physicians and non-physician practitioners who render 
Medicare Part B services to beneficiaries.  (This includes a physician or practitioner who (1) is 
the sole owner of a professional corporation, professional association, or limited liability 
company and (2) will bill Medicare through this business entity.) 
 
 
10.3.1.3.1 - Section 1 (Basic Information)  Form CMS-855I 
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
  A.  Purpose and Verification 
 
In this section, the supplier indicates the reason for submittal of the application.  Unless 
otherwise stated in this chapter, in another CMS directive, or as permitted by PECOS, the 
supplier may only check one reason for submittal.  For example, suppose a supplier is voluntarily 
terminating an enrollment as one supplier type and enrolling as a different supplier type; both 
transactions cannot be reported on the same application. 
 
With the exception of (1) the voluntary termination checkbox and (2) the effective date of 
termination---and except as stated in section 10.6.1.3 of this chapter---any blank data/checkboxes 
in the Basic Information section can be verified through any means (e.g., the PCV, e-mail, 
telephone, fax). 
 
B.  Voluntary Termination Reminder 
 
When a practitioner submits a Form CMS-855I application to either (1) add a practice location in 
a new state or (2) relocate to a new state entirely, the contractor that received the application 
shall determine whether the practitioner still has an active PECOS enrollment record in the 
other state(s).  If PECOS indeed indicates that the individual has an active practice location in 
the other state(s), the contractor should remind the practitioner that if he/she no longer intends to 
practice in that state, he/she must submit a Form CMS-855I voluntary termination application to 
the contractor for that jurisdiction.  The reminder should be furnished in the approval letter that 
the receiving contractor sends to the practitioner or, if more appropriate, via the PCV, e-mail, or 
other form of written correspondence. 
 
C.  Break in Medical Practice 
 
If the contractor receives a Form CMS-855I from a practitioner who was once enrolled in 
Medicare but has not been enrolled with any Medicare contractor for the previous 2 years, the 
contractor shall verify with the state (a) where the practitioner last worked and (b) whether the 
practitioner was convicted of a felony or had his/her license suspended or revoked.  If such an 
adverse action was imposed, the contractor shall take action consistent with the instructions in 
this chapter. 
 
10.3.1.3.2 - Section 2 (Personal Identifying Information)  Form CMS-855I 
(Rev.  11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Licensure Information  
 
1.  General Instructions 
 
(The extent to which the applicant must complete the licensure information depends upon the 
supplier type involved.  Requirements will vary by supplier type and by location; for instance, 
some states may require a particular supplier type to be certified but not licensed, or vice 
versa.  (A License Not Applicable checkbox is for instances where a state does not require 
licensure).)   
  The only licenses that must be submitted with the application are those required by Medicare or 
the state to function as the supplier type in question.  Licenses and permits that are not of a 
medical nature are not required.  In addition, and as mentioned above, instances can occur where 
the supplier need not be licensed at all in a particular state; the contractor shall still ensure, 
however, that the supplier meets all applicable state and Medicare requirements. 
 
The contractor shall verify that the supplier is licensed and/or certified to furnish services in: 
 
  The state in which the supplier is enrolling. 
 
  Any other state within the contractors jurisdiction in which the supplier (per the Practice 
Location Information section of the Form CMS-855I) will maintain a practice location. 
 
2.  Notarization 
 
If the applicant submits a license that is not notarized or "certified true," the contractor shall 
verify the license with the appropriate state agency. (A notarized copy of an original document 
has a stamp that says "official seal," along with the name of the notary public, the state, the 
county, and the expiration date of the notary's commission.  A certified "true copy" of an original 
document has a raised seal that identifies the state and county in which it originated or is stored.) 
 
3.  Temporary Licenses 
 
If the supplier submits a temporary license, the contractor shall note the expiration date in 
PECOS.  Should the supplier fail to submit the permanent license after the temporary license 
expiration date, the contractor shall initiate revocation procedures.  (A temporary permit  one in 
which the applicant is not yet fully licensed and must complete a specified number of hours of 
practice in order to obtain the license  is not acceptable.) 
 
4.  Revoked/Suspended Licenses 
 
If the applicant had a previously revoked or suspended license reinstated, the applicant must 
submit a copy of the reinstatement notice with the application. 
 
5.  License Expiration/Revocation Dates for Non-Certified Suppliers 
 
For expired licenses, the contractor shall enter into PECOS the day after the expiration as the 
expiration date.  For revoked and suspended licenses, the contractor shall enter into PECOS the 
revocation date (not the day after) as the expiration date.  (See section 10.6.19(T) of this chapter 
for special instructions related to periodic license reviews.) 
 
6.  Accreditation 
 
If the supplier checks Yes, the contractor shall ensure that the listed accrediting body is one 
that CMS recognizes in lieu of a state survey or other certification for the supplier type in 
question.  If CMS does not recognize the accrediting body, the contractor shall advise the 
supplier accordingly.    
B.  Correspondence Address, Medical Record Correspondence Address, and Telephone 
Number 
 
1.  Correspondence Address  
 
The correspondence address must be one where the contractor can directly contact the applicant 
to resolve any issues once the supplier is enrolled in Medicare. It cannot be the address of a 
billing agency, management services organization, or the suppliers representative (e.g., attorney, 
financial advisor).  It can, however, be a P.O. Box or, in the case of an individual practitioner, 
the persons home address. 
 
The contractor need not verify the correspondence address. 
 
2.  Medical Records Correspondence Address  
 
The medical records correspondence address must be one where the contractor can directly 
contact the applicant regarding medical records once the supplier is enrolled in Medicare. It 
cannot be the address of a billing agency, management services organization, or the suppliers 
representative (e.g., attorney, financial advisor).  It can, however, be a P.O. Box or, in the case of 
an individual practitioner, the persons home address.  
 
Note that: (1) the contractor need not verify the medical records correspondence address; and (2) 
the medical records correspondence address does not apply to individuals reassigning all 
benefits. 
 
3.  Telephone Number 
 
The supplier may list any telephone number he/she wishes as the correspondence or medical 
record correspondence phone number.  The number need not link to the listed correspondence 
address.  If the supplier fails to list a correspondence or medical record telephone number and it 
is required for the application submission, the contractor shall develop for this information  
preferably via the PCV, e-mail, or fax.  The contractor shall accept a particular phone number if 
it has no reason to suspect that it does not belong to or is not somehow associated with the 
supplier.  The contractor need not verify the telephone number. 
 
C.  E-mail Addresses 
 
An e-mail address listed on the application can be a generic e-mail address.  It need not be that of 
a specific individual.  The contractor may accept a particular e-mail address if it has no reason to 
suspect that it does not belong to or is not somehow associated with the supplier. 
 
D.  Specialties 
 
A physician must indicate his/her supplier specialty via a checkmark, an X, or other symbol; if 
the physician has more than one specialty, he/she must indicate these specialties, showing "P" for 
primary and "S" for secondary.  (Non-physician practitioners must indicate their supplier type.) 
  The contractor shall verify that any supplier identifying a secondary specialty on the Form CMS-
855I application has the appropriate medical license.  The contractor shall validate the license 
using the states medical license website.  If an active license is not found, the contractor shall 
develop via telephone, fax, email, or mail to confirm the suppliers intent and to obtain a copy of 
the license, if applicable.   
 
The contractor shall deny the application if the individual fails to meet the requirements of 
his/her physician specialty (primary and/or secondary) or supplier type. 
 
E.  Education 
 
1.  Non-Physician Practitioners - The contractor shall verify all required educational information 
for non-physician practitioners.  While the non-physician practitioner must meet all federal and 
state requirements, he/she need not provide documentation of courses or degrees taken to satisfy 
these requirements unless the contractor requests it.  To the maximum extent possible, the 
contractor shall use means other than the practitioners submission of documentation---such as a 
state or school web site---to validate the persons educational qualifications. 
 
2.  Physicians - A physician need not submit a copy of his/her degree unless the contractor 
requests it.  To the maximum extent possible, the contractor shall use means other than the 
physicians submission of documentation---such as a state or school web site--to validate the 
persons educational status. 
 
F.  Relocation to a New State: License Reviews 
 
When a practitioner submits a Form CMS-855I application to either (1) add a practice location in 
a new state or (2) relocate to a new state entirely, the contractor that received the application 
shall review state licensing board information for the prior state to determine: 
 
  Whether the practitioner had his/her medical license revoked, suspended, or inactive (due to 
retirement, death, or voluntary surrender of license), or otherwise lost his/her license, and 
 
  If the practitioner has indeed lost his or her medical license, whether he/she reported this 
information via the Form CMS-855I within the timeframe specified in 42 CFR  424.520. 
 
If the practitioner is currently enrolled and did not report the adverse action to Medicare in a 
timely manner, the contractor shall---unless another directive in this chapter instructs otherwise, 
such as section 10.6.6----revoke the practitioners Medicare enrollment and establish the 
appropriate reenrollment bar length.  If the practitioner is submitting an initial enrollment 
application (e.g., is moving to a new state and contractor jurisdiction) and did not report the 
adverse action in Section 3 of the CMS-855I, the contractor shall--- unless another directive in 
this chapter instructs otherwise---- deny the enrollment application. 
 
10.3.1.3.3  Section 3 (Final Adverse Legal Actions/Convictions) - Form CMS-
855I   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
  See section 10.6.6 of this chapter for information regarding final adverse actions.  Except as 
otherwise stated, the PECOS policies in section 10.3 supersede those in section 10.6.6 (e.g., 
communicating with the provider via the PCV). 
 
10.3.1.3.4  Section 4 (Business Information) - Form CMS-855I   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Practice Location Verification  
 
The contractor shall verify that the practice locations listed on the application actually exist and 
are valid addresses with the United States Postal Service (USPS). PECOS includes a USPS 
Address Matching System Application Program Interface (API), which validates address 
information entered and flags the address if it is determined to be invalid, unknown, 
undeliverable, vacant, unlikely to deliver mail (No-Stat), a CMRA (i.e., UPS Store, mailboxes, 
etc.), or a known invalid address false positive.  These address types are not permitted in PECOS 
and are flagged upon entry.  To reiterate: the practice location address in the Practice Location 
Information section must be a valid address with USPS; addresses entered into PECOS are 
verified via computer software to determine if they are valid and deliverable. 
 
Any supplier submitting a Form CMS-855I application must submit the 9-digit ZIP Code for 
each practice location listed. 
 
If the Type of practice location checkbox in Section 4A is blank, the contractor can confirm 
the information via the PCV, e-mail, or fax. 
 
A practitioner who only renders services in patients' homes (i.e., house calls) must supply his/her 
home address in the Practice Location Information/Rendering Services in Patients Homes 
section.  In addition, if a practitioner renders services in a retirement or assisted living 
community, the Practice Location Information section must include the name and address of that 
community.  In either case, the contractor shall verify that the address is a physical address.  Post 
office boxes and drop boxes are not acceptable. 
 
If the physician or non-physician practitioner uses his/her home address as his/her practice 
location and exclusively performs services in patients homes, nursing homes, etc., no site visit is 
necessary. 
 
If an individual practitioner (1) is adding a practice location and (2) is normally required to 
complete a questionnaire in the Personal Identifying Information section of the Form CMS-855I 
specific to its supplier type (i.e.: physical therapists), the person must submit an updated 
questionnaire to incorporate services rendered at the new location. 
 
For suppliers paid via the Multi-Carrier System (MCS)--and except as otherwise stated in section 
10.3--the practice location name entered into PECOS shall be the legal business name. 
 
Each practice location is to be verified.  However, there is no need to separately contact each 
location on the application.  Such verification can be done via the contact person listed on the 
application; the contact persons verification shall be documented in PECOS.     
B.  Telephone Number Verification  
 
The contractor shall verify that the reported telephone number is operational and connects to the 
practice location/business listed on the application.  However, the contractor need not contact 
every location for applicants that are enrolling multiple locations; the contractor can verify each 
locations telephone number with the contact person listed on the application and note the 
verification accordingly in PECOS. (The telephone number must be one where patients and/or 
customers can reach the applicant to ask questions or register complaints.)  The contractor may 
also match the applicant's telephone number with known, in-service telephone numbers - via, for 
instance, the Yellow Pages or the Internet - to correlate telephone numbers with addresses. If the 
applicant uses his/her/its cell phone for their business, the contractor shall verify that this is a 
telephone connected directly to the business.  If the contractor cannot verify the telephone 
number, it shall request clarifying information from the applicant; the inability to confirm a 
telephone number may indicate that an onsite visit is necessary.  In some instances, a 1-800 
number or out-of-state number may be acceptable if the applicant's business location is in 
another state but his/her/its practice locations are within the contractors jurisdiction. 
 
C.  Unintended Changes 
 
Unless CMS specifies otherwise, any change in the suppliers phone number or address that the 
supplier did not cause (i.e., area code change, municipality renames the suppliers street) must 
still be updated via the Form CMS-855I. 
 
D.  Remittance Notices/Special Payments Mailing Address section 
 
The special payment address may only be one of the following: 
 
  One of the suppliers practice locations 
 
  A P.O. Box 
 
  A Lockbox. (The contractor shall request additional information if it has any reason to 
suspect that the arrangement---at least with respect to any special payments that might be made--
-may violate the Payment to Agent rules in Pub. 100-04, chapter 1, section 30.2.)  
 
  The suppliers billing agent.  The contractor shall request additional information if it has any 
reason to suspect that the arrangement  at least with respect to any special payments that might 
be made  may violate the Payment to Agent rules in Pub. 100-04, chapter 1, section 30.2. 
 
  Correspondence address 
 
If neither box in this section is checked and no address is provided, the contractor can contact the 
supplier by telephone, the PCV, e-mail, or fax to confirm the suppliers intentions.  If the 
special payments address is the same as the practice location, no further development is 
needed.  If, however, the supplier wants payments to be sent to a different address, the address in  the Remittance Notices/Special Payments Mailing Address section must be completed via the 
Form CMS-855I.  
 
E.  Do Not Forward (DNF) 
 
Unless instructed otherwise in another CMS directive, the contractor shall follow the DNF 
initiative instructions in Pub. 100-04, chapter 1, section 80.5.  Returned paper checks, remittance 
notices, or EFT payments shall be flagged if returned from the post office or banking institution, 
respectively, as this may indicate that the suppliers special payment address (Business 
Information of the Form CMS-855I) or EFT information has changed.  The supplier should 
submit a Form CMS-855I to change this address; if the supplier does not have an established 
enrollment record in PECOS, it must complete an entire Form CMS-855I and Form CMS-588.  
The Durable Medical Equipment MAC is responsible for obtaining, updating and processing 
Form CMS-588 changes. 
 
In situations where a supplier is closing his/her/its business and has a termination date (e.g., 
he/she is retiring), the contractor will likely need to make payments for prior services rendered.  
Since the practice location has been terminated, the contractor may encounter a DNF message.  
If so, the contractor should request the supplier to complete the special payment address 
section of the Form CMS-855I and to sign the certification statement.  The contractor, however, 
shall not collect any other information unless there is a need to do so. 
 
F.  EFT 
 
For new enrollees, all payments must be made via EFT.  The contractor shall thus ensure that the 
supplier has completed and signed the Form CMS-588 and shall verify that the bank account 
complies with Pub. 100-04, chapter 1, section 30.2. 
 
If an enrolled supplier that currently receives paper checks submits a Form CMS-855I change 
request  no matter what the change involves  the supplier must also submit: 
 
  A Form CMS-588 that switches its payment mechanism to EFT.  (The change request cannot 
be processed until the Form CMS-588 is submitted.)  All future payments (excluding special 
payments) must be made via EFT.  
 
  The contractor shall also verify that the bank account complies with Pub. 100-04, chapter 1, 
section 30.2. 
 
(Once a supplier changes its method of payment from paper checks to EFT, it must continue 
using EFT.  A supplier cannot switch from EFT to paper checks.) 
 
G.  Solely-Owned Organizations 
 
1.   Paper Applications  
 
All pertinent data for solely-owned organizations can be furnished via the Form CMS-855I 
alone.  The contractor, however, shall require the supplier to submit a Form CMS-855B, Form  CMS-855I, and Form CMS-855R if, during the verification process, it discovers that the supplier 
is not a solely-owned organization.  (NOTE:  A solely-owned supplier type that normally 
completes the Form CMS-855B to enroll in Medicare must still do so.  For example, a solely-
owned LLC that is an ambulance company must complete the Form CMS-855B even though the 
Practice Location Information/Sole Proprietor/Sole Proprietorship section makes mention of 
solely-owned LLCs.  Use of the Practice Location Information section of the Form CMS-855I is 
limited to suppliers that perform physician or practitioner services.) 
 
(Sole proprietorships need not complete the Business Information portions of Section 4 of the 
Form CMS-855I.  Per definition, a sole proprietorship is not a corporation, professional 
association, etc.  Do not confuse a sole proprietor with a physician whose business is that of a 
corporation, LLC, etc., of which he/she is the sole owner.) 
 
In the Business Information section, the supplier may list a type of business organization other 
than a professional corporation, a professional association, or a limited liability company (e.g., 
closely-held corporation).  This is acceptable so long as that business type is recognized by the 
state in which the supplier is located. 
 
The contractor shall verify all data furnished in the Business Information section (e.g., legal 
business name, TIN, adverse legal actions).  If the Business Information section is left blank, the 
contractor may assume it does not pertain to the applicant. 
 
A solely-owned physician or practitioner organization that utilizes the Business Information 
section to enroll in Medicare can generally submit change of information requests to Medicare 
via the Form CMS-855I.  However, if the change involves data not captured on the Form CMS-
855I, the change must be made on the applicable CMS form (e.g., Form CMS-855B, Form CMS-
855R). 
 
H. Individual Reassignment/Affiliation Information 
 
If the applicant indicates that he/she intends to render all or part of his/her services in a private 
practice, clinic/group, or any organization to which he/she would reassign benefits, the 
contractor shall ensure that the applicant (or the group or organization) has submitted a Form 
CMS-855R for each individual, clinic/group practice, or organization to which the individual 
plans to reassign benefits.  The contractor shall also verify that the individual, clinic/group 
practice, or organization is enrolled in Medicare.  If it is not, the contractor shall enroll the 
individual, clinic/group practice, or organization prior to approving the reassignment. 
 
I.  Sole Proprietor Use of EIN 
 
The practitioner may obtain a separate EIN if he/she wants to receive reassigned benefits as a 
sole proprietor. 
 
J.  NPI Information for Groups 
 
If an individual, clinic/group practice, or organization is already established in PECOS (i.e., 
status of "approved unless the Form CMS-855I is submitted for the purpose of revalidation), the 
physician or non-physician practitioner need not submit the NPI in the Business  Information/Individual Reassignment/Affiliation Information section of the Form CMS-855I.  
The only NPI that the physician or non-physician practitioner must supply is the NPI found in 
the Personal Identifying Information (Individual Information) section. 
 
NOTE:  Physicians and non-physician practitioners must furnish the NPI in the Business 
Information/Individual Reassignment/Affiliation Information section of the Form CMS-855I for 
individuals/groups/organizations not established in PECOS with a status of "approved." 
 
K.  Out-of-State Practice Locations 
 
Except as stated otherwise in section 10.3 or in another CMS directive, if a supplier is adding a 
practice location in another state, a separate, initial Form CMS-855I enrollment application is 
required for that location even if: 
 
  The location is part of the same organization (e.g., a solely-owned corporation),  
 
  The location has the same tax identification number (TIN) and legal business name (LBN), 
and 
 
  The location is in the same contractor jurisdiction. 
 
To illustrate, suppose the contractors jurisdiction consists of States X, Y, and Z.  Dr. Jones, a 
sole proprietor, is enrolled in State X with 2 locations.  He wants to add a third location in State 
Y under his social security number and his sole proprietorships employer identification number.  
A separate, initial Form CMS-855I application is required for the State Y location. 
 
10.3.1.3.5 - Sections 6, 8, 12, 13, and 14 - Form CMS-855I   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
(Except as otherwise stated, the PECOS policies in section 10.3 supersede those in sections 
10.6.7 et seq., 10.6.8, and 10.6.9 (e.g., communicating with the provider via the PCV.)   
 
Section 6 - See section 10.6.7 et seq. of this chapter for information concerning managing 
individuals and organizations. 
 
Section 8 - See section 10.6.8 of this chapter for information concerning billing agencies. (Note 
that if the telephone number in this section is blank, the number can be verified with the supplier 
via telephone, the PCV, e-mail, or fax.  If the entire section is blank (including the check box), 
no additional development is needed.) 
 
Section 12  See the Supporting Documents section of the Form CMS-855I for information 
concerning supporting documents. 
 
Section 13 - Contact Persons  
 
  If this section is completely blank, the contractor need not develop for this information and 
can simply contact the physician/practitioner.   
  If the Contact the individual listed in Section 2A checkbox in Section 13 is checked but the 
contact person information is incomplete (e.g., no telephone number listed), the contractor can 
either: (1) develop for this information via telephone, the PCV, e-mail, or fax; or (2) contact the 
physician/practitioner. 
 
See section 10.6.9 of this chapter for more information concerning the Contact Persons section of 
the Form CMS-855I. 
 
Section 14 - Penalties for Falsifying Information  
 
See the Penalties for Falsifying Information section of the Form CMS-855I for an explanation of 
penalties for deliberately furnishing false information in this application to gain or maintain 
Medicare enrollment. 
 
10.3.1.3.6 - Section 15 (Certification Statement) - Form CMS-855I   
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A. Applicability and Format 
 
Unless otherwise specified, the instructions in this section 10.3.1.3.6 apply to (1) signatures on 
the paper Form CMS-855I and (2) electronic signatures.   
 
For paper applications, valid signatures include handwritten (wet) signatures in ink and 
digital/electronic signatures (digital or electronic signatures such as those created by digital 
signature options established via software, such as Adobe). For web applications, electronic 
signatures are required; the contractor can contact its PEOG BFL for questions regarding 
electronic signatures. 
 
B. Signatories 
 
The enrolling or enrolled physician or non-physician practitioner is the only person who can sign 
the Form CMS-855I.  (This applies to initial enrollments, changes of information, reactivations, 
revalidations, etc.). This includes solely-owned entities listed in the Business Information section 
of Section 4 of the Form CMS-855I.  A physician or non-physician practitioner may not delegate 
the authority to sign the Form CMS-855I on his/her behalf to any other person.  (In the case of 
death, however, an executor of the estate may sign on behalf of the deceased supplier, though 
this only applies to change of information applications.) 
 
C.  Paper Submissions 
 
A signed certification statement must accompany the paper Form CMS-855I application.  If the 
supplier submits an invalid certification statement or fails to submit a certification statement at 
all, the contractor shall still proceed with processing the application. An appropriate certification 
statement shall be solicited as part of the development process  preferably via the PCV, e-mail, 
or fax. This includes certification statements that are: (a) unsigned; (b) undated; (c) signed (as 
reflected by the date of signature) more than 120 days prior to the date on which the contractor  received the application; (d) signed by someone other than the physician or non-physician 
practitioner (except as noted in section 10.3.1.3.6(B)); (e) missing; or (f) stamped.  The 
contractor shall send one development request to include a list of all of the missing required 
data/documentation, including the certification statement. The contractor may reject the 
suppliers application if the supplier fails to furnish the missing information on the enrollment 
application - including all necessary documentation - within 30 calendar days from the date the 
contractor requested it.  
 
Unless stated otherwise in this chapter or in another CMS directive: 
   
(i) The contractor shall begin processing the application upon receipt and shall develop for 
missing certification statements and all other missing information. 
 
(ii) The certification statement may be returned via scanned email or fax. 
 
(iii) Signature dates cannot be more than 120 days prior to the receipt date of the application. 
 
(iv) The contractor need not compare the suppliers signature with one already on file for that 
person to ensure it is the same individual.   
 
(v) The contractor shall not request the submission of a drivers license or passport to verify a 
persons signature or identity. 
 
D.  PECOS Submissions 
 
If the supplier submits an invalid certification statement, the contractor shall treat this as missing 
information and develop for a correct certification statement  preferably via the PCV, e-mail or 
fax.  (This includes certification statements that are: signed by someone other than the physician 
or non-physician practitioner (except as noted in section 10.3.1.3.6(B)).   The contractor shall 
send one development request to include a list of all of the data/documentation to be furnished or 
clarified, including, as applicable, the certification statement. The contractor may reject the 
suppliers application if the supplier fails to furnish said data/documentation within 30 calendar 
days from the date the contractor requested the missing information or documentation. 
 
Unless stated otherwise in this chapter or in another CMS directive: 
 
(i) The contractor shall (a) begin processing the application upon receipt via PECOS, (b) perform 
all required manual validations, and (c) develop for any needed clarifying or missing information 
or documentation consistent with section 10.3 above and all other applicable instructions in this 
chapter.   
 
(ii) The contractor need not compare the suppliers signature with one already on file for that 
person to ensure it is the same individual.   
 
(iii) The contractor shall not request the submission of a drivers license or passport to verify a 
persons signature or identity. 
  E.  Certification Statement Development 
 
The supplier must submit a newly signed certification statement as part of a development request 
as follows: 
 
(i) Paper applications: Via scanned e-mail, fax, or mail.  (Only the actual signature page is 
required; the additional page containing the certification terms need not be submitted. This also 
applies to the suppliers initial submission of a certification statement; such instances require the 
submission of only the signature page and not the certification terms.) 
 
(ii) Web applications  Via electronic signature.    
 
F.  Privacy Statement 
 
All information collected on the Form CMS-855I shall be entered into PECOS. The Privacy Act 
permits CMS to disclose information without an individuals consent if the information is to be 
used for a purpose that is compatible with the purpose(s) for which the information was 
collected.  Any such disclosure of data is known as a routine use. CMS will only release 
PECOS information that can be associated with an individual as provided for under Section III 
Proposed Routine Use Disclosures of Data in the System. Both identifiable and non-
identifiable data may be disclosed under a routine use. CMS will only collect the minimum 
personal data necessary to achieve the purpose of PECOS. To view the routine uses in their 
entirety, go to: https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-
Systems/Privacy/Downloads/0532-PECOS.pdf. 
 
10.3.1.3.7 - Additional Processing Information and Alternatives  Form CMS-
855I 
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Processing a Form CMS-855I Ownership Change of Information Application 
 
When a sole owner practitioner has sold his/her group to another individual practitioner and the 
EIN remains unchanged, the contractor shall process the transaction as a change of information 
via the Form CMS-855I to change the groups owner.  In doing so, the contractor shall: 
 
(i)  Verify that the EIN is solely owned by the new owner. 
 
(ii)  Make no change to the PTAN or effective date. 
 
(iii)  If applicable, require the prior sole owner individual to submit a voluntary termination 
application to terminate their individual enrollment/reassignment.  
 
B.  Unsolicited Additional Information 
 
If the supplier submits missing/clarifying data or documentation on its own volition (i.e., without 
being contacted by the contractor), the contractor shall include this additional 
data/documentation in its overall application review.  Any new or changed information that a  supplier submits prior to the date the contractor finishes processing a previously submitted 
change request shall be processed as a separate change request rather than an update to the 
original change request.  The contractor may process both changes simultaneously, but the 
change that was submitted first shall be processed to completion prior to the second one being 
processed to completion. 
 
C.  Processing Alternatives 
 
As stated in section 10.3, some of the application data elements and verification procedures that 
have previously been subject to a processing exception/alternative may no longer be so or are 
moot under PECOS 2.0.  (See section 10.3 for a discussion of such data and procedures.)  In such 
situations, the contractor shall disregard the exception/alternative and follow the instructions in 
section 10.3 and sections 10.3.1.3 through 10.3.1.3.6. 
 
1.  Information Disclosed Elsewhere 
 
If a data element on the suppliers Form CMS-855I application is missing but the information is 
disclosed (1) elsewhere on the application or (2) in the supporting documentation submitted with 
the application, the contractor need not obtain the missing data via an updated Form CMS-855I 
page and a newly-signed certification statement; no further development  not even by telephone 
 is required.  The following information, however, must be furnished in the appropriate 
section(s) of the Form CMS-855I, even if the data is identified elsewhere on the form or in the 
supporting documentation: 
 
a.  Except as otherwise stated in section 10.6.6 of this chapter, any final adverse action data 
requested in sections 3, 4A, and 6B of the Form CMS-855I 
 
b  Legal business names (LBN) or legal names (Note: If an application is submitted with a valid 
NPI-PTAN combination but (1) the LBN field is blank, (2) an incomplete or inaccurate LBN is 
submitted, or (3) the applicant includes a DBA name in the Business Information section of the 
Form CMS-855I --- and the contractor can confirm the correct LBN based on the NPI-PTAN 
combination provided, the contractor need not develop. (This also applies to the Employers 
Name for PAs in the Personal Identifying Information (PA Information) section of the Form 
CMS-855I).) 
 
c.  Tax identification numbers (TIN)  
 
d.  NPI-legacy number combinations in the Business Information section of the Form CMS-855I.  
(The contractor may use the shared systems, PECOS, or its provider files as a resource to 
determine the PTAN or NPI before developing with the supplier.) 
 
e.  Practitioner type in the Personal Identifying Information section of the Form CMS-855I  
 
If the supporting documentation currently exists in the suppliers file, the supplier need not 
submit that documentation again during the enrollment process. The contractor shall utilize the 
existing documentation for verification.  Unless stated otherwise in this chapter or another CMS 
directive, documentation submitted with a previously submitted enrollment application (or 
documentation currently uploaded in PECOS) qualifies as a processing alternative.  Also, the  contractor shall document in PECOS that the missing information was found elsewhere in the 
enrollment package. (This excludes information that must be verified at the current point in time 
(i.e., a license without a primary source verification method).)  In addition, the contractor shall 
not utilize information submitted along with opt-out applications for enrollment application 
processing or vice-versa. 
 
2.  Licenses 
 
If the supplier is required to submit a copy of a particular professional or business license, 
certification, registration, or degree but fails to do so, the contractor need not obtain such 
documentation from the supplier if the contractor can verify the information independently.  This 
can be done by: (1) reviewing and printing confirming pages from the applicable state, 
professional, or school web site; (2) requesting and receiving from the appropriate state, 
professional, or educational body written confirmation of the suppliers status therewith; or (3) 
utilizing another third-party verification source.  Similarly, if the supplier submits a copy of the 
applicable license, certification, registration, or degree but fails to complete the applicable 
section of the form, the section need not be completed if the data in question can be verified on 
the license/certification itself or via any of the three mechanisms described above. 
 
(The above-referenced written confirmation of the suppliers status can be in the form of a letter, 
fax, or e-mail, but it must be in writing.  Documentation of a verbal conversation between the 
contractor and the body in question does not qualify as appropriate confirmation.) 
 
This exception only applies to documents that traditionally fall within the category of licenses, 
registrations, certifications, or degrees.  It is inapplicable to items such as adverse action 
documentation, etc.  Furthermore, the exception is moot in cases where the state does not require 
a particular license/certification.  
 
3.  Drug Enforcement Agency Certificates (DEA) 
 
DEA certificates are not required.  If the applicable DEA certificate is not furnished or the 
applicable Form CMS-855I section is blank, no further development is needed. 
 
4.  City, State, and ZIP Code  
 
If an address (e.g., correspondence address, practice location) lacks a city, state, or zip + four, the 
contractor can verify the missing data in any manner it chooses. In addition, the contractor can 
obtain the zip + four from either the U.S. Postal Service or the Delivery Point Validation in 
PECOS. 
 
5.  Inapplicable Questions 
 
The supplier need not check no for questions that obviously do not apply to its supplier type.  
For instance, a nurse practitioner need not complete the Personal Identifying Information 
(Resident Information) section of the Form CMS-855I. 
 
6.  Additional Alternatives 
  (i)  If blank, the Type of Other Name and Gender can be captured orally.  
 
(ii)  If the contractor is aware that a particular state does not require licensure/certification and 
the Not Applicable boxes are not checked in the Personal Identifying Information section, no 
further development is needed. 
 
(iii)  Personal Identifying Information (Physician Specialty) section - If the supplier uses a 
checkmark, an X, or other symbol to identify his/her primary and secondary specialties (as 
opposed to a P or S), no additional development is needed.  
 
(iv)  When processing a non-physician practitioners (NPP) application, the contractor need not 
automatically request a copy of the NPPs degree or diploma (if it is not submitted) if his/her 
education can be verified through other authorized means.  Requesting a copy of the degree or 
diploma should only be done if educational information cannot otherwise be verified.  
 
(v) Medical or Professional School and Year of Graduation  If the Form CMS-855I lacks the 
medical or professional school and/or the year of graduation but the information is disclosed in 
the supporting documentation submitted with the application or it already exists in PECOS, no 
further development is needed.  
 
10.3.1.4 - Medicare Enrollment Application for Reassignment of Medicare 
Benefits  Form CMS-855R 
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
Consistent with 42 CFR  424.80(b)(1) and (b)(2) and Pub. 100-04, Chapter 1, sections 
30.2.1(D) and (E) and 30.2.6 and 30.2.7, Medicare may pay: (1) a physician or other providers 
or suppliers employer if the provider or supplier is required, as a condition of employment, to 
turn over to the employer the fees for his or her services; or (2) an entity (i.e., a person, group, or 
facility) that is enrolled in the Medicare program for services furnished by a physician or other 
provider or supplier under a contractual arrangement with that entity.  This means that Part A 
and Part B entities other than physician/practitioner group practices can receive reassigned 
benefits, assuming the requirements for a reassignment exception are met.   
 
An individual who renders Medicare Part B services and seeks to reassign his/her benefits to an 
eligible entity should complete the Form CMS-855R for each entity eligible to receive 
reassigned benefits; the individual must be enrolled in Medicare as an individual prior to 
reassigning his/her benefits.  A Form CMS-855R application must also be completed for any 
individual who will terminate an existing reassignment.  However, the Form CMS-855R shall 
not be used to: 
 
(i) Report physician assistant (PA) reassignments. (Until further notice, PA reassignments must 
be reported via the Form CMS-855I.)  
 
(ii) Revalidate reassignments.  (The individual practitioner should only use the Form CMS-855I 
for revalidations and list his/her active reassignment information in the Business 
Information/Practice Location Information section thereof.) 
  To view the Form CMS-855R Processing Guide, go to: https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-
Items/CMS019033.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending. 
Except as stated otherwise, the procedures described in the Guide, which include processing 
alternatives and instructions, take precedence over all other instructions in this chapter 
concerning the processing of Form CMS-855R applications.  
 
10.3.1.4.1  Sections 1 through 5 of the Form CMS-855R 
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A. Basic Information (Section 1) 
 
(In this section, the supplier indicates the reason for submittal of the application.  Unless 
otherwise stated in this chapter, in another CMS directive, or as permitted by PECOS, the 
supplier may only check one reason for submittal.)   
 
Submission of a Form CMS-855R is required to terminate a reassignment.  A reassignment 
termination cannot be done via the Form CMS-855I (except for PECOS applications when the 
termination is for the last PTAN on an enrollment).  The effective date of termination as 
indicated on the Form CMS-855R is the day after the effective date of termination; payment will 
no longer be made to the organization to which benefits are reassigned the day after the 
termination effective date.  For example, suppose a physician submits a Form CMS-855R to 
terminate a reassignment to a group.  She lists June 30, 2022 as the termination date. The 
terminate effective date listed in PECOS and any correspondence to the supplier should be July 
1, 2022. 
 
In situations where the supplier is both adding and terminating a reassignment---and except as 
stated in section 10.3---each transaction must be reported on a separate Form CMS-855R; the 
same Form CMS-855R cannot be used for both transactions. 
 
B.  Organization/Group Receiving the Reassigned Benefits (Section 2) 
 
1.  Site of Service 
 
Per Pub. 100-04, chapter 1, section 30.2.7, a reassignment of benefits to any eligible entity is 
permitted regardless of where the service was rendered of whether the entity owns or leases that 
location.  As such, the contractor need not verify the entitys ownership or leasing arrangement 
with respect to the reassignment. 
 
2.  Organizational/Group Receiving the Reassigned Benefits  
 
The most common reassignment situation is a physician or practitioner who reassigns his/her 
benefits to a physician group. Here, the only required forms are the Form CMS-855R, a Form 
CMS-855I from the reassignor, and a Form CMS-855B for the reassignee.  The reassignees 
authorized or delegated official must sign the Form CMS-855B certification statement and the 
signatures section of the Form CMS-855R; the reassignor, too, must sign the Form CMS-855Rs 
signatures section.   
3.  Individual Receiving Reassigned Benefits 
 
An individual can receive reassigned benefits.  The most common example of this is a physician 
or practitioner who reassigns his/her benefits to a physician who is either (1) a sole proprietor, or 
(2) the sole owner of an entity listed in the Business Information section of the Form CMS-855I.  
Here, the only required forms are the Form CMS-855R and separate Form CMS-855Is from the 
reassignor and the reassignee.  (No Form CMS-855B or Form CMS-855A is involved.)  The 
reassignee himself/herself must sign the Certification Statements and Signatures section of the 
Form CMS-855R because there is no authorized or delegated official involved. 
 
The contractor shall follow the instructions in Pub. 100-04, Chapter 1, sections 30.2  30.2.16 to 
ensure that a physician or other provider or supplier is eligible to receive reassigned benefits. 
 
Regarding reassignment and revoked or deceased physicians, see section 10.6.17(G)(1) of this 
chapter. 
 
C.  Individual Practitioner Who is Reassigning Benefits (Section 3) 
 
If the individual seeking to reassign his or her benefits is not enrolled in Medicare, the person 
must complete a Form CMS-855I as well as a Form CMS-855R.  (The Forms CMS-855I and 
CMS-855R can be submitted concurrently.)  Moreover, if the entity to which the persons 
benefits will be reassigned is not enrolled in Medicare, the organization must complete a Form 
CMS-855B or, if applicable, a Form CMS-855A. (See section 10.4.1.2 of this chapter for 
additional instructions regarding the joint processing of Form CMS-855As, Form CMS-855Rs, 
Form CMS-855Bs, and Form CMS-855Is.)  
 
Benefits are reassigned to a provider or supplier, not to the provider/suppliers practice 
location(s).  As such, the contractor shall not require each practitioner in a group to submit a 
Form CMS-855R each time the group adds a practice location. 
 
The contractor need not verify whether the reassigning individual is a W-2 employee or a 1099 
contractor. 
 
D.  Primary Practice Location(s) (Section 4) 
 
This is the location(s) of the organization/group at which the individual practitioner will render 
services most of the time.  The organization/group with said location(s) must be currently 
enrolled or enrolling in Medicare.   Per section 10.3, however, the supplier need not specifically 
designate a primary practice location in Section 4.  The supplier need only list their practice 
locations. 
 
When a group practice adds a new practice location, each physician/practitioner who reassigns to 
the group and wants to bill from this new location must have a new PTAN issued to him/her if 
the group is issued a new PTAN.  (The group will only be issued a new PTAN if the new 
location is in a separate fee locality.)  However, he/she need not sign the groups Form CMS-
855R.  The group can simply add the practice location, designate the existing active 
physicians/practitioners who will bill from this location, and sign the application.    
E.  Contact Person Information (Section 5) 
 
(Regarding the optional contact person information in the Contact Person section of the Form 
CMS-855R, see section 10.6.9 of this chapter.)   
 
(i) If this section is completely blank, the contractor need not develop for this information and 
can simply contact the party that submitted the form (e.g., the enrolling physician). 
 
(ii) If a contact person is listed, any other missing data (e.g., address, e-mail) can be captured via 
telephone. 
 
10.3.1.4.2  Section 6 (Certification Statements and Signatures) - Form CMS-
855R 
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  General Reassignment Signature Policies 
 
1.  Format 
 
For paper applications, valid signatures include handwritten (wet) signatures in ink and 
digital/electronic signatures (digital or electronic signatures such as those created by digital 
signature options created in software, such as Adobe).  PECOS applications require an electronic 
signature; the contractor may contact its PEOG BFL for questions regarding electronic 
signatures. 
 
2.  Signatories 
 
i.  Initial - If an individual is initiating a reassignment, both he/she and the groups authorized or 
delegated official must sign the Certification Statements and Signatures section of the Form 
CMS-855R.  If either of the two signatures is missing on a paper application, the contractor shall 
develop for it.  
 
ii.  Termination - If an individual (or group) is terminating a reassignment, either party may sign 
the Certification Statements and Signatures section of the Form CMS-855R; obtaining both 
signatures is not required.  If no signatures are present on a paper application, the contractor shall 
develop for a signature.  
 
iii.  Change - For Form CMS-855R applications submitted to change and/or update the provider 
or suppliers Medicare enrollment data, the certification statement may be signed by either the 
physician/practitioner or the authorized or delegated official of the provider or supplier.   
 
3.  Official On/Not on File 
 
The authorized or delegated official who signs the Certification Statements and Signatures 
section of the Form CMS-855R must be currently on file with the contractor as such.  If this is a 
new enrollment - with a joint submission of the Form(s) CMS-855A or CMS 855B, Form CMS- 855I, and Form CMS-855R - the person must be listed on the Form CMS-855A or Form CMS-
855B as an authorized or delegated official.  
 
There may be situations where a Form CMS-855R is submitted and the reassignee is already 
enrolled in Medicare via the Form CMS-855B.  However, the authorized official is not on file.  
In this case, the contractor shall develop for a Form(s) CMS-855A or CMS-855B change request 
that adds the new authorized official.  
 
B.  Paper Submissions 
 
A signed certification statement shall accompany the paper Form CMS-855R application.  If an 
invalid certification statement is submitted or no certification statement is submitted at all, the 
contractor shall still proceed with processing the application. An appropriate certification 
statement shall be solicited as part of the development process  preferably via the PCV, e-mail, 
or fax. This includes certification statements that are: (a) unsigned; (b) undated; (c) signed (as 
reflected by the date of signature) more than 120 days prior to the date on which the contractor 
received the application; (d) missing; or (e) stamped. The contractor shall send one development 
request to include a list of all of the missing required data/documentation, including the 
certification statement. The contractor may reject the application if the submitter fails to furnish 
the missing information on the enrollment application - including all necessary documentation - 
within 30 calendar days from the date the contractor requested the missing information or 
documentation.  
 
Unless stated otherwise in this chapter or in another CMS directive: 
   
(i) The contractor shall begin processing the application upon receipt and shall develop for 
missing certification statements and all other missing information. 
 
(ii) The certification statement may be returned via scanned email or fax. 
 
(iii) Signature dates cannot be more than 120 days prior to the receipt date of the application. 
 
(iv) For paper applications that require development, the dated signature of only one of the 
organization/groups authorized or delegated officials needs to be on the certification statement 
that must be sent in within 30 days; obtaining the signatures of the other authorized and 
delegated officials is not required. 
 
(v) If the certification statement is signed by an individual who is not on file with the contractor 
as being an authorized or delegated official of the reassignee, the contractor may accept the 
certification statement but shall develop for information on the person in question in accordance 
with this section 10.3.1.4.1.  
 
(vi) The contractor need not compare the signature thereon with the same suppliers or 
authorized/delegated officials signature on file to ensure that it is the same person.  In addition, 
the contractor shall not request the submission of a drivers license or passport to verify a 
persons signature or identity. 
  C.  PECOS Submissions 
 
Unless stated otherwise in this chapter or in another CMS directive: 
 
(i) The contractor shall: (i) begin processing the application upon receipt via PECOS; (ii) 
perform all required manual validations; and (iii) develop for any needed clarifying or missing 
information or documentation consistent with section 10.3 and all other applicable instructions in 
this chapter.   
 
(ii) If an invalid certification statement is submitted, the contractor shall treat this as missing 
information and develop for a correct certification statement  preferably via the PCV, e-mail, or 
fax.  (This includes certification statements that are signed by a person unauthorized to do so 
under 42 CFR Part 424, subpart P.)  The contractor shall send one development request to 
include a list of all of the data/documentation to be furnished or clarified, including, as 
applicable, the certification statement. The contractor may reject the application if the submitter 
fails to furnish said data/documentation within 30 calendar days from the date of the contractors 
request.  
 
(iii) For PECOS applications that require development, at least one of the reassignees authorized 
or delegated officials must sign any certification statement that must accompany the suppliers 
response.  Obtaining the signatures of the other authorized and delegated officials is not required. 
 
(iv) For PECOS change of information applications - If the certification statement is signed by 
an individual who is not on file with the contractor as being an authorized or delegated official of 
the reassignee, the contractor may accept the certification statement but shall develop for 
information on the person in question in accordance with this section 10.3.1.4.1 of this chapter. 
 
(v) The contractor need not compare the submitted signature with that of the same individuals or 
authorized/delegated officials signature on file to ensure that it is the same person.  
 
(vi) The contractor shall not request the submission of a drivers license or passport to verify a 
persons signature or identity. 
 
D.  Certification Statement Development 
 
If the provider submits an invalid certification statement (as described in subsections (B) and (C) 
above, the contractor shall (using the procedures outlined in this chapter) develop for a correct 
certification statement and send a development letter to the provider.  
 
Newly signed certification statements furnished per a development request must be submitted as 
follows:  
 
(1) Paper applications - Via scanned email, fax, or mail.  Only the actual signature page is 
required; the additional page containing the certification terms need not be submitted.  This also 
applies to the initial submission of a certification statement; such instances require the 
submission of only the signature page and not the certification terms. 
 
(2) PECOS applications  Via electronic signature.   
E.  Privacy Statement 
 
The Privacy Act permits CMS to disclose information without an individuals consent if the 
information is to be used for a purpose that is compatible with the purpose(s) for which the 
information was collected.  Any such disclosure of data is known as a routine use. CMS will 
only release PECOS information that can be associated with an individual as provided for under 
Section III Proposed Routine Use Disclosures of Data in the System. Both identifiable and 
non-identifiable data may be disclosed under a routine use. CMS will only collect the minimum 
personal data necessary to achieve the purpose of PECOS.  To view the routine uses in their 
entirety, see https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-
Systems/Privacy/Downloads/0532-PECOS.pdf. 
 
10.3.1.4.3  Additional Form CMS-855R Policies and Processing Alternatives 
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Inter-Jurisdictional Reassignments 
 
If a physician/NPP (reassignor) is reassigning his or her benefits to an entity (reassignee) located 
in another contractor jurisdiction (a permissible practice), the principles in this section 
10.3.1.4.3(A) apply unless another CMS directive states otherwise.  
 
1.  The reassignor must be properly licensed or otherwise authorized to perform services in the 
state in which he/she has his/her practice location.  The practice location can be an office or even 
the individuals home (for example, a physician interprets test results in his home for an 
independent diagnostic testing facility).  
 
2.  The reassignor need not  pursuant to the reassignment - enroll in the reassignees contractor 
jurisdiction nor be licensed/authorized to practice in the reassignees state.  If the reassignor will 
be performing services within the reassignees state, the reassignor must enroll with the 
contractor for (and be licensed/authorized to practice in) that state.  
 
3.  The reassignee must enroll in the contractor jurisdictions in which (1) it has its own practice 
location(s), and (2) the reassignor has his or her practice location(s).  In Case (2), the reassignee:  
 
(i) Shall identify the reassignors practice location as its practice location on its Form CMS-
855B.  
 
(ii) Shall select the practice location type as Other health care facility and specify 
Telemedicine location in the Practice Location Information of its Form CMS-855B.  
 
(iii) Need not be licensed/authorized to perform services in the reassignors state.  
 
To illustrate, suppose Dr. Smith is located in Contractor Jurisdiction X and is reassigning his 
benefits to Jones Medical Group in Contractor Jurisdiction Y.  Jones must enroll with X and with 
Y.  Jones need not be licensed/authorized to perform services in Dr. Smiths state.  However, in  the Practice Location Information section of the Form CMS- 855B it submits to X, Jones must 
list Dr. Smiths location as its practice location.  
 
B. Reassignment to CAHs 
 
Reassignment to a Part A provider or supplier might occur when: (1) a physician or practitioner 
reassigns benefits to a hospital, skilled nursing facility, or critical access hospital billing under 
Method II (CAH II); or (2) a nurse practitioner reassigning to a CAH II.  
 
If the entity receiving the reassigned benefits is not a CAH II, it must enroll with the contractor 
via a Form CMS-855B, and the physician/practitioner reassigning benefits must complete and 
submit a Form CMS-855I and Form CMS-855R. 
 
If the entity receiving the reassigned benefits is a CAH II, the entity need not complete a separate 
Form CMS-855B to receive reassigned benefits.  The physician/practitioner can reassign benefits 
directly to the CAH IIs Part A enrollment. The distinction between CAHs billing Method I vs. 
Method II only applies to outpatient services.  It does not apply to inpatient services. 
 
Under Method I: 
 
  The CAH bills for facility services 
 
  The physicians/practitioners bill separately for their professional services 
 
Under Method II: 
 
  The CAH bills for facility services 
 
  If a physician/practitioner has reassigned his/her benefits to the CAH, the CAH bills for that 
particular physicians/practitioners professional service 
 
  If a CAH has elected Method II, the physician/practitioner need not reassign his/her benefits 
to the CAH.  For those physicians/practitioners who do not reassign their benefits to the CAH, 
the CAH only bills for facility services and the physicians/practitioners separately bill for their 
professional services (similar to Method I). 
 
Although physicians and non-physician practitioners are not required to reassign their benefits to 
a CAH that bills Method II, doing so allows them to participate in the Electronic Health Records 
(EHR) Incentive Program for Eligible Professionals (EPs). 
 
In this scenario, the Form CMS-855I and Form CMS-855R shall be submitted to the Part B 
MAC and the Form CMS-855A submitted to the Part A MAC.  The Part B MAC is responsible 
for reassigning the individual to the Part A entity. 
 
The reassignment to the Part A entity shall only occur if the Form CMS-855A for the CAH II has 
been finalized.  This can be determined by viewing PECOS to identify if an approved enrollment 
exists for the CAH II.  If one does not, the Part B MAC shall return the Form CMS-855I and/or  CMS-855R to the provider on the ground that it is inapplicable to the transaction in question 
(i.e., the Form CMS-855A has not been finalized).  If an enrollment record exists but is in an 
Approved Pending RO Review status, the Part B MAC shall contact the Part A MAC to 
determine if state/SOG Location (as applicable) approval has been received but not yet updated 
in PECOS prior to returning the applications. 
 
C.  Additional Policies and Processing Alternatives 
 
1.   Unsolicited Additional Information 
 
If the supplier submits additional/missing/clarifying data or documentation on its own volition 
(i.e., without being contacted by the contractor), the contractor shall include this additional 
data/documentation in its overall application review. Any new or changed information that a 
supplier submits prior to the date the contractor finishes processing a previously submitted 
change request constitutes a separate change request rather than an update to the original change 
request.  The contractor may process both changes simultaneously; however, the change that was 
submitted first shall be processed to completion prior to the second one being processed to 
completion. 
 
2.  Information Disclosed Elsewhere 
 
If an application is submitted with a valid NPI and PTAN combination but (1) the LBN field is 
blank, (2) an incomplete or inaccurate LBN is submitted, or (3) the applicant includes a DBA 
name in the Organization/Group (or Individual) Receiving the Reassigned Benefits section of the 
Form CMS-855R - and the contractor is able to confirm the correct LBN based on the NPI-
PTAN combination provided - the contractor need not develop.  
 
The contractor may use the shared systems, PECOS, or its provider files as a resource to 
determine the PTAN or NPI of the group/organization/individual that is receiving the reassigned 
benefits before developing with the supplier for existing individual practitioners only.  If 
information is missing from the Form CMS-855R that cannot be verified in PECOS, the shared 
systems, or provider files, the contractor shall pursue development.  (For example, group 
information is missing from the Form CMS-855R, is not included in the Form CMS-855I 
Business Information section, and cannot be verified elsewhere). 
   
3.  Related Applications - Processing Related Form CMS-855R and Form CMS-855I 
Applications 
 
If a newly enrolling supplier is reassigning benefits, the supplier must submit the Form CMS-
855I and the Form CMS-855R.  When one or both of these forms requires the contractor to 
develop for information, the contractor may apply to both the Form CMS-855I and Form CMS-
855R the receipt date of the first application that is submitted as complete (i.e. no further 
development is necessary).    
 
4.  Related Applications - Processing Related Form CMS-855R and Form CMS-855B 
Applications 
  If a newly enrolling group is accepting reassignment of benefits from an existing practitioner, it 
must submit both the Form CMS-855B and the Form CMS-855R. When one or both of these 
forms requires the contractor to develop for information, the contractor may apply to both the 
Form CMS-855B and Form CMS-855R the receipt date of the first application that is submitted 
as complete (i.e., no further development is necessary).  
 
10.3.1.5  Form CMS-855O  Medicare Enrollment Application for Eligible 
Ordering and Certifying Physicians, and other Eligible Professionals  
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
This form is used by physicians and other eligible professionals who wish to enroll in Medicare 
solely for the purpose of ordering and certifying the services/items described in 42 CFR  
424.507(a) and (b).  These physicians and other eligible professionals do not and will not send 
claims to a contractor for the services they furnish. In addition, suppliers who have opted out of 
Medicare are not permitted to enroll via the Form CMS-855O for purposes of ordering or 
certifying. 
 
The physician/other eligible professional need not submit a Form CMS-460, a Form CMS-588, 
or an application fee with his or her Form CMS-855O. 
 
10.3.1.5.1  Sections 1 through 7 of the Form CMS-855O  
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A. Basic Information (Section 1) 
 
In this section, the ordering or certifying individual indicates the reason for the application 
submittal.  Unless otherwise stated in this chapter, in another CMS directive, or as permitted by 
PECOS, the ordering or certifying individual may only check one reason for submittal.  
 
With the exception of the voluntary termination checkbox---and except as stated in section 
10.6.1.3 of this chapter---any blank data/checkboxes in the Basic Information section can be 
verified via any means (e.g., e-mail, telephone, fax). 
 
B.  Identifying Information (Section 2) 
 
1.   License/Certification/Registration Information 
 
The extent to which the ordering or certifying individual must complete the licensure, 
certification, or accreditation information depends upon the individuals supplier type.  
Requirements will vary by supplier type and by location; for instance, some states may require a 
particular supplier type to be certified but not licensed, or vice versa.  In general, individuals 
will have licensure information to submit.  However, a License Not Applicable check box is 
furnished for cases where a state does not require licensure or, for unlicensed residents, if the 
application submission includes either:  
 
(a) A residency contract signed and dated by both an official of the institution and the resident 
physician; or   (b) A letter on institution letterhead signed and dated by an official of the institution that (i) 
confirms the applicants status as a resident physician and (ii) contains, at a minimum, the 
applicants name.   
 
The only licenses that must be submitted with the application are those required by Medicare or 
the state to function as the ordering or certifying supplier type in question.  Licenses and permits 
not of a medical nature are not required.  In addition, cases might arise where the individual need 
not be licensed in a particular state at all; however, the contractor shall still ensure that the 
supplier meets all applicable state and Medicare requirements. 
 
If the supplier is required to submit a copy of a particular professional or business license, 
certification, registration, or degree but fails to do so, the contractor need not obtain such 
documentation from the supplier if the contractor can verify the information independently.  This 
can be done by: (1) reviewing and printing confirming pages from the applicable state, 
professional, or school web site; (2) requesting and receiving from the appropriate state, 
professional, or educational body written confirmation of the suppliers status therewith; or (3) 
utilizing another third-party verification source.  Likewise, if the supplier submits a copy of the 
applicable license, certification, registration, or degree but fails to complete the applicable 
section of the form, the section need not be completed if the data in question can be verified on 
the license/certification itself or via any of the three mechanisms above. 
 
2.  Correspondence Address and Telephone Number  
 
The correspondence address must be one at which the contractor can directly contact the 
applicant to resolve any issues once the supplier is enrolled in Medicare.  It cannot be the address 
of a billing agency, management services organization, chain home office, or the suppliers 
representative (e.g., attorney, financial advisor).  It can, however, be a P.O. Box or, in the case of 
an individual practitioner, the persons home address. The contractor need not verify the 
correspondence address. 
 
The applicant may list any telephone number he/she wishes as the correspondence phone 
number.  The number need not link to the listed correspondence address.  If the supplier fails to 
list a correspondence telephone number and the latter is required for the application submission, 
the contractor shall develop for this information  preferably via the PCV, e-mail, or fax.  The 
contractor shall accept a particular phone number if it has no reason to suspect it does not belong 
to or is not somehow associated with the supplier. The contractor need not verify the telephone 
number. 
 
3.  E-mail Addresses 
 
An e-mail address listed on the application can be a generic one. It need not be that of a specific 
individual.  The contractor may accept a particular e-mail address if it has no reason to suspect it 
does not belong to or is not somehow associated with the supplier. 
 
4.  Drug Enforcement Agency (DEA)  
  DEA certificates need not be submitted if the applicable DEA information was furnished on the 
Form CMS-855.  Likewise, if the aforementioned certificates are furnished but the applicable 
Form CMS-855 sections are blank, no further development is needed. 
 
C.  Final Adverse Legal Actions/Convictions (Section 3) 
 
See section 10.6.6 of this chapter for information regarding final adverse actions.  Except as 
otherwise stated, the PECOS policies in section 10.3 supersede those in section 10.6.6 (e.g., 
communicating with the provider via the PCV).   
 
D.  Medical Specialty Information (Section 4) 
 
The contractor shall validate that any supplier identifying a primary specialty on the Form CMS-
855O has the appropriate medical license.  The contractor shall validate the license using the 
states medical license website.  If an active license is not found, the contractor shall develop via 
telephone, fax, the PCV, e-mail, or mail to confirm the suppliers intent and to obtain a copy of 
the license, if applicable.   
 
E.  Important Address Information (Section 5) 
 
The address information furnished in the Important Address Information section of the Form 
CMS-855O helps the contractor contact the supplier directly, if necessary. 
 
F.  Contact Person Information (Section 6) 
 
(See section 10.6.9 of this chapter for more information on contact persons.  Except as otherwise 
stated, the PECOS policies in section 10.3 above supersede those in section 10.6.9.)   
 
If Section 6 is completely blank, the contractor need not develop for this information and can 
simply contact the physician or practitioner. 
 
There is no existing option on the Form CMS-855O form to delete a contact person.  The 
contractor shall therefore accept end-dates of a contact person via phone, the PCV, e-mail, fax, 
or mail from the individual himself/herself or a current contact person on file.  The contractor 
shall document in PECOS who requested the termination, how it was requested (email, phone or 
fax), and when it was requested.  The addition of contact persons must still be reported via the 
Form CMS-855O. 
 
G. Penalties for Falsifying Information (Section 7) 
 
See the Penalties for Falsifying Information section of the Form CMS-855O for the penalties that 
apply to suppliers for deliberately furnishing false information on this application to gain or 
maintain Medicare enrollment. 
 
10.3.1.5.2  Section 8 (Certification Statement) - Form CMS-855O  
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
  A. General Policies 
 
The enrolling or enrolled physician or other eligible professional is the only person who can sign 
the Form CMS-855O. This person cannot delegate the authority to sign the Form CMS-855O on 
his/her behalf to any other individual. This applies to initial enrollments, changes of information, 
reactivations, voluntary withdrawals, etc.  (Note: In the case of death, an executor of the estate 
may sign on behalf of the deceased supplier. This situation would only apply to change of 
information applications.) 
 
For paper applications, handwritten (wet) signatures in ink and digital/electronic signatures 
(digital or electronic signatures such as those created by digital signature options created in 
software, such as Adobe) are acceptable.  For web applications, electronic signatures are 
required; the contractor may contact its PEOG BFL for questions regarding electronic signatures. 
 
B.  Paper Applications 
 
A signed certification statement shall accompany the paper Form CMS-855O application.  If the 
supplier submits an invalid certification statement or fails to submit any certification statement at 
all, the contractor shall still proceed with processing the application. An appropriate certification 
statement shall be solicited as part of the development process  preferably via the PCV, e-mail, 
or fax. This includes certification statements that are: (a) unsigned; (b) undated; (c) signed (as 
reflected by the date of signature) more than 120 days prior to the date on which the contractor 
received the application); (d) signed by someone other than the physician or practitioner (except 
as otherwise noted in this section 10.3.1.5.2); (e) missing; or (f) stamped.  The contractor shall 
send one development request to include a list of all of the missing required data/documentation, 
including the certification statement. The contractor may reject the suppliers application if the 
supplier fails to furnish the missing information on the enrollment application - including all 
necessary documentation - within 30 calendar days from the date the contractor requested the 
missing information or documentation.  
 
Unless stated otherwise in this chapter or in another CMS directive: 
   
(i) The contractor shall begin processing the application upon receipt and shall develop for 
missing certification statements and all other missing information. 
 
(ii) The certification statement may be returned via scanned email or fax. 
 
(iii) Signature dates cannot be more than 120 days prior to the receipt date of the application. 
 
(iv) For paper applications that require development, the suppliers dated signature must be on 
the certification statement that is to be submitted within 30 days. 
 
(v) For paper changes of information applications---and except as stated in section 10.3.1.5.2(A)-
-the contractor shall only accept a certification statement signed by the individual physician or 
practitioner. 
  (vi) The contractor need not compare the Form CMS-855O signature with the same persons 
signature on file to ensure it is the same individual.   
 
(vii) The contractor shall not request the submission of a drivers license or passport to verify a 
persons signature or identity. 
 
C.  PECOS Submissions 
 
Unless stated otherwise in this chapter or in another CMS directive: 
 
(i) The contractor shall (a) begin processing the application upon receipt via PECOS; (b) perform 
all required manual validations; and (c) develop for any needed clarifying or missing information 
or documentation consistent with section 10.3 and all other applicable instructions in this 
chapter.  
 
(ii) If the supplier submits an invalid certification statement, the contractor shall treat this as 
missing information and develop for a correct certification statement  preferably via the PCV, 
e-mail, or fax.  (This includes certification statements that are signed by someone other than the 
physician or practitioner who signed the form (except as otherwise noted in this section 
10.3.1.5.2(A)).  The contractor shall send one development request to include a list of all of 
data/documentation to be furnished or clarified, including, as applicable, the certification 
statement.  The contractor may reject the suppliers application if the supplier fails to furnish said 
data/documentation within 30 calendar days from the date of the contractors request.   
 
(iii) For PECOS applications that require development, the suppliers dated signature must be on 
the certification statement to be sent in within 30 days. 
 
(iv) For PECOS change of information applications, the contractor shall only accept a 
certification statement signed by the individual physician or practitioner. 
 
(v) The contractor need not compare the Form CMS-855O signature with the same persons 
signature on file to ensure it is the same individual.   
 
(vi) The contractor shall not request the submission of a drivers license or passport to verify a 
persons signature or identity. 
 
D.  Certification Statement Development 
 
Newly signed certification statements furnished per a development request must be submitted as 
follows:    
 
(i) Paper applications -- Via scanned email, fax, or mail.  Only the actual signature page is 
required; the provider need not submit the additional page containing the certification terms. 
(This also applies to the providers initial submission of a certification statement.  Such instances 
require the submission of only the signature page and not the certification terms.) 
 
(ii) Web applications  Via electronic signature.      
E.  Privacy Statement 
 
The Privacy Act permits CMS to disclose information without an individuals consent if the 
information is to be used for a purpose that is compatible with the purpose(s) for which the 
information was collected. Any such disclosure of data is known as a routine use. The CMS 
will only release PECOS information that can be associated with an individual as provided for 
under Section III Proposed Routine Use Disclosures of Data in the System. Both identifiable 
and non-identifiable data may be disclosed under a routine use. CMS will only collect the 
minimum personal data necessary to achieve the purpose of PECOS. To view the routine uses in 
their entirety go to: https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-
and-Systems/Privacy/Downloads/0532-PECOS.pdf. 
 
10.3.1.5.3  Form CMS-855O Initial Applications and Change Requests 
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
The contractor shall follow all applicable instructions in section 10.3 when processing Form 
CMS-855O initial applications and change requests. 
 
A.  Processing Initial Form CMS-855O Submissions 
 
1.  Returns 
 
Section 10.4.1.4.2 of this chapter (which reflects 42 CFR  424.526) outlines the reasons for 
which the contractor may immediately return a Form CMS-855O.  If the contractor determines 
that one or more of these reasons applies, it may return the form in accordance with the 
instructions outlined in that section. 
 
2.  Verification 
 
Unless stated otherwise in this chapter or in another CMS directive, the contractor shall ensure 
that all information on the Form CMS-855O is verified.  This includes, but is not limited to: 
 
a.  Verification of the individuals name, date of birth, social security number, and NPI. 
 
b.  Verification that the individual meets the requirements for his/her supplier type.  
 
c.  Verification that the individual is of a supplier type that can legally order or certify. 
 
d.  Reviewing the Medicare Exclusion Database (MED) and System for Award Management 
(SAM) to ensure that the individual is not excluded or debarred.  (See section 10.6.6 of this 
chapter for additional adverse action verifications that may be required.) 
 
If, at any time during the verification process, the contractor needs additional or clarifying 
information from the physician/eligible professional, it shall follow existing CMS instructions 
for obtaining said data (e.g., sending a development letter). The information must be furnished to 
the contractor within 30 calendar days of the contractors request.   
3. Disposition  
 
Upon completion of its review of the form, the contractor shall approve, deny, or reject it. 
 
a.  Denial  
 
Grounds for denial are as follows: 
 
i.  The supplier is not of a type that is eligible to use the Form CMS-855O. 
 
ii.  The supplier is not of a type that is eligible to order or certify items or services for Medicare 
beneficiaries. 
 
iii.  The supplier does not meet the licensure, certification, or educational requirements for his or 
her supplier type. 
 
iv.  The supplier is excluded per the MED and/or debarred per the SAM. 
 
If the contractor believes that another ground for denial exists for a particular submission, it 
should contact its PEOG BFL for guidance. 
 
b.   Rejection  
 
The Form CMS-855O may be rejected if the supplier fails to furnish all required information on 
the form within 30 calendar days of the contractors request to do so.  (This includes situations in 
which information was submitted but could not be verified.)  The basis for rejection shall be 42 
CFR  424.525(a). (See section 4.1.4.3(A)(1) for more information on rejection bases.)   
 
c.  Denial or Rejection  PECOS and Letters 
 
When denying or rejecting an initial Form CMS-855O, the contractor shall: (1) switch the 
PECOS record to a denied or rejected status (as applicable); and (2) send a letter to the 
supplier notifying him/her of the denial or rejection and the reason(s) for it.  The letter shall 
follow the applicable letter formats described in section 10.7, et seq.  Denial letters shall be sent 
via certified mail.  Rejection letters shall be sent by mail, the PCV, or e-mail.  (NOTE: A denial 
triggers appeal rights.  A rejection does not.) 
 
d.  Approval 
 
If the Form CMS-855O is approved, the contractor shall: (1) switch the PECOS record to an 
approved status, and (2) send a letter (via mail, the PCV, or e-mail) to the supplier notifying 
him/her of the approval.  The letter shall follow the applicable format outlined in section 10.7.3 
of this chapter. 
 
4.  Miscellaneous Policies 
 
The contractor shall observe the following:   
a.  The supplier shall be treated as a non-participating supplier (or non-par). 
 
b.  If the supplier is employed by the DVA, the DOD, or the IHS, he/she  for purposes of the 
Form CMS-855O - need only be licensed or certified in one state.  Said state need not be the one 
in which the DVA or DOD office is located. 
 
c.  Nothing in this section 10.3.1.5.3(A) affects any existing CMS instructions regarding the 
processing of opt-out affidavits. 
 
d.  Suppliers cannot submit an abbreviated version of the Form CMS-855I in lieu of the Form 
CMS-855O. 
 
e.  Per 42 CFR  424.522(b), the effective date of a Form CMS-855O enrollment shall be the 
date on which the contractor received the application if all other requirements are met. 
 
f.  If the suppliers Form CMS-855O has been approved and he/she later wants to obtain 
Medicare billing privileges, he or she must voluntarily withdraw his/her Form CMS-855O 
enrollment prior to receiving Medicare billing privileges.  (The supplier must complete the Form 
CMS-855I in order to receive Medicare billing privileges.) 
 
B.  Processing Form CMS-855O Change of Information Requests  
 
1.  Receipt 
 
Section 10.4.1.4.2 of this chapter outlines the reasons for which the contractor may immediately 
return a Form CMS-855O.  If the contractor determines that one or more of these reasons 
applies, it may return the change request via the instructions outlined in that section. 
 
Suppliers who are enrolled in Medicare via the Form CMS-855I may not report changes to their 
enrollment information via the Form CMS-855O.  They must use the Form CMS-855I.  
Likewise, suppliers whose Form CMS-855O submissions have been approved must use the Form 
CMS-855O to report information changes; they cannot use the Form CMS-855I for this purpose. 
 
2.  Verification 
 
Unless stated otherwise in this chapter or in another CMS directive, the contractor shall verify 
the new information that the supplier furnished on the Form CMS-855O.   (This includes 
checking the supplier against the MED and the SAM.)  If, at any time during the verification 
process, the contractor needs additional or clarifying information, it shall follow existing CMS 
instructions for obtaining said data (e.g., sending a developmental letter).  The information must 
be furnished to the contractor within 30 calendar days of the contractors request. 
 
C. Disposition 
 
Upon completion of its review of the change request, the contractor shall approve, deny, or reject 
the submission.  The principal ground for denial will be that the new information was furnished  but could not be verified.  If the contractor believes this is the case or if another ground for denial 
exists with respect to a particular submission, it should contact its PEOG BFL for guidance. 
 
The change request may be rejected if the supplier failed to furnish all required information on 
the form within 30 calendar days of the contractors request to do so.  The basis for rejection 
shall be 42 CFR  424.525(a).  (See section 4.1.4.3(A)(1) for more information on rejection 
bases.)   
 
When denying or rejecting the change request, the contractor shall: (1) switch the PECOS record 
to a denied or rejected status (as applicable); and (2) send a letter (via mail, the PCV, or e-
mail) to the supplier notifying him/her of the denial or rejection and the reason(s) for it. 
 
If the change request is approved, the contractor shall (1) switch the PECOS record to an 
approved status and (2) send a letter (via mail, the PCV, or e-mail) to the supplier notifying 
him/her of the approval. 
 
D. Relocation 
 
Since the Form CMS-855O is a national enrollment, suppliers who relocate to another state need 
not disenroll in the current state and reenroll in the new state. The contractor that maintains the 
Form CMS-855O enrollment in PECOS is responsible for processing the change request, even if 
the supplier is relocating to a state outside of their jurisdiction. If any new licenses and/or 
certifications are obtained as a result of the suppliers relocation, the contractor shall ensure that 
the updated information is captured in the suppliers enrollment record.  
 
This policy applies to any physician, non-physician practitioner, or resident who is enrolled via 
the Form CMS-855O. 
 
10.3.1.5.4  Form CMS-855O Processing Alternatives and Miscellaneous 
Policies 
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Processing Alternatives 
 
The alternatives in this section 10.3.1.5.4(A) are applicable to all sections of the Form CMS-
855O, unless otherwise specified.  As stated in section 10.3, however, some of the application 
data elements and verification procedures that have previously been subject to a processing 
exception/alternative may no longer be so or are moot under PECOS 2.0.  (See section 10.3 for a 
discussion of such data and procedures.)  In such situations, the contractor shall disregard the 
exception/alternative and follow the instructions in sections 10.3 through 10.3.1.5.3. 
 
1.  General Alternatives 
 
(i) If blank, Type of Other Name and Gender can be captured orally.  
  (ii) If the contractor knows that a particular state does not require licensure/certification and the 
Not Applicable boxes are not checked in the Personal Identifying Information (License/ 
Certification/Registration Information) section, no further development is needed. 
 
(iii) When processing a non-physician practitioners (NPP) application, the contractor need not 
request a copy of the NPPs degree or diploma (if it is not submitted) if his/her education can be 
verified through other authorized means. Requesting a copy of the degree or diploma should only 
be done if educational information cannot otherwise be verified. 
 
2.  Information Disclosed Elsewhere 
 
If a data element on the Form CMS-855O application is missing but the information is disclosed 
(1) elsewhere on the application or (2) in the supporting documentation submitted with the 
application, the contractor need not obtain the missing data via an updated Form CMS-855O 
page and a newly-signed certification statement; no further development  not even by telephone 
 is required.  The following information, however, must be furnished in the appropriate 
section(s) of the Form CMS-855O, even if the data is identified elsewhere on the form or in the 
supporting documentation: 
 
(i) Except as otherwise stated in section 10.6.6 of this chapter, any final adverse action data 
requested in the Final Adverse Legal Actions section 
 
(ii) Legal names 
 
(iii) Tax identification number (TIN) 
 
(iv) NPI-legacy number combinations in the Identifying Information section (if applicable) 
(Note: The contractor may use the shared systems, PECOS, or its provider files as a resource to 
determine the PTAN or NPI before developing with the supplier.) 
 
(v) Data in the Basic Information section   
 
If the supporting documentation currently exists in the suppliers file, the supplier need not 
submit that documentation again during the enrollment process. The contractor shall utilize the 
existing documentation for verification. Documentation submitted with a previously submitted 
enrollment application (or documentation currently uploaded in PECOS) qualifies as a 
processing alternative unless stated otherwise in this chapter or in another CMS directive. Also, 
the contractor shall document in PECOS that the missing information was found elsewhere in the 
enrollment package. (However, this excludes information that must be verified at the current 
point in time (i.e., a license without a primary source verification method)). In addition, the 
contractor shall not utilize information submitted along with opt-out applications for enrollment 
application processing or vice-versa. 
 
3.  City, State, and ZIP Code  
 
If a particular address lacks a city or state, the contractor can verify the missing data in any 
manner it chooses.  In addition, the contractor can obtain the zip + four from either the U.S. 
Postal Service or Delivery Point Validation in PECOS.   
4.  Sectional Processing Alternatives 
 
The processing alternatives in this section 10.3.1.5.4 are in addition to, and not in lieu of, all 
other processing alternatives in section 10.3.1.5, et seq.  
 
B.   Unsolicited Additional Information 
 
If the supplier submits additional/missing/clarifying data or documentation on its own volition 
(i.e., without being contacted by the contractor), the contractor shall include this additional 
data/documentation in its overall application review. Any new or changed information that a 
supplier submits prior to the date the contractor finishes processing a previously submitted 
change request constitutes a separate change request rather than an update to the original change 
request.  The contractor may process both changes simultaneously; however, the change that was 
submitted first shall be processed to completion prior to the second one being processed to 
completion. 
 
C.  Conversion from Form CMS-855O to Form CMS-855I  PECOS Requirements 
 
Internet-based PECOS permits an individual supplier to convert his/her current Form CMS-855O 
application to a Form CMS-855I enrollment and vice versa.  Such suppliers shall follow the 
current process for creating a new application.  When PECOS detects existing approved 
enrollments, the supplier will be prompted to select from a list of those enrollments that will be 
used to pre-populate the information for the new application.  The supplier must confirm that 
he/she wants to withdraw the existing enrollments before the new application may be submitted. 
 
The enrollments to be withdrawn are displayed in a new section of the ADR in PECOS 
Administrative Interface (AI).  The contractor shall review this information and take the 
appropriate action to voluntarily withdraw the enrollments listed.  The contractor shall begin 
processing the Form CMS-855I enrollment but leave it in In Review status while withdrawing 
the other enrollments.  (For paper applications, a logging and tracking (L&T) submittal reason of 
Voluntary Termination shall be used to withdraw the Form CMS-855O enrollment.)  The 
effective date of the withdrawn enrollments shall be one day prior to the effective date of the 
Form CMS-855I enrollment.  If the Form CMS-855O enrollment requiring withdrawal is outside 
of the contractors jurisdiction, the contractor shall notify the other contractor via the PCV or 
email using the Associate Profile Contact List, stating that the enrollment needs to be 
voluntarily withdrawn.  The second contractor shall take action based on the email and retain the 
email as documentation. 
 
If the supplier submits a paper Form CMS-855I and a current Form CMS-855O enrollment exists 
within the contractor jurisdiction, the contractor shall voluntarily withdraw the Form CMS-855O 
enrollment.  If the current Form CMS-855O enrollment is outside of the contractors jurisdiction, 
the contractor shall notify the other contractor via the PCV or e-mail (using the Associate 
Profile Contact List) that the enrollment needs to be voluntary withdrawn.  The second 
contractor shall take action based on the email and retain the email as documentation. 
 
If the supplier submits a paper Form CMS-855O to voluntarily withdraw his/her enrollment as 
well as a paper Form CMS-855I to begin billing Medicare, the contractor shall not contact the  supplier to confirm the submissions unless the contractor has reason to believe that what was 
submitted was not the suppliers intention.  If it is determined that the supplier submitted 
applications to convert his/her existing Form CMS-855O enrollment into a Form CMS-855I 
enrollment in error (either via paper or PECOS), the contractor shall return the application (thus 
returning the enrollment record back to its previous state) because it is not needed and/or is 
inapplicable to the situation. 
 
G. Form CMS-855O Processing Guide 
 
Go to https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-
Manuals-IOMs-
Items/CMS019033.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending to view 
the CMS-855O Processing Guide, which constitutes a general Form CMS-855O processing 
guide for suppliers and contractors. The procedures described in the Guide, which include 
processing alternatives and processing instructions for the Form CMS-855O, take precedence 
over all other instructions in this chapter concerning the processing of Form CMS-855O 
applications. 
 
10.3.1.5.5  Form CMS-855O Revocations  
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
If the contractor determines that grounds exist for revoking the suppliers Form CMS-855O 
enrollment, it shall:  
 
(i) Switch the suppliers PECOS record to a revoked status 
 
(ii) End-date the PECOS record  
 
(iii) Send a letter via certified mail to the supplier stating that his/her Form CMS-855O 
enrollment has been revoked.  The letter shall follow the format outlined in section 10.7.8 of this 
chapter. 
 
Grounds for revoking the suppliers Form CMS-855O enrollment are as follows: 
 
(i) The supplier is no longer of a type that is eligible to order or certify 
 
(ii) The supplier no longer meets the licensure, certification, or educational requirements for his 
or her supplier type 
 
(iii) The supplier is excluded per the MED and/or debarred per the SAM 
 
For purposes of the Form CMS-855O only, the term revocation effectively means that: 
 
(i) The supplier may no longer order or certify Medicare services based on his/her having 
completed the Form CMS-855O process. 
  (ii) If the supplier wishes to submit another Form CMS-855O, he/she must do so as an initial 
applicant. 
 
There are appeal rights associated with the revocation of a suppliers Form CMS-855O 
enrollment. 
 
10.3.1.6  Form CMS-855S  Medicare Enrollment Application for Durable 
Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) 
Suppliers  
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
This application should be completed by DMEPOS suppliers.  . 
 
(Note that the Form CMS-855S section numbers in PECOS may not correspond precisely to 
those on the paper Form CMS-855S.) 
 
10.3.1.6.1  Sections 1 through 13  Form CMS-855S 
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Basic Information (Section 1) 
 
In this section, the supplier indicates the reason for submittal of the application.  Unless 
otherwise stated in this chapter, in another CMS directive, or as permitted by PECOS, the 
supplier may only check one reason for submittal.  Additionally, the supplier will identify its 
business and business location in this section. 
 
B.  Identifying Information (Section 2) 
 
1. Locations and Addresses - Except for locations used only as warehouse and/or repair facilities, 
the supplier must submit a completed Form CMS-855S application for each physical location.  
Each address must be a street address as recorded by the USPS, and P.O. boxes will not be 
accepted. 
 
2. Hours  The supplier must list their posted hours of operation as displayed at the 
aforementioned business location.  Unless otherwise stated in this chapter or in another CMS 
directive, the supplier shall have a minimum of 30 hours of operation per week. 
 
3. Unavoidable Phone Number or Address Changes  Unless CMS specifies otherwise, any 
change in the suppliers phone number or address that the supplier did not cause (e.g., area code 
change, municipality renames the suppliers street) must still be updated via the Form CMS-
855S.  
 
See section 10.2.5 of this chapter for information on accreditation requirements. 
 
C.  Final Adverse Legal Actions (Section 3) 
  See section 10.6.6 of this chapter for information regarding final adverse actions.  Except as 
otherwise stated, the PECOS policies in section 10.3 supersede those in section 10.6.6 (e.g., 
communicating with the supplier via the PCV).   
 
D.  Important Address Information (Section 4) 
 
See the Important Address Information section of the Form CMS-855S for more background on 
this matter. 
 
E.  Ownership Interest and/or Managing Control Information (Organizations) (Section 5) 
 
See section 10.6.7 et seq. of this chapter for information concerning owning and managing 
organizations.   
 
F.  Ownership Interest and/or Managing Control Information (Individuals) (Section 6) 
 
See section 10.6.7 et seq. of this chapter for information concerning owning and managing 
individuals.   
 
G.  Comprehensive Liability Insurance Information and Surety Bond Information (Section 
7) 
 
See section 10.2.5 of this chapter for information regarding comprehensive liability insurance 
and surety bond information.    
 
H.  Billing Agency Information (Section 8) 
 
(See section 10.6.8 of this chapter for more information on billing agencies.  Except as otherwise 
stated, the PECOS policies in section 10.3 above supersede those in section 10.6.8.)   
 
If the telephone number in the Billing Agency Information section is blank, the number can be 
verified with the supplier by telephone, the PCV, e-mail, or fax.  If the entire section is blank 
(including the check box), no additional development is necessary. 
 
I.  Supporting Documents (Section 12) 
 
See the Supporting Documents section of the Form CMS-855S for information concerning 
supporting documents. 
 
J.  Contact Person Information (Section 13) 
 
If this section is completely blank, the contractor need not develop for this information and can 
simply contact an authorized or delegated official. 
 
If neither box is checked but the contact person information is incomplete (e.g., no telephone 
number listed), the contractor can either: (1) develop for this information by telephone, the PCV, 
e-mail, or fax; or (2) contact an authorized or delegated official. 
  There is no existing option on the Form CMS-855S to delete a contact person.  The contractor 
shall therefore accept end-dates of a contact person via telephone, the PCV, e-mail, fax, or mail 
from the individual supplier, the authorized or delegated official, or a current contact person on 
file.  The contractor shall document in PECOS who requested the termination, how it was 
requested (email, phone or fax), and when it was requested.  The addition of contact persons 
must still be reported via the appropriate Form CMS-855S. 
 
See section 10.6.9 of this chapter for more information on contact persons.  Except as otherwise 
stated, the PECOS policies in section 10.3 above supersede those in section 10.6.9.   
 
K. Penalties for Falsifying Information (Section 14) 
 
See the Penalties for Falsifying Information section of the Form CMS-855S for an explanation of 
penalties that apply to suppliers for deliberately furnishing false information in this application to 
gain or maintain enrollment in the Medicare program.   
 
10.3.1.6.2  Authorized and Delegated Officials  Form CMS-855S  
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  General Requirement 
 
For Form CMS-855S initial applications, the certification statement must be signed and dated by 
an authorized official of the supplier. (See section 10.1.1 for a definition of authorized official 
and section 10.3.1.1.11 for detailed information on authorized officials.).   For Form CMS-855S 
applications to change, update, and/or revalidate the suppliers Medicare enrollment data, the 
certification statement may be signed and dated by an authorized or delegated official of the 
supplier.  
 
For paper applications, handwritten (wet) signatures in ink and digital/electronic signatures 
(digital or electronic signatures such as those created by digital signature options created in 
software, such as Adobe) are acceptable.  For web applications, electronic signatures are 
required; the contractor may contact its PEOG BFL for questions regarding electronic signatures. 
 
B.  Qualifications 
 
1.  Authorized Officials 
 
See section 10.3.1.1.11 for information regarding the requirements to be an authorized official. 
 
2.  Delegated Officials 
 
A delegated official is an individual to whom an authorized official delegates the authority to 
report changes and updates to the suppliers enrollment record or to sign revalidation 
applications.  The delegated officials signature binds the organization both legally and 
financially, as if the signature was that of the authorized official. Before the delegation of 
authority is established, the only acceptable signature on the enrollment application to report  updates or changes to the enrollment information is that of the authorized official currently on 
file with Medicare.   
 
The delegated official must be an individual with an ownership or control interest in (as that 
term is defined in 1124(a)(3) of the Social Security Act) or be a W-2 managing employee of the 
supplier.  Section 1124(a)(3) defines an individual with an ownership or control interest as: 
 
(i) A five percent direct or indirect owner of the supplier, 
 
(ii) An officer or director of the supplier (if the supplier is a corporation), or 
 
(iii) Someone with a partnership interest in the supplier if the supplier is a partnership 
 
The delegated official must be a delegated official of the supplier, not of an owning organization, 
parent company, chain home office, or management company.  One cannot use his/her status as a 
W-2 managing employee of the suppliers parent company, management company, or chain 
home office as a basis for his/her role as the suppliers delegated official. 
 
Section 6 (Ownership Interest and/or Managing Control Information) of the Form CMS-855S 
must be completed for all delegated officials.  
 
A delegated official has no authority to sign an initial application.  However, as explained above, 
a delegated official may (i) sign a revalidation application or change request and (ii) sign off on 
changes/updates submitted in response to a contractors request to clarify or submit information 
needed to continue processing the supplier's initial application. 
 
Delegated officials may not delegate their authority to any other individual.  Only an authorized 
official may delegate the authority to make changes and/or updates to the supplier's Medicare 
data or to sign revalidation applications. 
 
For purposes of the Delegated Officials information captured in the Individual Ownership 
Interest and/or Managing Control Information section only, the term "managing employee" 
means any individual--including a general manager, business manager, or administrator--who 
exercises operational or managerial control over the supplier, or who conducts the day-to-day 
operations of the supplier.  However, this does not include persons who, either under contract or 
through some other arrangement, manage the day-to-day operations of the supplier but who are 
not actual W-2 employees.  For instance, suppose the supplier hires Joe Smith as an independent 
contractor to run its day-to-day-operations.  Under the definition of "managing employee" in the 
Individual Ownership and/or Managing Control section of the Form CMS-855S, Smith would 
have to be listed in that section.  Yet Smith cannot be a delegated official because he is not an 
actual W-2 employee of the supplier.  Independent contractors are not considered "managing 
employees" for purposes of qualifying as a delegated official.  
 
2.  W-2 Form - Unless the contractor requests it to do so, the supplier need not submit a copy of 
the owning/managing individuals W-2 to verify an employment relationship. 
 
3.  Number of Delegated Officials - The supplier can have as many delegated officials as it 
chooses.  Conversely, the supplier need not have any delegated officials.  Should no delegated  officials be listed, however, the authorized official(s) remains the only individual(s) who can 
report changes and/or updates to the supplier's enrollment data. 
 
4.  Effective Date - The delegated officials effective date in PECOS should be the effective date 
listed in the Delegated Officials section or the receipt date of the Form CMS-855S application. 
 
5.  Social Security Number - To be a delegated official, the person must have and must submit 
his/her social security number (SSN).  An Individual Taxpayer Identification Number (ITIN) 
cannot be used in lieu of an SSN in this regard. 
 
6.  Deletion of a Delegated Official - If a delegated official is being deleted, documentation 
verifying that the person no longer is or qualifies as a delegated official is not required.  Also, the 
signature of the deleted official is not needed. 
 
7.  Delegated Official Not on File - If the supplier submits a change of information (e.g., change 
of address) and the delegated official signing the form is not on file, the contractor shall ensure 
that: (1) the person meets the definition of a delegated official; (2) Section 6 of the Form CMS-
855S is completed for that person; and (3) an authorized official signs off on the addition of the 
delegated official.  (NOTE: The original change request and the addition of the new official shall 
be treated as a single change request (i.e., one change request encompassing two different 
actions) for purposes of enrollment processing and reporting.) 
 
8.  Signature on Paper Application  
 
If the supplier submits a paper Form CMS-855S change request, the contractor may accept the 
signature of a delegated official in the Assignment of Delegated Officials or Authorized Official 
Certification Statement and Signature sections of the Form CMS-855S. 
 
In addition, the Delegated Officials telephone number can be left blank. No further development 
is needed. 
 
C.  Privacy Statement 
 
The Privacy Act permits CMS to disclose information without an individuals consent if the 
information is to be used for a purpose that is compatible with the purpose(s) for which the 
information was collected. Any such disclosure of data is known as a routine use. The CMS 
will only release PECOS information that can be associated with an individual as provided for 
under Section III Proposed Routine Use Disclosures of Data in the System. Both identifiable 
and non-identifiable data may be disclosed under a routine use. CMS will only collect the 
minimum personal data necessary to achieve the purpose of PECOS. To view the routine uses in 
their entirety go to: https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-
and-Systems/Privacy/Downloads/0532-PECOS.pdf. 
 
 
10.3.1.6.3  Additional Processing Information and Alternatives for Form 
CMS-855S 
(Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23)   
A.  Unsolicited Additional Information 
 
If the supplier submits missing/clarifying data or documentation on its own volition (i.e., without 
being contacted by the contractor), the contractor shall include this additional 
data/documentation in its overall application review.  Any new or changed information that a 
supplier submits prior to the date the contractor finishes processing a previously submitted 
change request is no longer considered to be an update to that change request.  Rather, it is 
considered to be and shall be processed as a separate change request.  The contractor may 
process both changes simultaneously, but the change that was submitted first shall be processed 
to completion prior to the second one being processed to completion. 
 
B. Information Disclosed Elsewhere 
 
If a data element on the suppliers Form CMS-855S application is missing but the information is 
disclosed (1) elsewhere on the application or (2) in the supporting documentation submitted with 
the application, the contractor need not obtain the missing data via an updated Form CMS-855S 
page and a newly-signed certification statement.  No further development  not even by 
telephone  is required.  The following information, however, must be furnished in the 
appropriate section(s) of the Form CMS-855S, even if the data is identified elsewhere on the 
form or in the supporting documentation: 
 
(i) Except as otherwise stated in section 10.6.6 of this chapter, any final adverse action data 
requested in the Final Adverse Legal Actions section and in the Final Adverse Legal Action 
History of the Organizational and Individual Ownership and/or Managing Control sections of the 
Form CMS-855S 
 
(ii) Tax identification numbers (TIN)  
 
(iii) Supplier type in the Products/Accreditation Information section of the Form CMS-855S  
 
If the supporting documentation currently exists in the suppliers file, the supplier is not required 
to submit that documentation again during the enrollment process. The contractor shall utilize the 
existing documentation for verification. Documentation submitted with a previously submitted 
enrollment application (or documentation currently uploaded in PECOS) qualifies as a 
processing alternative, unless stated otherwise in this chapter or another CMS directive. Also, , 
the contractor shall document in PECOS that the missing information was found elsewhere in the 
enrollment package. (This excludes information that must be verified at the current point in time 
(i.e., a license without a primary source verification method).)  In addition, the contractor shall 
not utilize information submitted along with opt-out applications for enrollment application 
processing or vice-versa. 
 
10.3.2  CMS-20134  Enrollment Form: Information and Processing 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
The Form CMS-20134 application (Medicare Enrollment Application for Medicare 
Diabetes Prevention Program (MDPP) Suppliers) should be completed by organizations  furnishing MDPP services to Medicare beneficiaries. In-Person MDPP suppliers 
participating in the Center for Medicare and Medicaid Innovations expanded model, which 
exclusively furnishes MDPP to beneficiaries in in-person settings with limited exceptions 
for virtual makeup sessions, may begin enrolling in Medicare on January 1, 2018. 
 
This section 10.3.2 et seq. contains instructions for processing the various sections of the 
Form CMS-20134 and addresses important related MDPP policies.  When processing Form 
CMS-20134 applications submitted via PECOS, the contractor shall also follow the 
applicable PECOS instructions in section 10.3 of this chapter.  In the event a policy or 
operational practice in section 10.3.2 et seq. is contrary to that in section 10.3 (e.g., 
communication mechanisms, validation, documentation submission), the latter takes 
precedence. 
 
10.3.2.1  CMS-20134 (Section 1 - Basic Information)   
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Reason for Submittal 
 
In this section, the supplier indicates the reason for submittal of the application.  Unless 
otherwise stated in this chapter, in another CMS directive, or as permitted by PECOS, the 
supplier may only check one reason for submittal.  For example, suppose a supplier is 
changing its tax identification number (TIN).  The supplier must submit two applications: 
(1) an initial Form CMS-20134 as a new supplier; and (2) a Form CMS-20134 voluntary 
termination.  Both transactions cannot be reported on the same application. 
 
With the exception of (1) the voluntary termination checkbox and (2) the effective date of 
termination data in the Basic Information section of the Form CMS-20134, any blank 
data/checkboxes in the Basic Information section can be verified through any means the 
contractor chooses (e.g., e-mail, telephone, the PCV, fax). 
 
B.  Centers for Disease Control (CDC) Diabetes Prevention Recognition Program 
(DPRP)  
 
To be eligible to enroll as an MDPP supplier, an entity must have either: 
  MDPP preliminary recognition or 
  DPRP full recognition 
 
Note that MDPP preliminary recognition includes both interim preliminary recognition as 
designated by CMS as well as preliminary DPRP recognition as designated by the CDC. 
 
Organizations with preliminary or full CDC DPRP recognition must submit to CMS a copy 
of its recognition letter provided by CDC. To verify the applicants eligibility, the 
contractor shall:  
  Verify that a letter has been submitted for each organizational code provided in 
Sections 2 and 4 of the Form CMS-20134    Verify that (1) any letters provided have appropriate letterhead from CDC and (2) 
each reflects that the organization has met either preliminary or full recognition 
with an expiration date that has not passed 
  Verify that the organization code or codes provided in Sections 2 and 4 of the Form 
CMS-20134 matches both the organization code on the letter(s) and the 
organization code on CDCs online registry, which is updated just-in-time and can 
be found at 
https://nccd.cdc.gov/DDT_DPRP/CMS/DPRP_Recognized_Organizations_Full_Li
st.aspx  
  Verify that the CDCs online registry or any list provided by CMS indicates that the 
entity associated with that organization code is associated with an in-person 
delivery mode and that a delivery mode of in-person is noted in the letters 
letterhead 
  Verify that CDCs online registry indicates that the entity associated with that 
organization code has met either preliminary or full recognition  
  Verify that the name associated with the organization code on CDCs online 
registry is consistent with what is listed on the letter, as well as what is provided in 
Sections 2 or 4 of the Form CMS-20134 
 
Certificates or letters of the above recognitions are the only eligibility documents required 
by Medicare to function as the supplier type in question.  Any other licenses, certificates, 
and permits that (1) are not of a medical nature or (2) are of a medical nature but unrelated 
to MDPP are not required. 
 
C.  Recognition Status  
 
In situations where an MDPP supplier is required to submit a copy of its CDC recognition 
but fails to do so, the contractor need not obtain such documentation from the supplier if 
the contractor can verify the information independently. This may be done by: (1) 
reviewing and printing (or electronically saving in PECOS) confirming pages from the 
Centers for Disease Control and Prevention Web site; (2) requesting and receiving from the 
CDC written confirmation of the suppliers status therewith; or (3) utilizing another third-
party verification source. Similarly, if the supplier submits a copy of the applicable 
recognition but fails to complete the applicable section of the form, the section need not be 
completed if the data in question can be verified on the recognition itself or via any of the 
three mechanisms described above in this paragraph. The contractor shall not develop for a 
correction to the form if the recognition information can be verified as described above.  
 
The above-referenced written confirmation of the suppliers status can be in the form of a 
letter, fax, or email, but it must be in writing. Documentation of a verbal conversation 
between the contractor and the body in question does not qualify as appropriate 
confirmation.  
 
10.3.2.2  CMS-20134 (Section 2 - Identifying Information)   
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Correspondence Address and Telephone Number   
Regarding the Correspondence Address section of the Form CMS-20134, the 
correspondence address must be one where the contractor can directly contact the applicant 
to resolve any issues once the supplier is enrolled in Medicare. Although the contractor 
need not verify the correspondence address, the latter cannot be the address of a billing 
agency, management services organization, chain home office, or the suppliers 
representative (e.g., attorney, financial advisor).  It can, however, be a P.O. Box or, in the 
case of an individual practitioner, the persons home address. 
 
Concerning the telephone number in the Correspondence Address section of the Form 
CMS-20134, the supplier may list any telephone number it wishes as the correspondence 
phone number.  The number need not link to the listed correspondence address.  If the 
supplier fails to list a correspondence telephone number and the latter is required for the 
application submission, the contractor shall develop for this information using the 
procedures outlined in this chapter (e.g., the PCV for PECOS applications).  The contractor 
shall accept a particular phone number if it has no reason to suspect that it does not belong 
to or is not somehow associated with the supplier. The contractor is not required to verify 
the telephone number. 
 
B.  E-mail Addresses 
 
An e-mail address listed on the application can be a generic e-mail address.  It need not be 
that of a specific individual.  The contractor may accept a particular e-mail address if it has 
no reason to suspect that it does not belong to or is not somehow associated with the 
supplier. 
 
Regarding unavoidable phone number or address changes (and unless CMS specifies 
otherwise), any change in the suppliers phone number or address that the supplier did not 
cause (e.g., area code change, municipality renames the suppliers street) must still be 
updated via the Form CMS-20134. 
 
C.  Supplier Identification Information 
 
Regarding Supplier Identification Information  Business Information, the contractor may 
capture all information in the Identifying Information (Business Information) section (with 
the exception of the TIN and legal business name (LBN) by telephone, fax, the PCV, e-
mail, or a review of the suppliers Web site. 
 
10.3.2.3  CMS-20134 (Section 3 - Final Adverse Legal 
Actions/Convictions)   
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
Refer to section 10.6.6 of this chapter for information regarding final adverse actions.  Except as 
otherwise stated, the PECOS policies in section 10.3 supersede those in section 10.6.6 (e.g., 
communicating with the provider via the PCV).   
  10.3.2.4  CMS-20134 (Section 4 - MDPP Location Information)  
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Background  
 
The MDPP location address must be a valid address with the United States Postal Service 
(USPS). Addresses entered into PECOS are verified via computer software to determine if 
they are valid and deliverable.  The contractor shall verify that each practice location listed 
on the application actually exists and is a valid address with the USPS. PECOS includes a 
USPS Address Matching System Application Program Interface (API), which validates 
address information entered and flags the address if it is determined to be invalid, 
unknown, undeliverable, vacant, unlikely to deliver mail (No-Stat), a CMRA (i.e., UPS 
Store, mailboxes, etc.) or a known invalid address false positive.  These address types are 
not permitted in PECOS and are flagged upon entry.  
 
The contractor shall verify that the reported telephone number is operational and connects 
to the practice location/business listed on the application.  However, the contractor need not 
contact every location for applicants that are enrolling multiple locations; the contractor 
can verify each locations telephone number with the applicable contact person listed on 
the application and note the verification accordingly in PECOS.  (The telephone number 
must be one where patients and/or customers can reach the applicant to ask questions or 
register complaints.)  The contractor may also match the applicant's telephone number with 
known, in-service telephone numbers - via, for instance, the Yellow Pages or the Internet - 
to correlate telephone numbers with addresses. If the provider uses his/her/its cell phone for 
their business, the contractor shall verify that this is a telephone connected directly to the 
business.  If the contractor cannot verify the telephone number, it shall request clarifying 
information; the inability to confirm a telephone number may indicate that an onsite visit is 
necessary.  In some instances, a 1-800 number or out-of-state number may be acceptable if 
the 's MDPP location is in another state but his/her/its practice locations are within the 
contractors jurisdiction. 
 
In addition:  
 
  Any supplier submitting a Form CMS-20134 application must submit the 9-digit ZIP 
Code for each practice location listed. 
 
  In the MDPP Location Information section of the Form CMS-20134, the checkboxes 
identifying the type of MDPP location must be completed to indicate if the location 
is the MDPP suppliers administrative location or the community setting. If the type 
of location is apparent to the contractor, the MDPP supplier need not complete the 
administrative location type.  The contractor can confirm the information via 
telephone, e-mail, the PCV, or fax.  
 
  Each administrative location shall be verified. However, the contractor need not 
separately contact each location on the application. Such verification can be done 
via the contact person listed on the application; the contact persons verification 
shall be documented in PECOS.    
B.  Do Not Forward (DNF) 
 
Unless instructed otherwise in another CMS directive, the contractor shall follow the DNF 
initiative instructions in CMS Publication (Pub.) 100-04, chapter 1, section 80.5.  Returned 
paper checks, remittance notices, or electronic funds transfer (EFT) payments shall be 
flagged if returned from the post office or banking institution, respectively, as this may 
indicate that the suppliers special payment address (Practice Location section of the 
Form CMS-20134) or EFT information has changed.  The supplier should submit a Form 
CMS-20134 or Form CMS-588 request to change this address; if the supplier does not have 
an established enrollment record in PECOS, it must complete an entire Form CMS-20134 
and Form CMS-588.  The Durable Medical Equipment MAC is responsible for obtaining, 
updating, and processing Form CMS-588 changes. 
 
In situations where the supplier is closing his/her/its business and has a termination date (e.g., 
he/she is retiring), the contractor will likely need to make payments for prior services rendered.  
Since the practice location has been terminated, the contractor may encounter a DNF message.  
If so, the contractor should request the supplier to complete the special payment address 
section of the Form CMS-20134 and to sign the certification statement.  The contractor, 
however, shall not collect any other information unless there is a need to do so.   
 
C.  Remittance Notices/Special Payments 
 
For new enrollees, all payments must be made via EFT.  The contractor shall thus ensure 
that the supplier has completed and signed the Form CMS-588 and shall verify that the 
bank account complies with Pub. 100-04, chapter 1, section 30.2. 
 
In the MDPP Location Information/Remittance Notice and Special Payments Address 
section of the Form CMS-20134, if neither box is checked and no address is provided, the 
contractor can contact the supplier by telephone, e-mail, the PCV, or fax to confirm the 
suppliers intentions.  If the special payments address is indeed the same as the practice 
location, no further development is needed.  If, however, the supplier wants payments to be 
sent to a different address, the address in Section 4B of the Form CMS-20134 must be 
completed.  
 
If an enrolled supplier that currently receives paper checks submits a Form CMS-20134 
change request  no matter what the change involves  the following apply:  
 
  The supplier must submit a Form CMS-588 that switches its payment mechanism to 
EFT.  (The change request cannot be processed until the Form CMS-588 is 
submitted.)  All future payments (excluding special payments) must be made via 
EFT.  
 
  The contractor shall verify that the bank account complies with Pub. 100-04, 
chapter 1, section 30.2. 
    Once a supplier changes its method of payment from paper checks to EFT, it must 
continue using EFT.  A supplier cannot switch from EFT to paper checks.) 
 
The special payment address may only be one of the following: 
 
  One of the suppliers practice locations 
 
  A P.O. box 
 
  The suppliers billing agent.  The contractor shall request additional 
information if it has any reason to suspect that the arrangement  at least 
with respect to any special payments that might be made  may violate the 
Payment to Agent rules in Pub. 100-04, chapter 1, section 30.2. 
 
  The chain home office address.  Per Pub.100-04, chapter 1, section 30.2, a 
chain organization may have payments to its providers sent to the chain 
home office.  The LBN of the chain home office must be listed on the Form 
CMS-588.  The TIN on the Form CMS-588 should be that of the supplier.  
 
  Correspondence address 
 
  A lock box 
 
D.  Additional MDPP Supplier Location Information 
 
The MDPP set of services is unique in that it is delivered in group settings and can be 
delivered by non-traditional health care providers who meet certain eligibility criteria. 
Given this aspect of MDPP suppliers, MDPP services are often delivered within 
community locations to increase access. Thus, the locations associated with MDPP 
suppliers differ slightly than traditional practice locations of other health care providers and 
suppliers. 
 
1.  Administrative Locations  
 
MDPP suppliers must have at least one administrative location and report all administrative 
locations on their Form CMS-20134 or PECOS equivalent. As noted in section 10.1.1 of 
this chapter, an administrative location is the physical location: (1) associated with the 
suppliers operations; (2) from where coaches are dispatched or based; and (3) where 
MDPP services may or may not be furnished. If an entity enrolls as an MDPP supplier but 
does not furnish MDPP services at its administrative location, it should deliver and disclose 
any and all community settings where it furnishes MDPP services.  
 
An administrative location:  
 
  Cannot be a private residence 
    Must have signage posted on the exterior of the building or suite, in a building 
directory, or on materials located inside of the building. Such signage may include, 
for example, the MDPP suppliers LBN or doing business as (DBA) name, as well 
as hours of operation.  
 
  Must be open for business and have employees, staff, or volunteers present during 
operational hours  
 
All administrative locations related to the MDPP supplier must be disclosed.  However, 
given that MDPP suppliers may be non-traditional health care providers engaged in non-
health care related activities, not all organizations run by the entity may constitute an 
administrative location. For example, if an advocacy organization operates two sites and 
only one of them offers MDPP services, only the site offering MDPP would be considered 
an administrative location. Should a coach be based or dispatched from their non-
administrative location site to offer MDPP services in community settings, this location 
would become an administrative location. (See section 10.2.6 of this chapter for 
information regarding the frequency with which MDPP suppliers must report this change.)  
 
As MDPP suppliers fall within the high-risk level of categorical screening under 42 CFR  
424.518, their administrative locations are subject to site visits. See sections 10.6.20(A) and 
(B) of this chapter for additional information concerning site visits.   
 
2.  Community Settings 
 
When determining whether a location is considered an administrative location or a 
community setting, MDPP suppliers must consider whether their organizational entity is 
the primary user of that space and whether coaches are based or dispatched from this 
location. If so, the location would be considered an administrative location, even if this 
location dually provides other services benefiting the community. In comparison, 
community settings are locations not primarily associated with the supplier where many 
activities occur, including MDPP services; that is, a community setting is a location where 
the supplier furnishes MDPP services outside of its administrative locations in a meeting 
location that is open to the public but not primarily associated with the supplier. 
 
An MDPP supplier must update its enrollment application with locations where services 
are furnished in community settings. While these settings are not subject to site visits, they 
serve as a form of recordkeeping and accountability for the MDPP supplier.  
 
3.  Out-of-State Practice Locations 
 
If a supplier is adding a practice location in another state that is within the contractors 
jurisdiction, a separate, initial Form CMS-20134 enrollment application is not required if 
both of the following conditions are met: 
 
  The location is not part of a separate organization (e.g., a separate corporation, 
partnership) 
    The location does not have a separate TIN and LBN 
 
Consider the following examples: 
 
Example 1 - The contractors jurisdiction consists of States X, Y and Z.  Jones MDPP 
Center (JMC), Inc., is enrolled in State X with 3 locations.  It wants to add a fourth location 
in State Y.  The new location will be under JMC, Inc.  JMC will not be establishing a 
separate corporation, LBN, or TIN for the fourth location.  Both of the above conditions are 
therefore met.  JMC can add the fourth location via a change of information request rather 
than an initial application.  The change request must include all information relevant to the 
new location (e.g., licensure, new managing employees).   
 
Example 2 - The contractors jurisdiction consists of States X, Y and Z.  Jones MDPP 
Practice (JMP), Inc., is enrolled in State X with three locations.   It wants to add a fourth 
location in State Y but under a newly created, separate entity - Jones MDPP Practice, LP.  
The fourth location must be enrolled via a separate, initial Form CMS-20134. 
 
Example 3 - The contractors jurisdiction consists of States X, Y and Z.  Jones MDPP 
Practice (JMP), Inc., is enrolled in State X with three locations.  It wants to add a fourth 
location in State Q.  Since State Q is not within the contractors jurisdiction, a separate 
initial enrollment for the fourth location is necessary. 
 
10.3.2.5  CMS-20134 (Sections 5 & 6 - Owning and Managing 
Organizations and Individuals)   
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
Sections 5 and 6 of the Form CMS-20134 collect data regarding the MDPP suppliers 
organizational and individual owners and managing parties.  For detailed information 
regarding the completion of these sections and the validation of the data thereon, see 
section 10.6.7 of this chapter.   
 
Except as otherwise stated, the PECOS policies in section 10.3 supersede those in section 10.6.7 
et seq. (e.g., communicating with the provider via the PCV).    
 
10.3.2.6  Reserved for Future Use 
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
   
10.3.2.7  CMS-20134 (Section 7  Coach Roster)   
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
A.   Background Information  
 
Only organizations, and not individuals, are eligible to enroll as an MDPP supplier. 
However, MDPP services are furnished to Medicare beneficiaries by MDPP coaches in 
group settings. Though these individuals furnish MDPP services on behalf of MDPP 
suppliers, only the MDPP supplier itself enrolls in Medicare.  To enable CMS to better 
ensure the integrity of the program and the safety of the beneficiaries it serves, MDPP  suppliers must report identifying information on coaches in the Coach Roster section of the 
Form CMS-20134. If a coach is being added or changed, the updated information must be 
reported via a Form CMS-20134 change request 
 
B. Coach Eligibility and Screening 
 
As indicated in section 10.2.6 of this chapter and as outlined in the MDPP supplier 
standards, MDPP suppliers cannot include on their roster (or allow MDPP services to be 
furnished by) an ineligible coach.  Accordingly, an MDPP coach must not: 
 
  Currently have Medicare billing privileges revoked and be currently subject to a 
reenrollment bar 
 
  Currently have its Medicaid billing privileges terminated for-cause or be excluded by 
a state Medicaid agency 
 
  Currently be excluded from any other federal health care program, as defined in 42 
CFR 1001.2, in accordance with section 1128, 1128A, 1156, 1842, 1862, 1867 or 
1892 of the Act. 
 
  Currently be debarred, suspended, or otherwise excluded from participating in any 
other federal procurement or nonprocurement program or activity in accordance with 
the Federal Acquisition Streamlining Act implementing regulations and the 
Department of Health and Human Services nonprocurement common rule at 45 CFR 
part 76. 
 
  Have, in the previous 10 years, one of the following state or federal felony 
convictions: 
 
  Crimes against persons, such as murder, rape, assault, and other similar crimes for 
o
which the individual was convicted, as defined under 42 CFR 1001.2, had a guilty 
plea or adjudicated pretrial diversion. 
 
  Financial crimes, such as extortion, embezzlement, income tax evasion, insurance 
o
fraud and other similar crimes for which the individual was convicted, as defined 
under 42 CFR 1001.2, had a guilty plea or adjudicated pretrial diversion. 
 
  Any felony that placed the Medicare program or its beneficiaries at immediate risk, 
o
such as a malpractice suit that results in the individual being convicted, as defined 
under 42 CFR 1001.2, had a guilty plea or adjudicated pretrial diversion of criminal 
neglect or misconduct. 
 
  Any felonies for which the individual was convicted, as defined under 42 CFR 
o
1001.2, had a guilty plea or adjudicated pretrial diversion that would result in 
mandatory exclusion under section 1128(a) of the Act. 
  Upon enrollment or any changes to the Coach Roster section of the Form CMS-20134 that 
results in a new coach being added, the contractor shall verify that the coach is not 
presently excluded from the Medicare program by the HHS Office of the Inspector General 
(OIG) or through the System for Award Management (SAM) (formerly, the General 
Services Administration Excluded Parties List System) and, to the extent possible, whether 
or not an individual coach meets the above eligibility criteria. Should the contractor 
determine that an ineligibility criterion has been met pursuant to that screening but is either 
unsure of the matter or unclear as to what action should next be taken, the contractor may 
contact its Provider Enrollment & Oversight Group (PEOG) Business Function Lead (BFL) 
for guidance.   
 
C.   Coach Eligibility Start and End-Dates 
 
MDPP coaches may have a high turnover rate. To document which coaches are active with 
a supplier at a given time, each coach will have an eligibility start and, if applicable, an 
eligibility end-date. 
 
For each change to the Coach Roster section of the Form CMS-20134, the MDPP supplier 
must indicate the date of such change.  (If the date of change for an individual coach is 
completely blank, the contractor must develop for this information.) Per 42 CFR  
424.205(d), an MDPP supplier must report all changes to its coach roster within 30 days of 
the change. 
 
If the contractor determines the coach to be ineligible, the coachs eligibility start and end-
date shall be documented as the same date; this effectively means that the coach was never 
eligible.  Two other means by which a coach may get an eligibility end-date are as follows: 
 
  When the MDPP supplier removes that coach from its roster.  Here, the eligibility 
end-date would be the date the MDPP supplier indicated when it updated the 
Coach Roster section to remove the coach.   
  When the MDPP supplier with which he or she is associated is revoked or does not 
revalidate its enrollment. Here, the coachs eligibility end-date is the same as the 
date the MDPP suppliers billing privileges were no longer effective.  
 
An MDPP supplier may only be paid for services furnished by eligible coaches within their 
eligibility start and end-dates. 
 
D. Consequences for Coach Ineligibility  
 
If the contractor or CMS determines that an MDPP supplier has an ineligible coach on its 
roster, the MDPP coach would be non-compliant with the MDPP supplier standards. The 
supplier would thus have its enrollment denied or revoked, as appropriate under  
424.530(a)(1) or 424.535(a)(1). Consistent with existing procedures, MDPP suppliers may 
submit a corrective action plan (CAP) removing this coach from its roster within 30 days of 
receiving notice of its enrollment denial or revocation, and, if compliant and as applicable, 
could obtain or maintain Medicare enrollment. (See section 10.6.18 of this chapter for more 
information on CAPs.)  In this CAP situation, the supplier need not submit any  documentation beyond updating the Coach Roster section of the Form CMS-20134 to 
remove the ineligible coach.  
 
E.  Special Revocation for Knowingly Using an Ineligible Coach 
 
While MDPP supplier standards indicate that an MDPP supplier may not include an 
ineligible coach on its roster or allow him/her to furnish MDPP services on its behalf to 
Medicare beneficiaries, the MDPP supplier is not prohibited from continuing to employ or 
otherwise permit the coach to volunteer for other services unrelated to MDPP. Should CMS 
identify that an MDPP supplier is knowingly allowing an ineligible coach to continue 
furnishing MDPP services, the MDPP supplier would be revoked under  424.205(h)(5) 
and any other revocation authority.  In this context, knowingly means that the MDPP 
supplier meets all of the following five conditions; specifically, the supplier: 
 
  Received an enrollment denial or revocation notice for failing to meet the MDPP 
standard in  424.205(d)(3); 
  Was provided notice by CMS or the contractor of the coachs ineligibility, and the 
applicable reason(s);    
  Submitted a CAP to remove the coach;  
  Became compliant once again and obtained or maintained its enrollment; but  
  Continued to allow the ineligible coach who was removed from the Coach Roster 
section of the Form CMS-20134 to provide MDPP services in violation of the CAP. 
 
See section 10.4(M)(4)(d) of this chapter for more information. 
 
10.3.2.8  CMS-20134 (Section 8  Billing Agency Information)   
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
(Regarding the Billing Agency Information section of the Form CMS-20134, refer to section 
10.6.8 of this chapter.  Except as otherwise stated, the PECOS policies in section 10.3 supersede 
those in section 10.6.8.)   
 
Note that if the telephone number in Section 8 is blank, the number can be verified with the 
supplier by telephone, the PCV, e-mail, or fax.  If the section is blank (including the check 
box), no additional development is necessary. 
 
10.3.2.9  CMS-20134 (Section 13  Contact Person) 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
(Regarding the Contact Person section of the Form CMS-20134, see sections 10.3 and 10.6.9 of 
this chapter.  Except as otherwise stated, the PECOS policies in section 10.3 supersede those in 
section 10.6.9.)   
 
If Section 13 is completely blank, the contractor need not develop for this information and 
can simply contact an authorized or delegated official.  If neither box in Section 13 is 
checked but the contact person information is incomplete (e.g., no telephone number  listed), the contractor can either: (1) develop for this information by telephone, the PCV, e-
mail, or fax; or (2) contact an authorized or delegated official. 
 
There is no current option on the Form CMS-20134 to delete a contact person.  Therefore, 
the contractor shall accept the end-date of a contact person via telephone, email, the PCV, 
fax, or mail from the individual supplier, the authorized or delegated official, or a current 
contact person on file.  The contractor shall document in PECOS who requested the 
termination, how it was requested (email, phone or fax), and when it was requested.  The 
addition of contact persons must still be reported via the Form CMS-20134. 
 
(See section 10.6.9 of this chapter for more information regarding the Contact Person 
section of the Form CMS-20134.) 
 
10.3.2.10  CMS-20134 (Section 14  Penalties for Falsifying Information)  
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
See the Penalties for Falsifying Information section of the Form CMS-20134 for an 
explanation of penalties that apply to MDPP suppliers for deliberately furnishing false 
information on the Form CMS-20134 to obtain or maintain Medicare enrollment.   
 
10.3.2.11  CMS-20134 (Section 15  Certification Statement and 
Authorized Officials)  
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
 (Unless indicated otherwise below or in another CMS directive, the instructions in this section 
apply to (1) signatures on the paper Form CMS-20134, and (2) signatures for PECOS 
applications.)    
 
For paper applications, handwritten (wet) signatures in ink and digital/electronic signatures 
(digital or electronic signatures such as those created by digital signature options in 
software, such as Adobe) are acceptable.   For web applications, the supplier can sign it 
electronically or upload the signature and then submit the application.  The contractor shall 
contact its PEOG BFL for questions regarding electronic signatures. 
 
A.  Paper Submissions 
 
A signed certification statement shall accompany the paper Form CMS-20134. If the 
supplier submits an invalid certification statement or no certification statement at all, the 
contractor shall still continue processing the application. An appropriate certification 
statement shall be solicited as part of the development process  preferably via the PCV, 
email, or fax. This includes certification statements that are: (a) unsigned; (b) undated; (c) 
was signed (as reflected by the date of signature) more than 120 days prior to the date on 
which the contractor received the application; (d) missing altogether; or (e) stamped. The 
contractor shall send one development request that lists all of the missing/deficient required 
data/documentation, including the certification statement. The contractor may reject the 
suppliers application if the supplier fails to furnish the missing information and/or correct 
the deficient data on the enrollment application - including all necessary documentation -  within 30 calendar days from the date the contractor requested the information or 
documentation.  
 
Unless stated otherwise in this chapter or in another CMS directive: 
 
  The contractor shall begin processing the application upon receipt and shall 
develop for missing/deficient certification statements and all other 
missing/deficient information, including the application fee, upon review. 
 
  As applicable, the certification statement may be returned via scanned email or 
fax. 
 
  As mentioned previously, signature dates cannot be prior to 120 days of the 
receipt date of the application. 
 
  For paper applications that require development, it is only necessary that the 
dated signature of at least one of the suppliers authorized or delegated officials 
be on the certification statement that must be sent in within 30 days; the 
signatures of the other authorized and delegated officials need not be obtained. 
 
  For paper change of information applications (as the term changes of 
information is defined in section 10.4 et al. of this chapter), if the certification 
statement is signed by an individual who is not on file with the contractor as 
being an authorized or delegated official of the supplier, the contractor may 
accept the certification statement but shall develop for information on this 
person. 
 
   The contractor need not compare the signature on the Form CMS-20134 with 
the same authorized or delegated officials signature on file to ensure that it is 
the same person.  
 
   The contractor shall not request the submission of a drivers license or 
passport to verify a persons signature or identity. 
 
B.  PECOS Submissions 
 
Unless stated otherwise in this chapter or in another CMS directive: 
 
(i)  The contractor shall (a) begin processing the application upon receipt via PECOS; (b) 
perform all required manual validations; and (c) develop for any needed clarifying or missing 
information or documentation consistent with section 10.3 and all other applicable instructions in 
this chapter.   
 
(ii)  If the supplier submits an invalid certification statement, the contractor shall treat this as 
missing information and develop for a correct certification statement  preferably via the PCV, 
email, or fax.  (This includes certification statements that are signed by a person unauthorized to 
do so under 42 CFR Part 424, subpart P.)  The contractor shall send one development request  that includes a list of all of the data/documentation to be furnished or clarified, including, as 
applicable, a correct certification statement. The contractor may reject the suppliers application 
if the supplier fails to furnish said data/documentation within 30 calendar days from the date of 
the contractors request.  
 
(iii)  For PECOS applications that require development, at least one of the suppliers authorized 
or delegated officials has to sign any certification statement that must accompany the suppliers 
response.  Obtaining the signatures of the other authorized and delegated officials is not required.  
 
(iv)  For PECOS changes of information (as the term changes of information is defined in 
section 10.4.4 of this chapter), if the certification statement is signed by an individual who is not 
on file with the contractor as an authorized or delegated official of the supplier, the contractor 
may accept the certification statement.  However, it shall develop for information on the person 
in question consistent with the procedures in this chapter.   
 
(v)  The contractor is not required to compare the signature thereon with the same suppliers, 
authorized officials, or delegated officials signature on file to ensure that it is the same person.  
 
(vi) The contractor shall not request the submission of a drivers license or passport to verify a 
persons signature or identity. 
 
C.  Certification Statement Development 
 
If, as already mentioned, the supplier submits an invalid certification statement (as described in 
subsections (A) and (B)), the contractor shall develop for a correct certification statement and 
send a development letter to the supplier.  The provider must submit the requested certification 
statement as follows:  
 
(i) Paper applications -- Via scanned email, fax, or mail.  Only the actual signature page is 
required; the provider need not submit the additional page containing the certification terms. 
(This also applies to the providers initial submission of a certification statement.  Such instances 
require the submission of only the signature page and not the certification terms.) 
 
(ii) PECOS applications  Via electronic or uploaded signature.    
 
D.  Authorized Officials 
 
Except as stated otherwise, the instructions in this section 10.3.2.11(D) apply to: (1) 
signatures on the paper Form CMS-20134; and (2) electronic or uploaded signatures for 
PECOS applications.) 
 
1.  Requirements 
 
As defined in 42 CFR  424.502, an authorized official is an appointed official (for example, 
chief executive officer, chief financial officer, general partner, chairman of the board, or direct 
owner) to whom the organization has granted the legal authority to enroll it in the Medicare 
program, to make changes or updates to the organizations status in the Medicare program, and  to commit the organization to fully abide by the statutes, regulations, and program instructions of 
the Medicare program.  The person must have the authority to legally and financially bind the 
supplier to) the requirements set forth in 42 CFR  424.510 (and other applicable Medicare 
regulations) and to act on behalf of the organization. 
 
An authorized official is not restricted to the examples of the titles outlined above; 
however, the person must hold a position of similar status and authority within the provider 
or supplier organization.  Additional titles could include, but are not limited to, executive 
director, administrator, president, and vice-president.  The contractor shall consider the 
individuals title and the authority granted by the organization when determining whether 
an individual qualifies as an authorized organization. If the contractor is unsure of the 
persons qualifications or authority, it shall contact its PEOG BFL for further clarification. 
The contractor shall obtain PEOG BFL approval if the only role of the listed authorized 
official is Contracted Managing Employee.  
 
If an authorized official is listed as a Contracted Managing Employee in the Individual 
Ownership and/or Managing Control section of the Form CMS-20134 and does not qualify 
as an authorized official under some other category in this section, he/she cannot be an 
authorized official.  The contractor shall notify the supplier accordingly. If the person is not 
listed as a Contracted Managing Employee in the Individual Ownership and/or Managing 
Control section and the contractor has no reason to suspect that the person does not qualify 
as an authorized official, no further investigation is required. Should the contractor have 
doubts that the individual qualifies as an authorized official, it shall contact the official or 
the applicant's contact person to obtain more information about the official's job title and/or 
authority to bind.  If the contractor remains unconvinced that the individual qualifies as an 
authorized official, it shall notify the supplier that the person cannot be an authorized 
official. If that person is the only authorized official listed and the supplier refuses to use a 
different authorized official, the contractor shall deny the application. 
 
For purposes of determining an authorized officials qualifications, identifying the supplier 
is not determined solely by the suppliers TIN.  Rather, the organizational structure is the 
central factor.  For instance, suppose a chain drug store, Company X, wants to enroll 100 of 
its pharmacies with the contractor.  Each pharmacy has a separate TIN and must therefore 
enroll separately.  Yet all of the pharmacies are part of a single corporate entity  Company 
X.  In other words, there are not 100 separate corporations in our scenario but merely one 
corporation whose individual locations have different TINs.  Here, an authorized official 
for Pharmacy #76 can be someone at Xs headquarters (assuming the definition of 
authorized official is otherwise met), even though this main office might be operating 
under a TIN that is different from that of #76.  This is because headquarters and Pharmacy 
#76 are part of the same organization/corporation.   
 
2.  Required Signature 
 
For Form CMS-20134 initial applications, the certification statement must be signed and 
dated by an authorized official of the supplier. (See sections 10.1.1 and 10.3.2.11(D) of this 
chapter for a definition of authorized official.) The supplier can have an unlimited 
number of authorized officials so long as each meets the definition of an authorized  official.  The Individual Ownership and/or Managing Control section of the Form CMS-
20134 must be completed for each authorized official. 
 
(For revalidation and changes of information, either the authorized or delegated official 
must sign the application. (See sections 10.1.1 and 10.3.2.12 of this chapter for a definition 
of delegated official.).   
 
3.  Changes and Deletions in Authorized Officials  
 
A change in authorized officials does not impact the authority of existing delegated 
officials to report changes and/or updates to the supplier's enrollment data or to sign 
revalidation applications. 
 
If an authorized official is being deleted, the contractor need not obtain (1) that officials 
signature or (2) documentation verifying that the person is no longer an authorized official. 
 
4.  Authorized Official Not on File 
 
If the supplier submits a change of information (e.g., change of address) and the authorized 
official signing the form is not on file, the contractor shall ensure that: (1) the person meets 
the definition of an authorized official; and (2) the Individual Ownership and/or Managing 
Control section of the Form CMS-20134 is completed for that person.  The signature of an 
existing authorized official is not needed to add a new authorized official.  Note that the 
original change request and the addition of the new official shall be treated as a single 
change request (i.e., one change request encompassing two different actions) for purpose of 
enrollment processing and reporting. 
 
5.  Effective Date  
 
The effective date in PECOS for the Certification Statement section of the Form CMS-
20134 should be the date of signature. 
 
6.  Social Security Number 
 
To be an authorized official, the person must have and must submit his/her social security 
number (SSN).  An Individual Taxpayer Identification Number (ITIN) cannot be used in 
lieu of an SSN in this regard.   
 
7.  Telephone Number  
 
The authorized officials telephone number can be left blank. No further development is 
needed. 
 
10.3.2.12  CMS-20134 (Section 16  Delegated Officials) 
(Rev. 10800; Issued: 05-20-21; Effective: 06-22-21; Implementation: 06-22-21) 
 
A.  Background   
A delegated official is an individual to whom an authorized official listed in the 
Certification Statement section of the Form CMS-20134 delegates the authority to report 
changes and updates to the suppliers enrollment record or to sign revalidation applications.  
The delegated officials signature binds the organization both legally and financially, as if 
the signature was that of the authorized official. Before the delegation of authority is 
established, the only acceptable signature on the enrollment application to report updates or 
changes to enrollment information is that of the authorized official currently on file with 
Medicare.  A delegated official has no authority to sign an initial application.  However, the 
delegated official may (i) sign a revalidation application and (ii) sign off on 
changes/updates submitted in response to a contractors request to clarify or submit 
information needed to continue processing the supplier's initial application. 
 
The delegated official must be an individual with an ownership or control interest in (as 
that term is defined in  1124(a)(3) of the Social Security Act), or be a W-2 managing 
employee of, the supplier. 
 
Section 1124(a)(3) defines an individual with an ownership or control interest as: 
 
  A five percent direct or indirect owner of the provider, 
 
  An officer or director of the provider (if the provider is a corporation), or 
 
  Someone with a partnership interest in the provider (if the provider is a 
partnership) 
 
For purposes of information captured in the Delegated Official section only, the term 
"managing employee" means any individual (including a general manager, business 
manager, or administrator) who exercises operational or managerial control over the 
supplier, or who conducts the day-to-day operations of the supplier.  However, this does 
not include persons who, either under contract or through some other arrangement, manage 
the day-to-day operations of the supplier but who are not actual W-2 employees.  For 
instance, suppose the supplier hires Joe Smith as an independent contractor to run its day-
to-day-operations.  Under the definition of "managing employee" in the Individual 
Ownership and/or Managing Control section of the Form CMS-20134, Smith would have 
to be listed in that section.  Yet under the Delegated Official section definition (as 
described above), Smith cannot be a delegated official because he is not an actual W-2 
employee of the supplier.  Independent contractors are not considered "managing 
employees" under the Delegated Official section of the Form CMS-20134. 
 
The Ownership Interest and Managing Control Information in the Individual Ownership 
and/or Managing Control section of Form CMS-20134 must be completed for all delegated 
officials.  
 
B.  Specific Delegated Official Policies 
  1.  Further Delegation  A delegated official may not delegate his/her authority to any 
other individual.  Only an authorized official may delegate the authority to make 
changes and/or updates to the supplier's Medicare data or to sign revalidation 
applications. 
 
2.   W-2 Form - Unless the contractor requests it to do so, the supplier need not submit a 
copy of the owning/managing individuals W-2 to verify an employment relationship. 
 
3.   Number of Delegated Officials - The supplier can have as many delegated officials as it 
chooses.  Conversely, the supplier need not have any delegated officials.  Should no 
delegated officials be listed, however, the authorized official(s) remains the only 
individual(s) who can report changes and/or updates to the supplier's enrollment data. 
 
4.   Effective Date - The effective date in PECOS for the Delegated Official section of the 
Form CMS-20134 should be the date of signature. 
 
5.   Social Security Number - To be a delegated official, the person must have and must 
submit his/her SSN.  An ITIN cannot be used in lieu of an SSN in this regard. 
 
6.   Deletion of Delegated Official - If a delegated official is being deleted, documentation 
verifying that the person no longer is or qualifies as a delegated official is not required.  
Also, the signature of the deleted official is not needed. 
 
7.   Delegated Official Not on File - If the supplier submits a change of information (e.g., 
change of address) and the delegated official signing the form is not on file, the 
contractor shall ensure that (1) the person meets the definition of a delegated official, 
(2) the Individual Ownership and/or Managing Control section of the Form CMS-
20134 is completed for that person, and (3) an authorized official signs off on the 
addition of the delegated official.  (NOTE: The original change request and the addition 
of the new official shall be treated as a single change request (i.e., one change request 
encompassing two different actions) for purpose of enrollment processing and 
reporting.) 
 
8.   Signature on Paper Application - If the supplier submits a paper Form CMS-20134 
change request, the contractor may accept the signature of a delegated official in the 
Certification Statement or Delegated Official sections of the Form CMS-20134. 
 
9.   Telephone Number - In addition, the delegated officials telephone number can be left 
blank. No further development is needed. 
 
10.3.2.13  CMS-20134 (Section 17  Supporting Documents)  
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
(In addition to the instructions in this section 10.3.2.13, refer to: (1) the Supporting 
Documents section of the Form CMS-20134 for information concerning supporting 
documents; and (2) section 10.3 of this chapter for instructions regarding the submission of   
documentation with PECOS applications.)   
As already stated in this section 10.3.2.1, MDPP suppliers must have MDPP preliminary 
recognition or full recognition, as determined by CMS.  See section 10.3.2.1 for more 
information on required documentation. 
 
10.3.2.14  Additional Form CMS-20134 Processing Information and 
Alternatives 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
The processing alternatives in section 10.3.2.14 are in addition to, and not in lieu of, any other 
processing alternatives described in this chapter or another CMS directive.  These processing 
alternatives also apply notwithstanding any instruction in this chapter to the contrary.  As stated 
in section 10.3, however, some of the application data elements and verification procedures that 
have previously been subject to a processing exception/alternative may no longer be so or are 
moot under PECOS 2.0.  (See section 10.3 for a discussion of such data and procedures.)  In such 
situations, the contractor shall disregard the exception/alternative and follow the instructions in 
section 10.3. 
 
A.  Unsolicited Additional Information 
 
If the supplier submits missing/clarifying data or documentation on its own volition (i.e., 
without being contacted by the contractor), the contractor shall include this additional 
data/documentation in its overall application review. Any new or changed information a 
supplier submits prior to the date the contractor finishes processing a previously submitted 
change request is no longer considered to be an update to that change request.  Rather, it is 
considered to be and shall be processed as a separate change request.  The contractor may 
process both changes simultaneously, but the change that was submitted first shall be 
processed to completion prior to the second one being processed to completion. 
 
B.  Information Disclosed Elsewhere 
 
If a data element on the suppliers Form CMS-20134 application is missing but the 
information is disclosed (1) elsewhere on the application or (2) in the supporting 
documentation submitted with the application, the contractor need not obtain the missing 
data via an updated Form CMS-20134 page and a newly-signed certification statement; no 
further development  not even by telephone  is required.  The following information, 
however, must be furnished in the appropriate section(s) of the Form CMS-20134, even if 
the data is identified elsewhere on the form or in the supporting documentation: 
 
  Any final adverse action data requested in the Final Adverse Legal 
Actions/Convictions section (Section 3) and Organizational and Individual 
Ownership and/or Managing Control Final Adverse Legal Action History sections 
(Sections 5B and 6B) of the Form CMS-20134 
 
  The applicants legal business name (LBN) or legal name (Note: If an application is 
submitted with a valid National Provider Identifier (NPI) and Provider Transaction 
Access Number (PTAN) combination but (1) the LBN field is blank, (2) an  incomplete or inaccurate LBN is submitted, or (3) the applicant includes a DBA 
name in the MDPP Location Information section of the Form CMS-20134, the 
contractor need not develop if it can confirm the correct LBN based on the NPI and 
PTAN combination provided.  
 
  Tax Identification Number 
 
(The contractor may use the shared systems, PECOS, or its supplier files as a resource to 
determine the PTAN or NPI before developing with the supplier.) 
 
If required supporting documentation currently exists in the suppliers file, the supplier 
need not submit that documentation again during the enrollment process. The contractor 
shall utilize the existing documentation for verification. Documentation submitted with a 
previously submitted enrollment application, or documentation currently uploaded in 
PECOS, qualifies as a processing alternative unless stated otherwise in this chapter or any 
CMS directive. Also, per section 10.6.19(H) of this chapter, the contractor shall document 
in PECOS that the missing information was found elsewhere in the enrollment package.  
However: 
 
   This excludes information that must be verified at the current point in time (e.g., a 
license without a primary source verification method)  
   The contractor shall not utilize information submitted along with opt-out 
applications for enrollment application processing or vice-versa 
 
C.  City, State, and ZIP Code  
 
If an address (e.g., correspondence address, practice location) lacks a city, state or zip + 
four, the contractor can verify the missing data in any manner it chooses. (Note that the 
contractor can obtain the zip + four from either the USPS or the Delivery Point Validation 
in PECOS.) 
 
10.3.3  Other Enrollment Forms: Information and Processing  
(Rev. 10868; Issued: 07-14-21; Effective: 08-13-21; Implementation: 08-13-21) 
 
The forms or form types described in this section 10.3.3 et seq. are routinely submitted with 
an enrollment application. 
 
For purposes of sections 10.3.3.1 and 10.3.3.2, all references to the Form CMS-855 include 
the Form CMS-20134, unless otherwise stated. 
 
10.3.3.1  Form CMS-588  Electronic Funds Transfer (EFT) 
Authorization Agreement  
(Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
An EFT agreement (Form CMS-588) authorizes CMS to deposit Medicare payments directly 
into a provider/suppliers bank account.   
A.  Processing the Form CMS-588  Specific Situations 
 
When a Form CMS-588 is received, the contractor shall review the form and develop for any 
deficiencies or missing information prior to approval.  All EFT data shall be entered into 
PECOS. 
 
1.  Unsolicited Information  
 
If the provider/supplier submits missing/clarifying data or documentation on its own volition 
(i.e., without being contacted by the contractor), the contractor shall include this additional 
data/documentation in its overall form review.  
 
2.  Missing or Incorrect Provider Transaction Access Number (PTAN) or CMS 
Certification Number (CCN) on the Form CMS-588   
 
If the PTAN and/or CCN is missing or incorrect but the contractor can ascertain the correct 
number (1) via the supporting documents submitted, (2) elsewhere on the form, or (3) via 
PECOS, the shared systems, or the provider files, the contractor need not pursue 
development.  (Note that social security numbers and employer identification numbers do not 
fall within this exception.)  
 
3.  Missing or Incorrect Social Security Number (SSN) or Employer Identification Number 
(EIN) Checkbox on the Form CMS-588  
 
If the Form CMS-588 is received and the checkbox for the SSN or EIN is either not checked 
or is incorrectly checked, the contractor may proceed without further development if the 
contractor can ascertain the correct option via the supporting documents submitted or 
elsewhere on the form. 
 
4.  Name on Account 
 
As stated on the Form CMS-588, the account to which EFT payments are made must exclusively 
bear the name of the physician or individual practitioner, or the legal business name (LBN) of 
the person or entity enrolled with Medicare.  Accordingly, the contractor shall accept accounts 
that (1) solely list the LBN or (2) list the LBN and the Doing Business As name (so long as the 
LBN is listed first). 
 
B.  Form CMS-588 Information Specific to Suppliers of Durable Medical Equipment, 
Prosthetics, Orthotics, and Supplies (DMEPOS) 
 
1.  The NPEs now process all Form CMS-588 forms submitted by DMEPOS suppliers.  The 
DME MACs no longer perform this function.  The NPEs will input all EFT data into PECOS. 
 
2.  CMS previously only required the submission of a DMEPOS suppliers Form CMS-588 upon 
initial enrollment.  DMEPOS suppliers are now required to submit a Form CMS-588 upon any 
Form CMS-855S initial enrollment, revalidation, reactivation, or any change of information if 
the supplier is currently paid via paper checks.   
3.  A DMEPOS suppliers EFT information will be applied across all four DME MAC 
jurisdictions.  It will not be limited to the DME MAC jurisdiction listed on the suppliers Form 
CMS-855S enrollment application. 
 
4.  EFT payments will not be made until the bank account is fully verified.   
 
C.  Form CMS-588 Signature Requirements 
 
For paper applications, handwritten (wet) signatures in ink and digital/electronic signatures 
(digital or electronic signatures such as those created by digital signature options created in 
software, such as Adobe) are acceptable.   For web applications, the supplier can sign it 
electronically or upload the signature and then submit the application.  The contractor shall 
contact its PEOG BFL for questions regarding electronic signatures. 
 
D.  Verification 
 
Providers and suppliers may submit a Form CMS-588 via paper or through PECOS.  In either 
case, the contractor shall ensure that: 
 
(i)  All EFT arrangements comply with CMS Pub. 100-04, chapter 1, section 30.2.5. 
 
(ii) The information submitted on the Form CMS-588 is complete and accurate. (Except as 
otherwise stated in this chapter or another CMS directive, the contractor shall develop for any 
missing information.) 
 
(iii) The provider/supplier submitted (1) a voided check or (2) a letter from the bank 
verifying the account information. 
 
(iv)  The routing number and account number matches what was provided on the Form CMS-
588. 
 
(v) The signature is valid.   
 
(vi)  The contractor shall forgo development if the Part I: Reason for Submission (Individual 
vs. Group) section is left blank or an incorrect option is selected but the contractor can make 
the correct determination based on the provider/suppliers existing file or additional 
information submitted with the application. 
 
Once it has been processed, the Form CMS-588 will be printed and delivered (along with the 
voided check and bank letter verifying the account information) to the contractors financial 
area for proper processing of the EFT data.  If this information cannot be verified and the 
provider/supplier fails to timely respond to a developmental request, the contractor shall 
reject the Form CMS-588 and, if applicable, the accompanying Form CMS-855 or Form 
CMS-20134. 
 
E.  Miscellaneous EFT Policies 
  1.  Banking Institutions 
 
All payments must be made to a banking institution. EFT payments to non-banking 
institutions (e.g., brokerage houses, mutual fund families) are not permitted. 
 
If the provider/suppliers bank of choice does not or will not participate in the 
provider/suppliers proposed EFT arrangement, the provider/supplier must select another 
financial institution. 
 
2.  Sent to the Wrong Unit  
 
If a provider/supplier submits an EFT change request to the contractor but not to the latters 
enrollment unit, the recipient unit shall forward it to the enrollment staff, which shall then 
process the change.  The enrollment unit is responsible for processing EFT changes. As such, 
while it may send the original EFT form back to the recipient unit, the enrollment unit shall 
keep a copy of the EFT form and append it to the provider/suppliers Form CMS-855 in the 
file. 
 
3.  Bankruptcies and Garnishments 
 
If the contractor receives a copy of a court order to send payments to a party other than the 
provider/supplier, it shall contact the applicable SOG Locations Office of General Counsel. 
 
4.  Closure of Bank Account 
 
If a provider/supplier has closed its bank/EFT account but will remain enrolled in Medicare, 
the contractor shall place the provider/supplier on payment withhold until a Form CMS-588 
(and Form CMS-855, if applicable) is submitted and approved by the contractor.  If such an 
agreement is not submitted within 90 days after the contractor learned that the account was 
closed, the contractor shall commence deactivation procedures in accordance with the 
instructions in this chapter.  The basis for deactivation would be  424.540(a)(2) due to the 
provider/suppliers failure to submit updated EFT information within 90 days of the change.  
 
5.  Reassignments 
 
If a physician or non-physician practitioner is reassigning all of his/her benefits to another 
supplier and the latter is not currently on EFT, neither the practitioner nor the reassignee 
needs to submit a Form CMS-588.  This is because (1) the practitioner is not receiving 
payment directly, and (2) accepting a reassignment does not qualify as a change of 
information request.   If, however, the group later submits a change of information request 
and is not on EFT, it must submit a Form CMS-588. 
 
6.  Final Payments  
 
If a non-certified supplier (e.g., physician; ambulance supplier) voluntarily withdraws from 
Medicare and needs to obtain its final payments, the contractor shall send such payments to 
the supplier's EFT account of record.  If the account is defunct, the contractor can send 
payments to the suppliers special payments address or, if none is on file, to any of the  suppliers practice locations on record.  If neither the EFT account nor the aforementioned 
addresses are available, the supplier shall submit a Form CMS-855 or Form CMS-588 
request identifying where it wants payments to be sent. 
 
7.  Chain Organizations 
 
Per CMS Pub. 100-04, chapter 1, section 30.2, a chain organization may have payments to its 
providers be sent to the chain home office. However, and except as otherwise permitted for 
PECOS applications under PECOS 2.0, any mass EFT changes (involving large numbers of 
chain providers) must be submitted and processed in the same fashion as any other change in 
EFT data.  For instance, if a chain has 100 providers and each wants to change its EFT 
account to that of the chain home office, 100 separate Form CMS-588s must be submitted 
(again, unless PECOS 2.0 permits a consolidated submission for PECOS applications).  If 
any of the chain providers have never completed a Form CMS-855 before, they must do so at 
that time. 
 
8.  Consolidation of EFT Accounts 
 
The contractor shall follow the instructions in section 10.6.23 of this chapter regarding the 
consolidation of a providers or suppliers EFT accounts.  These instructions take precedence 
over any contrary guidance in this chapter. 
 
10.3.3.2  Form CMS-460  Medicare Participating Physician or Supplier 
Agreement  
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
This agreement establishes that the Medicare provider/supplier accepts assignment of the 
Medicare Part B payment for all services (1) for which the participant is eligible to accept 
assignment under the Medicare law and regulations and (2) which are furnished while the 
agreement is in effect. (This only applies to suppliers that complete the Forms CMS-855B, 
CMS-855S, and CMS-855I.)  The contractor shall follow the instructions in CMS Pub. 100-
04, chapter 1, sections 30 through 30.3.12.3 when handling issues related to par agreements 
and assignment. Queries concerning the interpretation of such instructions shall be referred to 
the responsible CMS component.  
 
Individual physicians and non-physician practitioners who only reassign benefits to a 
clinic/group practice inherit the par status established by the clinic/group practice; 
accordingly, these physicians and non-physician practitioners need not submit the Form 
CMS-460.  However, if the individual physician/practitioner maintains a private practice 
separate from the reassignment, he/she may designate his/her own par status. See the 
instructions in CMS Pub. 100-04, chapter 1, section 30 for applying the correct par status to 
clinic/group practices, organizations and individuals in private practice. 
 
A.  PECOS Information 
 
All suppliers must choose to be either par or non-par when enrolling and must maintain the 
same par status across all lines of business. The contractor shall search PECOS to determine  if an enrollment already exists with the enrolling provider/suppliers legal business 
information (i.e.: legal business name, federal tax identification number).  
 
No par status change shall be made by the contractor without confirmation from the 
provider/supplier first. In the event that a provider/supplier submits a par agreement and they 
are currently enrolled as non-par, the contractor must confirm with the provider/supplier that 
the change in the par status is valid for all lines of business. Likewise, if a provider/supplier 
does not submit a par agreement, and they are enrolled as par or non-par, the contractor shall 
confirm that the provider/supplier is not changing their current par status across all lines of 
business. 
 
B.  Valid signatures  
 
For paper applications, handwritten (wet) signatures in ink and digital/electronic signatures 
(digital or electronic signatures such as those created by digital signature options created in 
software, such as Adobe) are acceptable.   For web applications, the supplier can sign it 
electronically or upload the signature and then submit the application.  The contractor shall 
contact its PEOG BFL for questions regarding electronic signatures. 
 
10.4  Medicare Enrollment: Contractor Processing Duties and Related 
Policies 
(Rev. 11020; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21) 
 
10.4.1  General Processing Functions 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
This section 10.4.1 et seq. outlines the general methods that contractors shall follow when 
processing enrollment applications.  (More specific processing activities can be found elsewhere 
in this chapter (e.g., sections 10.3.1 et seq., 10.6.6, etc.)).  Should an inconsistency or gap exist 
between the general procedures outlined in section 10.4.1 et seq. and those of greater specificity 
in other sections of this chapter, the latter shall take precedence unless otherwise noted; this 
includes the instructions in section 10.3 concerning PECOS applications.   
 
The CMS stresses that nothing in this section 10.4.1 et seq. (except as stated to the contrary) 
supplants more detailed instructions in this chapter (or another CMS directive) pertaining to, for 
instance: (1) processing alternatives; (2) referrals to the state agency; (3) processing policies 
specific to certain CMS applications (e.g., CMS-855, CMS-20134) and certain sections thereof. 
 
All references to provider include supplier unless stated otherwise. 
 
10.4.1.1  Overview of the Process 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Typical Steps 
 
In general, the application review and verification process is as follows: 
  1.  Contractor receives application 
 
2.  Contractor reviews application and verifies data thereon.  (For PECOS applications, some of 
this data will have been verified when the provider enters its enrollment information into 
PECOS.)  
 
3.  If (i) required data/documentation is missing, (ii) data cannot be verified, and/or (iii) there are 
data discrepancies, contractor requests missing/clarifying information from the provider. 
 
4.  If applicable, contractor (i) verifies any newly furnished data or (ii) seeks additional 
data/clarification from provider 
 
5.  Certain situations may require referral to the state agency (the state) and, after receiving 
information from the state, referral to CMS PEOG before a final determination is rendered. 
 
6.  Final determination 
 
Section 10.4.1 et seq. is structured so as to generally follow the preceding six steps.  
 
B.  Non-Form CMS-855 and CMS- 20134 Documentation 
 
There are situations where the contractor processes non-Form CMS-855 and CMS- 20134 forms 
and other documentation relating to provider enrollment.  Such activities include, but are not 
limited to: 
 
  EFT agreements (Form CMS-588) submitted alone 
 
  "Do Not Forward" issues 
 
  Par agreements (Form CMS-460) 
 
  Returned remittance notices 
 
  Informational letters received from other contractors 
 
  Diabetes self-management notices 
 
  Verification of new billing services 
 
  Paramedic intercept contracts 
 
  1099 issues that need to be resolved 
 
  Opt-out affidavits 
 
  Surety bond updates and cancellations 
  The contractor shall: 
 
(i) Follow the instructions in section 10.3 regarding the uploading into PECOS of documentation 
received outside of an application submission; and 
 
(ii) Note in PECOS the date of the document submission with a description of the document.  
(The specific language lies within the contractors discretion.) 
 
10.4.1.2  Receipt of Application 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Acknowledgment of Receipt of Application  
 
The contractor may, but is not required to, send out acknowledgment letters or e-mails in cases 
where PECOS did not automatically do so. 
 
B.  Pre-Screening of Application 
 
The contractor is no longer required to pre-screen provider enrollment applications. 
 
C.  Reassignment Packages 
 
(For PECOS applications, note that some of the following instructions regarding development 
may not apply and the contractor can thus disregard them.  This is because PECOS will require 
the applicable missing forms at the time the provider is completing the application.)  
 
In situations where an entity wants to simultaneously (i) enroll a group practice, (ii) enroll the 
individual practitioners therein, and (iii) reassign benefits accordingly, the instructions below 
apply.  As early in the process as possible, the contractor shall examine the incoming forms to 
see if a reassignment may be involved; also, the contractor is encouraged (though not required) 
to have the same analyst handle all three applications in the package. 
 
Only the Form CMS-855Rs are submitted - If a brand-new group with new practitioners is 
attempting to enroll but submits only the Form CMS-855Rs for its group members (i.e., neither 
the initial Form CMS-855B nor the initial Form CMS-855Is were submitted), the contractor shall 
develop for the other forms upon receipt and processing.  
 
Only the Form CMS-855R is submitted and a Form CMS-855A or CMS-855B and Form CMS-
855I is already on file  Suppose an individual: (1) submits only the Form CMS-855R without 
including the Form CMS-855A or Form CMS-855B and Form CMS-855I; and (2) indicates on 
the Form CMS-855R that he/she will be reassigning all or part of his/her benefits to the CAH II. 
The contractor shall not develop for the other forms if they are already on file.  The contractor 
shall simply process the Form CMS-855R and reassign it to the Form CMS-855A.  
 
Only the Form CMS-855B is submitted - If a brand-new group wants to enroll but submits only 
the Form CMS-855B without including the Form CMS-855Is and Form CMS-855Rs for its 
group members (i.e., the Form CMS-855B arrives alone without the other forms), the contractor  shall develop for the other forms if they are not submitted upon receipt and processing of the 
Form CMS-855B.  
 
Only the Form CMS-855I is submitted  Suppose an individual: (1) submits only the Form 
CMS-855I without including the Form CMS-855B and Form CMS-855R; and (2) indicates on 
the Form CMS-855I that he/she will be reassigning all or part of his/her benefits to the group 
practice. The contractor shall develop for the other forms if they are not submitted upon receipt 
and processing of the Form CMS-855I.  
 
Only the Form CMS-855I is submitted in CAH situation - Suppose an individual: (1) submits 
only the Form CMS-855I; and (2) indicates on the Form CMS-855I that he/she will be 
reassigning all or part of his/her benefits to an existing Part A CAH II. The contractor shall 
develop for the Form CMS-855R if it is not submitted upon receipt and processing of the Form 
CMS-855I.  Upon receipt of the Form CMS-855R, the contractor shall process the application 
and reassign the individual to the Part A entity. 
 
Form CMS-855A and Form CMS-855B never submitted - Suppose an individual is joining a 
group that was enrolled prior to the Form CMS-855A or Form CMS-855B (i.e., the group or 
CAH II never completed a Form CMS-855).  The contractor shall develop for a Form CMS-
855A from the CAH II or Form CMS-855B from the group. Once the group or CAH IIs or 
groups application is received and processed, the contractor shall process the new reassignment.  
 
10.4.1.3  Review of Applications10_4_1_4s10_4_1_3_5 
(Rev. 11020; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21) 
 
Unless stated otherwise in this chapter or in another CMS directive, the instructions in this 
section 10.4.1.3 et seq. apply to: 
 
  The Form CMS-855A, Form CMS-855B, Form CMS-855I, Form CMS-855R, Form CMS-
855O, Form CMS-20134, and opt-out affidavits.  
 
  All Form CMS-855, CMS-20134, and opt-out affidavit transaction types identified in this 
chapter (e.g., changes of information, reassignments). 
 
10.4.1.3.1  Initial Steps of Review of Application 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Opening Review  Basic Activities  
 
Except as stated otherwise in this chapter (see sections 10.3, 10.3.1 et seq., and 10.4.1 for more 
details) or when a processing alternative applies, the contractor shall undertake the following: 
 
1.  Confirmation of Completion - Ensure that the provider has completed all required data 
elements on the Form CMS-855, Form CMS-20134, or opt-out affidavit (including all effective 
dates) and that all supporting documentation has been furnished.  The contractor shall also 
ensure that the provider has completed the application in accordance with the instructions (1) in 
this chapter and in all other CMS directives and (2) on the Form CMS-855 or Form CMS-20134.   (The instructions on the Form CMS-855 or Form CMS-20134 shall be read and applied in 
addition to, and not in lieu of, the instructions in this chapter and all other applicable CMS 
directives.) 
 
2.  Verification - Verify and validate all information the provider furnished on the Form CMS-
855, Form CMS-20134, or opt-out affidavit (assuming a data source is available).  (For PECOS 
applications, note that PECOS will automatically verify certain information.  See section 10.3 of 
this chapter for more information.)  
 
3.  State Agency - Coordinate with the state and/or SOG Location as needed. 
 
4.  Exclusion/Debarment  Follow the instructions in section 10.6.6 of this chapter with respect 
to reviewing the MED and SAM. 
 
B.  Paper Applications 
 
1.  General Background Information 
 
The contractor shall begin processing the application upon receipt and shall develop for missing 
certification statements and all other missing information (including the application fee) upon 
review. This includes but is not limited to:   
 
  Ensuring that all required data elements on the application have been completed and that all 
required supporting documentation has been submitted 
 
  Ensuring that the provider submitted a valid and dated certification statement signed by an 
appropriate individual (e.g., the enrolling physician for Form CMS-855I applications) 
 
  Validating all data on and submitted with the application (assuming that a data source is 
available)  
 
  As applicable, and consistent with section 10.3 of this chapter, entering into PECOS all 
information contained on the application. 
 
Except as otherwise prescribed in section 10.3 of this chapter, the contractor may begin the 
verification process at any time.   
 
 
 
 
2.  Photocopying Pages 
 
The contractor may accept photocopied pages in any Form CMS-855 or Form CMS-20134 it 
receives so long as the application contains a valid signature.  For example, suppose a 
corporation wants to enroll five medical clinics it owns.  The Section 5 data on the Form CMS-
855B is exactly the same for all five clinics.  The contractor may accept photocopied Section 5  pages for these providers.  However, valid signatures must be furnished in Section 15 of each 
application. 
 
3.  White-Out & Highlighting 
 
The contractor shall not write on or highlight any part of the original Form CMS-855 or Form 
CMS-20134 application or any supplementary pages the applicant submits (e.g., copy of license).  
Provider usage of white-out is acceptable, although the contractor should contact the applicant to 
resolve any ambiguities.  In addition, the contractor must determine whether the amount of 
white-out used on a particular application is within reason. For instance, if an entire application 
page is whited-out, the contractor should request that the page be resubmitted. 
 
C.  PECOS Applications 
 
The contractor shall begin processing the application upon receipt and shall develop for 
additional/clarifying/missing data consistent with the instructions in section 10.3 and other 
pertinent sections of this chapter.    
 
10.4.1.3.2  Data Verification 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Means of Verification 
 
Except as stated otherwise in this chapter or in another CMS directive, the contractor shall verify 
and validate  via the most cost-effective methods available, including via PECOS (as described 
and directed in section 10.3) - all information furnished by the provider on or with its 
application, assuming a data source is available.  The general purpose of the verification process 
is to ensure that all of the data furnished on the Form CMS-855 or Form CMS-20134 is accurate. 
 
Examples of verification techniques include, but are not limited to: (i) site visits; (ii) third-party 
data validation sources; (iii) state professional licensure and certification websites (e.g., medical 
board sites); (iv) federal licensure and certification websites (if applicable); (v) state business 
web sites (e.g., to validate doing business as name); and (vi) Yellow Pages (e.g., to verify 
certain phone numbers). 
 
The list of verification techniques identified in this section 10.4.1.3.2 is not exhaustive.  Except 
as prescribed otherwise in section 10.3, if the contractor is aware of another means of validation 
that is as cost-effective and accurate as those listed, it may use it.  However, all SSNs and NPIs 
listed on the application shall be verified through PECOS.  The contractor shall not request an 
SSN card or drivers license to verify an individuals identity or SSN. 
 
B.  Overall Verification Principles 
 
Unless stated otherwise in this chapter or in another CMS directive, the following apply: 
 
1.  A data element is considered verified when, after attempting at least one means of 
validation, the contractor is confident that the data is accurate.  (The contractor shall use its best  judgment when making this assessment.) 
 
2.  The contractor need only make one verification attempt (i.e., need only use one validation 
technique) before either: (i) concluding that the furnished data is accurate; or (ii) requesting 
clarifying information if the data element cannot be verified (though the contractor is encouraged 
to make a second attempt using a different validation means prior to requesting clarification).   
 
C.  Concurrent Reviews 
 
(For PECOS application submissions, note that PECOSs automatic verifications of applications 
from related entities shall take precedence  e.g., in terms of length of time between application 
submissions, depth of the relationship between the associated parties  over the instructions in 
this section 10.4.1.3.2(C).)    
 
If the contractor receives multiple Form CMS-855 or Form CMS-20134s for related entities, it 
can perform concurrent reviews of similar data.  For instance, suppose a chain home office 
submits initial Form CMS-855As for four of its chain providers.  The ownership information 
(Sections 5 and 6) and chain home office data (Section 7) is the same for all four providers.  The 
contractor need only verify the ownership and home office data once; it need not do so four 
times  once for each provider.  However, the contractor shall document in each providers 
PECOS record that a single verification check was made for all four applications. 
 
For purposes of this requirement: (1) there must be an organizational, employment, or other 
business relationship between the entities; and (2) the applications must have been submitted 
within a few weeks of each other.  As an illustration, assume that Group Practice A submits an 
initial Form CMS-855B on January 1. Group Practice B submits one on October 1.  Section 6 
indicates that Joe Smith is a co-owner of both practices, though both entities have many other 
owners that are not similar.  In this case, the contractor must verify Mr. Smiths data in both 
January and October.  It cannot use the January verification and apply it to Group Bs application 
because: (1) the applications were submitted nine months apart; and (2) there is no evidence that 
the entities are related.  
 
D.  Contacting another Contractor 
 
During the verification process, the contractor may need to contact another Medicare contractor 
for information regarding the provider.  The latter contractor shall respond to the former 
contractors request within three business days absent extenuating circumstances. 
 
E.  Proof of Life Documentation 
 
When an enrollment record is updated to reflect an erroneous date or report of death, the 
contractor shall request documentation that supports proof of life (e.g., Retirement, Survivors, 
and Disability Insurance document issued by SSA).  If the provider cannot obtain such 
documentation, the contractor shall submit a request to its PEOG BFL containing the providers 
name, date of birth, and SSN so that CMS can confirm proof of life with SSA. 
  10.4.1.3.3  Requesting Missing/Clarifying Data/Documentation 
(Development)  
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
This section 10.4.1.3.3 addresses the contractors solicitation of missing/clarifying 
information/documentation and/or a valid certification statement.  The policies herein apply 
except as otherwise stated in this chapter (e.g., section 10.3) or another CMS directive. 
 
A. Only One Request Needed  
 
The contractor need only make one request.  Of course, the contractor should respond to any of 
the providers telephone calls, e-mails, etc., resulting from the request.  Yet the contractor need 
not  on its own volition  make an additional request unless the contractor uncovers missing 
data (or data that must be clarified) that it failed to detect prior to sending the original 
development letter.  
 
To the extent possible, the contractor should avoid contacting the provider for missing/clarifying 
data/documentation until it has attempted to validate all of the data on the application.  This will 
obviate the need to contact the provider each time the contractor discovers an issue. 
 
B.  Commencement of Timeframe  
 
The provider has 30 calendar days to furnish the information or documentation the contractor 
requested.  This 30-day clock commences on the day on which the contractor sends the 
development request (e.g., via the PCV).  
 
C.  Telephonic Requests 
 
Unless otherwise stated in this chapter or in another CMS directive, telephonic requests for 
missing/clarifying data/documentation are generally not permitted for paper or PECOS 
applications; it is important that requests for information or clarification be formalized in writing.  
However, in cases where CMS permits telephonic requests for such data, the contractor shall 
adhere to the following: 
 
1.  A telephonic request is made when the contractor: (1) speaks with an appropriate provider 
official, or (2) leaves a message either with an appropriate officials staff (e.g., his/her executive 
assistant) or with an appropriate officials voice mail service.  In situation (2), the contractor 
shall leave the name and telephone number of an appropriate individual at the contractor site 
who the official can contact; otherwise, the contact does not qualify as a legitimate request for 
clarification. 
 
2.  When leaving a message, the contractor shall also state that the requested data/clarification 
must be furnished within 30 days. 
 
3.  Telephone requests shall be made on weekdays between 9 am and 5 pm of the providers 
time zone. 
  4.  The 30-day clock begins on the day (1) of the telephone conversation with the appropriate 
official, or (2) the message is left.   
 
5.  All telephone activity that falls within this subsection (C) shall be documented in PECOS 
consistent with the instructions in section 10.6.19(H) of this chapter. 
 
D.  Inability to Contact Provider  
 
If the contractor cannot, for the reasons listed in (i) through (iii) below, communicate with the 
provider to request information/documentation, it shall attempt one alternative means of 
communication: 
 
(i)  The mailed letter is returned because the provider is not at that address; 
 
(ii) The contractor cannot e-mail (e.g., via the PCV) the letter to the provider because of issues 
with the recipients e-mail system; or  
 
(iii) The providers fax number is repeatedly busy 
 
If an alternative communication, too, cannot be completed for one of the above reasons, the 
contractor need not make another attempt to obtain the data and may reject the application once 
the applicable 30-day period expires.  However, it is strongly advised that the contractor make a 
third attempt to contact the provider prior to taking this step, especially if it appears the provider 
is acting in good faith.  (The contractor shall document in PECOS each attempt to contact the 
provider.) 
 
(With respect to e-mail (including via the PCV), an alternative communication includes sending 
an e-mail to another listed contact person, delegated official, or authorized official.)  
 
E.  Development Reasons and Elements of Letter  
 
1.  Paper Applications 
 
a.  Reasons to Develop 
 
Development is necessary if the provider or supplier: (i) submits an application with at least one 
missing required data element; (ii) fails to submit at least one required document; (iii) submits an 
invalid certification statement; (iv) writes N/A (or a variation thereof) in response to a question 
that requires a yes or no answer; or (v) submits the full application via fax or e-mail unless 
the contractor has provided for an exception based on extenuating circumstances or the 
submission via this means is otherwise authorized by CMS.  (If the contractor instructs the 
provider to submit the application via fax or e-mail, the contractor shall inform its PEOG BFL.) 
 
Development is also required if the contractor determines that clarification is needed regarding 
certain information (e.g., particular data cannot be verified or there are data inconsistencies).  
 
b.  Elements of a Development Letter 
  If any of the development reasons in section 10.4.1.3.3(E)(1)(a) above apply, the contractor shall 
send a development letter to the provider  preferably via the PCV, e-mail or fax - that contains, 
at a minimum, the applicable elements in (i) through (vi) below.  (See section 10.7 et seq. of this 
chapter for these model letters.) 
 
i.  A list of all of the missing required data/documentation, an explanation of the certification 
statements deficiencies, and/or the issues/information to be clarified. 
 
ii. A request that the provider submit the missing data/documentation, clarification, and/or 
revised certification statement within 30 calendar days. 
 
iii. Unless the only data that is missing is documentation, a request that the provider submit an 
appropriately signed and dated certification statement.  (This certification statement will cover 
both the submission of any missing data as well as any deficiencies associated with the original 
certification statement.)  The provider may submit the certification statement via scanned e-mail, 
fax or mail. 
 
(A new certification statement is not required if the only missing material is documentation or if 
the requested clarification does not require any changes to the providers Form CMS-855 or 
CMS-20134 application.) 
 
iv. If missing data is involved, the contractor shall direct the provider to the CMS Web site at 
which the CMS-855 or CMS-20134 forms can be found.   
 
v. A fax number and mailing address to which the missing/clarifying data/documentation/correct 
certification statement can be sent to the contractor. An e-mail address may be included if 
applicable. 
 
vi. The name and phone number of a contact person at the contractor site. An e-mail address may 
be included if applicable. 
 
2.  PECOS Applications 
 
a.  Reasons to Develop 
 
Development is necessary if the provider or supplier: (i) submits an application with at least one 
required data element that needs clarification; or (ii) fails to submit at least one required 
document. 
 
b.  Elements of a Development Request 
 
When developing for more information, the contractor shall send a request to the provider via the 
PCV containing: 
 
(i) A list of all missing documentation or information to be clarified;  
 
(ii) A request that the provider submit the data/materials in question within 30 calendar days; and 
  (iii) The name and phone number (an e-mail address is optional) of a contact person at the 
contractor site. 
 
The contractor shall not attempt to contact the provider for the missing/clarified information or 
documentation prior to sending the PCV request referenced above, though the contractor is free 
to make a follow-up contact with the provider after sending the PCV request.  
 
10.4.1.3.4 - Receiving Missing/Clarifying Data/Documentation (Response to 
Development)  
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
(Note that references to missing information will generally only apply to paper applications.) 
 
A.  Requirement to Furnish All Missing/Clarifying Material 
 
The provider must furnish all missing/clarifying data/documentation the contractor requested 
within the 30-day timeframe.  Whether the provider furnished all information is a decision 
resting solely with the contractor.  Should the provider furnish some (but not all) of the requested 
data/clarification within the specified time period, the contractor need not contact the provider 
again to request the remaining information. For instance, suppose the contractor requested 
clarification regarding data the provider furnished in Sections 3, 4, and 5 of the Form CMS-
855A.  The provider only clarified the Section 3 data.  The contractor may reject the application 
without attempting another contact.   
 
B.  Format of Furnishing Missing/Clarifying Data 
 
1.  Paper Applications 
 
Unless stated otherwise in this chapter or in another CMS directive, the provider shall: (1) 
provide the missing/clarification information (excluding documentation) on the applicable Form 
CMS-855 or CMS-20134 page(s) and (2) submit the material via mail, fax, the PCV, or scanned 
e-mail. A newly signed and dated certification statement must accompany the Form CMS-855 or 
CMS-20134 page(s) containing any missing data  unless the only missing information is 
supporting documentation, in which case no new certification statement is needed. The provider 
may submit the certification statement via scanned e-mail, fax, the PCV, or mail (paper 
submissions) along with any missing information. 
 
2.  PECOS Applications 
 
Unless stated otherwise in this chapter or in another CMS directive, the provider must furnish the 
clarifying data/documentation and/or missing/clarifying documentation via PECOS.  (See section 
10.3 for more information.)  
 
C.  Format of Clarifying Data 
 
(For both paper and PECOS applications, the provider must submit any missing/clarifying data 
or documentation and any required new certification statement within 30 days of the original  request for clarification (rather than 30 days from the date of any follow-up request to provide 
the data.))  
 
1.  Paper Applications  
 
In cases where clarifying (as opposed to missing) information is requested, the contractor may 
accept the clarification by e-mail, fax, the PCV, or letter.  If the provider furnishes the 
clarification via telephone, the contractor shall  unless another CMS directive states otherwise - 
request that the provider furnish said clarification in writing (preferably via e-mail). 
 
If the furnished clarification requires the provider to change or alter data that must be reported on 
the paper Form CMS-855 or CMS-20134, the contractor shall instruct the provider (via a follow-
up e-mail or fax) to (1) submit the revised data on the applicable paper CMS-855 or CMS-20134 
or PECOS application and (2) furnish a new certification statement.  The provider must submit 
the certification statement via scanned PCV, e-mail, fax, or mail. 
 
2.  PECOS Applications  
 
The provider must furnish any clarifying information or missing documentation via the PCV if 
no updates to its PECOS application are needed (e.g., no documentation need be uploaded, no 
changes to its Section 4 enrollment data are required).  If application updates and/or 
documentation are required, the contractor shall instruct the provider (via the PCV) to (1) submit 
the clarified information via PECOS and (2) furnish a new certification statement in PECOS.  
(Paper certification statements are not permitted.)   
 
Consider the following illustrations: 
 
EXAMPLE 1: The contractor notifies the provider via an e-mailed letter on March 1 of a 
discrepancy regarding its ownership information on the paper Form CMS-855A.  The provider e-
mails the contractor on March 3 and explains the discrepancy.  Based on this e-mail, the 
contractor determines that the provider must correct its ownership data in Section 5 of its Form 
CMS-855A.  The contractor sends a follow-up e-mail to the provider on March 7 instructing the 
provider to do so.  The provider must submit the revised data on the Form CMS-855 or CMS-
20134 (with a new certification statement) by March 31 (not April 6, or 30 days from the date of 
the follow-up e-mail). 
 
EXAMPLE 2:  The contractor notifies the provider via a PCV-transmitted letter on March 1 of a 
discrepancy regarding certain ownership information on its PECOS Form CMS-855A.  The 
provider telephones the contractor on March 6 and explains the discrepancy to the contractors 
satisfaction.  Although the discrepancy does not require the provider to make any revisions to its 
Form CMS-855A, the contractor shall request that the provider furnish its explanation in writing 
via the PCV no later than 30 days from its March 1 e-mail (or March 31), not 30 days from the 
date of its March 6 request for the written explanation. 
 
EXAMPLE 3: The contractor notifies the provider via a PCV-transmitted letter on March 1 of a 
discrepancy regarding certain ownership information on its PECOS Form CMS-855A.  
Determining (based on the contractors notification) that the ownership information it provided 
was incorrect, it submits a revised Section 5 of its Form CMS-855A to the contractor with a new  certification statement via PECOS but without any accompanying explanation of the change.  
The contractor receives the revised Section 5 on March 12.  If the contractor determines that the 
discrepancy has been resolved via the revised submission, it need not contact the provider for a 
written explanation.  (This is because the clarification was furnished in writing via the Form 
CMS-855 or CMS-20134 itself.)  If, however, the contractor would like a written explanation or 
otherwise needs clarification about the submission, it may request that the provider submit a 
written explanation via the PCV no later than March 31.   
 
D.  Maintenance of Received Material 
 
Paper Applications  The contractor shall maintain all missing/clarifying information or 
documentation received (including new certification statements) in PECOS via the uploading 
process described in section 10.3.   
 
PECOS Applications  The contractor shall maintain in PECOS all clarifying 
information/documentation and/or missing documentation.   
 
 
10.4.1.3.5  Provider/Supplier Fails to Submit Requested Data/Documentation  
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
If, in the contractors view, the provider failed to submit all of the requested data/documentation 
and/or a valid certification statement if required (e.g., as a correction to the original certification 
statement, as part of a request for missing data, etc.), the contractor may: 
 
  Reject the application if the 30-day period has elapsed,  
 
  Wait until the 30-day period has elapsed and then reject the application, or 
 
  Extend the 30-day period no more than an additional 30 days if (1) it appears that the 
provider is making a good-faith effort to comply with the development letter and/or (2) the 
provider furnished most of the requested data.  For instance, suppose the contractor requested 5 
pieces of clarifying information.  The provider timely submitted 4 of them and furnished a signed 
certification statement.  Since the provider appears to be acting in good faith, the contractor is 
encouraged to continue working with the provider. 
 
If the provider fails to fully respond to a second request, the contractor may either: (1) reject the 
application if the original 30-day period has elapsed, (2) wait until the 30-day period has elapsed 
and then reject the application, or (3) make a third request using the procedures described above. 
 
10.4.1.4  Application Disposition  
(Rev. 11020; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21) 
 
 
10.4.1.4.1  Approvals  
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
  (This section 10.4.1.4.1 does not apply in situations where another CMS instruction contains 
alternative direction.) 
 
A.  Non-Certified Suppliers and Individual Practitioners 
 
(This section 10.4.1.4.1(A) does not apply to ambulatory surgical centers, portable x-ray 
suppliers, DMEPOS suppliers, MDPP suppliers, or providers and suppliers that complete the 
Form CMS-855A.) 
 
If the contractor approves a suppliers enrollment, it shall notify the supplier via letter of the 
approval.  The letter shall follow the content and format of the applicable model letter in section 
10.7 et seq. of this chapter.  
 
The contractor shall send the approval letter via e-mail, mail, or fax for paper applications (and 
the PCV for PECOS applications) within 5 business days of approving the enrollment 
application in PECOS.  (This timeframe should allow for the updating the enrollment 
information in the shared systems (MCS, FISS or VMS)).  For all applications other than the 
Form CMS-855S, the contractor shall send the letter to the suppliers contact person if one is 
listed; otherwise, the contractor may send the letter to the supplier at the suppliers 
correspondence address or special payment address. 
 
B.  Certified Providers and Certified Suppliers 
 
(This section 10.4.1.4.1(B) only applies to: (1) initial Form CMS-855A applications or CHOW, 
acquisition/merger, or consolidation applications submitted by the new owner; and (2) initial 
ambulatory surgical center and portable x-ray supplier applications.  Note also that this 
subsection (B) contains only general instructions regarding certified provider/supplier approvals.  
Instructions in other chapter 10 sections (e.g., sections 10.2.1 et seq., 10.2.2 et seq., section 10.3, 
10.6.1 et seq.) may contain more specific direction, such as with the processing of FQHC 
applications.  Except as stated otherwise, these more specific instructions take precedence over 
those in this section 10.4.1.4.1(B)).  To illustrate, processes for transitioned provider initial 
enrollment (e.g., hospitals, HHAs) are described in provider-specific sections of section 10.2.1, 
et seq.) and take precedence over those in this section 10.4.1.4.1(B). 
 
If the contractor decides to recommend approval of the provider or suppliers application, the 
contractor shall send a recommendation letter to the applicable state agency, with a copy to the 
SOG Location.  The recommendation letter shall follow the guidance and format of the 
applicable template letter in section 10.7 et seq. of this chapter.  The contractor may also include 
an explanation of any special circumstances, findings, or other information that the state should 
know about.  The letter can be sent to the state/SOG Location via mail, fax, or e-mail. 
 
Also, the contractor: 
 
(i) Shall send either a photocopy (not the original), faxed version, or e-mail version of the final 
completed Form CMS-855 to the state agency, along with all updated Form CMS-855 pages, 
explanatory data, documentation, correspondence, final sales agreements, etc. (which can also be 
sent via mail, fax, or e-mail).  If the Form CMS-855, associated documentation, and 
recommendation letter are mailed, they should be included in the same package.     
(ii) Shall not send a copy of the Form CMS-855 to the SOG Location unless the latter 
specifically requests it or if the transaction in question is one for which state involvement is 
unnecessary. 
 
(iii) Notify the applicant that the contractor has completed its initial review of the application.  
The notification can be furnished via e-mail, the PCV, or via the letter identified in Section 
10.7.5 of this chapter (which may be sent to the applicants contact person). The contractor may, 
but is not required to, send a copy of its recommendation letter to the provider as a means of 
satisfying this requirement.  However, the contractor should not send a copy to the provider if the 
recommendation letter contains sensitive information. 
 
C.  DMEPOS Suppliers  
 
As stated in 42 CFR  424.57(b), a DMEPOS supplier must, among other things, meet the 
following conditions to be eligible to receive payment for a Medicare-covered item: (i) the 
supplier has submitted a complete Form CMS-855S (including all supporting documentation) to 
the applicable contractor); and (ii) the item was furnished on or after the date the contractor 
issued to the supplier a DMEPOS supplier number conveying Medicare billing privileges.    
 
D.  Medicare Diabetes Prevention Program (MDPP) Suppliers 
 
As stated in 42 CFR  424.205(d), an MDPP supplier must, among other things, not have an 
ineligible coach on its roster. Though the MDPP suppliers effective date for billing privileges is 
the date a successful Form CMS-20134 application was submitted, the contractor must notify 
MDPP suppliers of their application approval because some MDPP suppliers may not begin 
furnishing services until receiving such information. 
 
If the contractor approves an MDPP suppliers enrollment, it shall notify the supplier via letter of 
the approval.  The letter shall follow the content and format of the applicable model letter in 
section 10.7 et seq. of this chapter.    
 
Absent a CMS instruction or directive to the contrary, the contractor shall send the approval 
letter within 5 business days of approving the enrollment application in PECOS.  The letter shall 
be sent to the suppliers contact person if one is listed; otherwise, the contractor may send the 
letter to the suppliers correspondence address or special payment address. 
 
For claims submitted by MDPP suppliers prior to the date of enrollment, the contractor shall 
follow the instructions in Pub. 100-04, chapter 1, section 70, with respect to the claim filing 
limit.  Payments cannot be made for services furnished prior to the date the applicant submitted 
an application or CAP that resulted in successful enrollment. 
 
E.  Additional Copies of Approval Letters 
 
With the exception of Form CMS-855S applications, if any contact person listed on a 
provider/suppliers enrollment record requests a copy of the provider/suppliers Medicare 
approval letter, the contractor shall send it to the contact person via e-mail, the PCV, fax, or mail.   (This excludes certification letters from the state or SOG Location, for the contractor does not 
generate these approvals. Also, see section 10.3 of this chapter for information regarding those 
contact persons for PECOS applications/enrollments who can and cannot receive documents or 
information pertaining to a specific application.)  
 
For Form CMS-855S application approval letters, suppliers may contact their applicable NPE 
East or NPE West contractor for a copy thereof.   
 
10.4.1.4.2 - Returns  
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Reasons/Grounds for Return 
 
(See 42 CFR  424.526 for regulatory provisions regarding application returns.)   
 
Notwithstanding any other directive to the contrary in this chapter or another CMS directive, the 
contractor (including the NSC) may immediately return the enrollment application to the 
provider only in the instances described below and which are outlined in  424.526(a)(1) through 
(13).  Except as otherwise indicated in the specific return reason, this policy applies to all 
applications identified in this chapter (e.g., initial applications, change requests, Form CMS-
855O applications, Form CMS-588 submissions, change of ownership (CHOW) applications, 
revalidations, reactivations, etc.) (Note that some of these return reasons may no longer apply or 
will be rendered moot with the advent of PECOS 2.0): 
 
(1) The provider/supplier sent its paper Form CMS-855, Form CMS-588, or Form CMS-20134 
to the incorrect contractor for processing (e.g., the application was sent to Contractor X instead 
of Contractor Y). 
 
(2) The contractor received the application more than 60 days prior to the effective date listed on 
the application.  (This does not apply to (i) initial Form CMS-855A applications and (ii) 
ambulatory surgical centers and portable x-ray suppliers submitting an initial Form CMS-855B 
application.) 
 
(3) The seller or buyer in a CHOW submitted its Form CMS-855A or Form CMS-855B 
application more than 90 days prior to the anticipated date of the sale.   
 
(4) The contractor received an initial application more than 180 days prior to the effective date 
listed on an application from an ambulatory surgical center, a portable x-ray supplier, or a 
provider/supplier submitting a Form CMS-855A application. 
 
(5) The contractor confirms that the provider or supplier submitted an initial enrollment 
application prior to the expiration of the time period in which it is entitled to appeal the denial of 
its previously submitted application. 
 
(6)  The provider/supplier submitted an initial application prior to the expiration of their existing 
reenrollment bar or reapplication bar. 
  (7) The application is not needed for (or is inapplicable to) the transaction in question.  Examples 
include, but are not limited to, the following: 
 
  A rebuttal decision has been issued (therefore, the submitted Form CMS-855, Form 
CMS-588, or Form CMS-20134 is not needed). (See section 10.4.8.1(A) of this chapter 
for more information.) 
 
  The application is to be returned per section 10.6.1.1.3.1.1 of this chapter. 
 
(8) The provider/supplier submitted a revalidation application more than 7 months prior to their 
revalidation due date. 
 
(9) The MDPP supplier submitted an application with a coach start date more than 30 days in the 
future. 
 
(10) A provider/supplier requests that their application be withdrawn prior to or during 
processing.  
 
(11) A provider/supplier submits an application that is an exact duplicate of an application that 
has already been processed or is currently being processed or is pending processing.  
 
(12) The provider/supplier submits a paper Form CMS-855 or Form CMS-20134 enrollment 
application that is outdated or has been superseded by a revised version.  
 
(13) The provider/supplier submits a Form CMS-855A or Form CMS-855B initial application 
followed by a Form CMS-855A or Form CMS-855B change of ownership application.  If the 
Medicare contractor 
 
(i)  Has not yet made a recommendation for approval concerning the initial application, both 
applications may be returned. 
 
(ii)  Has made a recommendation for approval concerning the initial application, the Medicare 
contractor may return the change of ownership application.  If, per the Medicare contractors 
written request, the provider or supplier fails to submit a new initial Form CMS-855A or Form 
CMS-855B application containing the new owners information within 30 days of the date of the 
letter, the Medicare contractor may return the originally submitted initial Form CMS-855A or 
Form CMS-855B application. 
 
(The difference between a rejected application and a returned application is that the former 
is typically based on the providers failure to respond to the contractors request for missing or 
clarifying information.  A returned application is effectively considered a non-submission.) 
 
Note that the contractor need not request additional information in any of these scenarios.  For 
instance, if the application is not necessary for the particular transaction, the contractor can 
return the application immediately; if the provider already submitted an application fee, the 
contractor shall follow existing instructions regarding the return of the fee. 
  B.  Procedures for Returning the Application 
 
If the contractor returns the application, the following apply: 
 
(i) The contractor shall notify the provider via the applicable return letter (sent by mail, the PCV, 
or e-mail) that the application is being returned, the reason(s) for the return, and how to reapply. 
 
(ii) The contractor shall not enter the application into PECOS.  No L & T record shall be created. 
 
(iii) Any application resubmission requires a brand new certification statement page containing a 
signature and date.  The provider cannot simply add its signature to the original certification 
statement it submitted.  (This does not apply to e-signature situations.) 
 
(iv) For paper applications, the contractor shall: (A) keep the original application and supporting 
documents and return a copy; (B) make a copy or scan of the application and documents and 
return the originals to the provider; or (C) simply send a letter to the provider (in lieu of sending 
the originals or a copy thereof) explaining that the application is being returned (though not 
physically returned) and why.  (If the contractor chooses the third approach and the provider 
requests a copy of its application, the contractor should fax or mail it to the provider.) 
 
See section 10.3 of this chapter for more information regarding the return of applications. 
 
C.  Special Situations Concerning Changes of Information and Changes of Ownership 
 
1.  Expiration of Timeframe for Reporting Changes - If the contractor returns a change of 
information or CHOW submission and the applicable 90-day or 30-day period for reporting the 
change has expired, the contractor shall send an e-mail to its PEOG BFL notifying him or her of 
the return.  PEOG will determine whether the provider/suppliers Medicare billing privileges 
should be deactivated or revoked and will notify the contractor of its decision. 
 
2. Timeframe Not Yet Expired - If the contractor returns a change of information or CHOW 
submission and the applicable 90-day or 30-day period for reporting the change has not yet 
expired, the contractor shall send the e-mail referenced in section 10.4.1.4.2(C)(1) after the 
expiration of said time period unless the provider has resubmitted the change request/CHOW. 
 
3  Second Return, Rejection, or Denial  If, per section 10.4.1.4.2, the provider resubmits the 
change of information or CHOW application and the contractor either returns it again, rejects it, 
or denies it, the contractor shall send the e-mail referenced in section 10.4.1.4.2(C)(1) regardless 
of whether the applicable timeframe has expired.  PEOG will determine whether the 
provider/suppliers Medicare billing privileges should be deactivated or revoked and will notify 
the contractor of its decision. 
 
D.  Reactivations  
 
If the contractor returns a reactivation application, the providers Medicare billing privileges 
shall remain deactivated. 
  E.  Revalidations 
 
If the contractor returns a revalidation application, the contractor shall  unless an existing CMS 
instruction or directive states otherwise - deactivate the providers Medicare billing privileges 
under 42 CFR  424.540(a)(3) if the applicable time period for submitting the revalidation 
application has expired.  If it has not expired, the contractor shall deactivate the providers 
billing privileges after the applicable time period expires unless the provider has resubmitted the 
revalidation application.  If the provider indeed resubmits the application and the contractor 
returns it again, rejects it, or denies it, the contractor shall  absent another CMS instruction to 
the contrary - deactivate the providers billing privileges, assuming the applicable time period 
has expired. 
 
10.4.1.4.3 - Rejections 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Background 
 
1.  Rejection Reasons 
 
a.  Section 424.525(a)(1)(i) through (x)  Submission of Complete Information 
 
In accordance with 42 CFR  424.525(a)(1)(i) through (x), the contractor (including the NSC) 
may reject the providers application if the provider fails to furnish complete information on the 
enrollment application within 30 calendar days from the date the contractor requested the 
missing information.  For purposes of this policy, this includes situations where the provider 
submitted an application that falls into one of the following categories and, upon the contractors 
request to submit a new or corrected complete application, the provider failed to do so within 30 
days of the request: 
 
(i) The application is missing data required by CMS or the contractor to process the application 
(such as, but not limited to, names, Social Security Number, contact information, and practice 
location information).   
 
(ii) The application is unsigned or undated. 
 
(iii) The application contains a copied or stamped signature. 
 
(iv) The application is signed (as reflected by the date of signature) more than 120 days prior to 
the date on which the contractor received the application. 
 
(v) The application is signed by a person unauthorized to do so under this 42 CFR Part 424, 
subpart P.   
 
(vi) For paper applications, the required certification statement is missing. 
 
(vii) The paper application is completed in pencil. 
  (viii) The application is submitted via fax or e-mail when the provider or supplier was not 
otherwise permitted to do so. 
 
(ix) The provider or supplier failed to submit all of the forms needed to process a Form CMS-
855 reassignment package within 30 days of receipt.   
 
(x) The provider or supplier submitted the incorrect Form CMS-855 application.  (For example, 
the provider or supplier submitted a Form CMS-855A application when a Form CMS-855B 
application was required.) 
 
(Note that certain rejection grounds are inapplicable to PECOS applications (e.g., Form CMS-
855 application was completed in pencil, certification statement is missing)). 
 
b.  Section 424.525(a)(2) - Documentation 
 
In accordance with 42 CFR  424.525(a)(2), the contractor (including the NSC) may reject the 
application if the provider or supplier fails to furnish all required supporting documentation 
within 30 calendar days of submitting the application. 
 
c.  Section 424.525(a)(3)  Application Fee 
 
Consistent with 42 CFR  424.525(a)(3), the contractor (including the NSC) may reject the 
application if the institutional provider (as that term is defined in  424.502) does not submit the 
application fee in the designated amount or a hardship waiver request (1) with the application at 
the time of filing and (2) after development for the fee by the contractor.  This means that the 
contractor shall develop for a non-submitted fee rather than return the application.  (It need not 
develop for a waiver, however.)  If the institutional provider fails to submit the fee (or a waiver) 
within 30 days of the request, the contractor can reject the application. 
 
2.  Applicability 
 
a.  Development 
 
The applications described in subsections (A)(1)(a) through (c) above shall be developed, rather 
than returned.  For instance, if a provider submits an application completed in pencil, the 
contractor shall request the provider to submit a new application, either in ink or via Internet-
based PECOS. 
 
b.  Transaction and Form Types 
 
Per  424.525(e)---and except as otherwise specified in the applicable reason for rejection--- 
424.525(a)(1) through (3) apply to all CMS provider enrollment application submissions, 
including, but not limited to, the following: 
 
  Form CMS-855 initial applications, change of information requests, changes of ownership, 
revalidations, and reactivations.   
  Form CMS-588 (Electronic Funds Transfer (EFT) Authorization Agreement) submissions.      Form CMS-20134 (Medicare Enrollment Application; Medicare Diabetes Prevention 
Program (MDPP) Suppliers) submissions.   
  Any electronic or successor versions of the forms identified in paragraphs  424.525(e)(1) 
through (3).) 
 
B.  Timeframe 
 
The 30-day clock identified in  424.525(a) starts on the date the contractor mails, faxes, or e-
mails (e.g., via the PCV) the development letter or other request for information to the provider.  
If the contractor makes a follow-up request for information, the 30-day clock does not start 
anew; rather, it keeps running from the date the development letter was sent.  However, the 
contractor has the discretion to extend the 30-day timeframe if it determines that the provider is 
actively working with the contractor to resolve any outstanding issues. 
 
C.  Incomplete Responses  
 
The provider must furnish all missing and clarifying data and/or documentation requested by the 
contractor within the applicable timeframe.  If the provider furnishes some, but not all, of the 
requested information, the contractor is not required to contact the provider again to request the 
remaining data.  It can simply reject the application at the expiration of the aforementioned 30-
day period.  Consider the following example: 
 
EXAMPLE: A provider submits a Form CMS-855A in which Section 3 is blank.  On March 1, 
the contractor requests that Section 3 be fully completed.  On March 14, the provider submits an 
application with the Final Adverse Action History question completed.  However, the report of 
each adverse action, date, applicable body, and resolution data fields remains blank.  The 
contractor need not make a second request for this data to be furnished.  It can reject the 
application on March 31, or 30 days after its initial request was made. 
 
 
 
 
 
D.  Creation - Paper Applications Only 
 
If the contractor cannot complete the intake or data entry process in PECOS because of missing 
data and the application is subsequently rejected, the contractor shall disposition the application 
accordingly in PECOS consistent with existing CMS guidance.   
 
E.  Other Impacts of a Rejection 
 
1.  Changes of Information and CHOWs 
 
a.  Expiration of Timeframe for Reporting Changes - If the contractor rejects a change of 
information or CHOW submission per this chapter and the applicable 90-day or 30-day period 
for reporting the change has expired, the contractor shall send an e-mail to its PEOG BFL 
notifying him or her of the rejection.  PEOG will determine whether the provider/suppliers  Medicare billing privileges should be deactivated or revoked and will notify the contractor of its 
decision. 
 
b. Timeframe Not Yet Expired - If the contractor rejects a change of information or CHOW 
submission and the applicable 90-day or 30-day period for reporting the change has not yet 
expired, the contractor shall send the e-mail referenced in subsection (E)(1)(a) above after the 
expiration of said time period unless the provider/supplier has resubmitted the change 
request/CHOW. 
 
c.  Second Rejection, Return, or Denial  If, per subsection (E)(1)(b) above, the provider 
resubmits the change of information or CHOW application and the contractor either rejects it 
again, returns it, or denies it, the contractor shall send the e-mail referenced in subsection 
(E)(1)(a) above regardless of whether the applicable timeframe has expired.  PEOG will 
determine whether the providers Medicare billing privileges should be deactivated or revoked 
and will notify the contractor of its decision. 
 
F.  Reactivations 
 
If the contractor rejects a reactivation application, the providers Medicare billing privileges shall 
remain deactivated. 
 
G.  Revalidations 
 
If the contractor rejects a revalidation application per this chapter 10, the contractor shall  
unless an existing CMS instruction or directive states otherwise - deactivate the 
provider/suppliers Medicare billing privileges under 42 CFR  424.540(a)(3) if the applicable 
time period for submitting the revalidation application has expired.  If it has not expired, the 
contractor shall deactivate the provider/suppliers billing privileges after the applicable time 
period expires unless the provider/supplier has resubmitted the revalidation application.  If the 
provider/supplier indeed resubmits the application and the contractor rejects it again, returns it, 
or denies it, the contractor shall  absent a CMS instruction to the contrary - deactivate the 
providers billing privileges, assuming the applicable time period has expired. 
 
H.  Additional Rejection Policies 
 
1.  Resubmission after Rejection  
 
If the providers application is rejected, the provider must complete and submit a new Form 
CMS-855 or CMS-20134 (either via paper or Internet-based PECOS) and all necessary 
documentation. 
 
2.  Applicability 
 
Unless stated otherwise in this chapter or another CMS directive, this section 10.4.1.4.3 applies 
to all applications identified in this chapter (e.g., initial applications, change requests, Form 
CMS-855O applications, Form CMS-588 submissions, CHOW applications, revalidations, and 
reactivations). 
  3.  Physicians and Non-Physician Practitioners 
 
Incomplete applications submitted by physicians and non-physician practitioners shall be 
rejected (unless a denial reason exists) if they fail to provide the requested information within the 
designated timeframe. 
 
4.  Notice 
 
If the contractor rejects an application, it shall notify the provider via letter (sent via fax, mail, 
the PCV, or e-mail) that the application is being rejected, the reason(s) for the rejection, and how 
to reapply.  Absent a CMS instruction or directive to the contrary, the letter shall be sent to the 
provider no later than 5 business days after the contractor concludes that the providers 
application should be rejected. 
 
5.  Copy of Application  
 
Paper Applications - If the contractor rejects an application, it shall either (1) keep the original 
application and all supporting documents or (2) maintain the scanned submission of the 
application and documents in PECOS and return the originals to the provider.  If the contractor 
chooses the former approach and the provider requests a copy of its application, the contractor 
may fax or mail it to the provider. 
 
PECOS  Since the application was submitted electronically via PECOS and all supporting 
documents were uploaded consistent with section 10.3 of this chapter, the contractor need not 
return any documents to the provider.  
 
10.4.2 - Denials  
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
In executing the instructions in section 10.4.2 et seq. of this chapter, the contractor shall also 
adhere to: 
 
(i)  The supplemental and superseding instructions in section 10.6.6 of this chapter concerning 
final adverse actions (e.g., referrals to PEOG);  
   
(ii) The letter formats and verbiage in section 10.7 et seq. of this chapter;  
 
(iii) The PECOS 2.0 instructions in section 10.3 of this chapter; and 
 
(iv)  Any other directive that, per CMS, explicitly pre-empts any instruction(s) in section 10.4.2 
et seq. of this chapter.   
 
If any instruction in categories (i) through (iv) above conflict with that in section 10.4.2 et seq., 
the instruction in (i), (ii), (iii), or (iv) applies.  In addition, the contractor shall adhere to any 
instruction in (i), (ii), (iii), or (iv) above that addresses a denial-related matter not discussed in 
section 10.4.2 et seq. 
  10.4.2.1 - Denials  General Principles 
(Rev. 11020; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21) 
 
A.  Notification Letters for Denials  
 
If the contractor finds a legal basis for denying an application - and, if applicable under section 
10.4.2 et seq., section 10.6.6, or another CMS directive, receives approval from PEOG for said 
denial - the contractor shall deny the application and notify the provider by letter.  Except as 
stated otherwise in this chapter, the denial letter shall contain: 
 
(i)  A legal (i.e., regulatory) basis for each reason for the denial; 
 
         (ii) A clear explanation of why the application is being denied, including the facts or evidence 
that the contractor used in making its determination; 
 
         (iii) An explanation of why the provider does not meet the applicable enrollment criteria; 
 
  (iv) The appropriate regulatory basis (e.g., 42 CFR  424.530(a)(1)) for the denial. (The 
contractor shall not use provisions from this chapter 10 as the basis for denial.)   
 
(v) Procedures for submitting a corrective action plan (CAP, for denials based on 42 CFR  
424.530(a)(1)); and  
 
(vi) Complete and accurate information about the providers further appeal rights. 
 
In addition, the letter shall follow the format of the applicable model denial letter in section 10.7 
et seq. of this chapter. 
 
There is no reenrollment bar for denied applications.  Reenrollment bars apply only to 
revocations. 
 
B.   When Prior PEOG Approval of the Denial Necessary   
 
For cases involving 42 CFR  424.530(a)(3) (Felony Convictions),  424.530(a)(4) (False or 
Misleading Information or Application),  424.530(a)(6) (Existing Overpayment at Time of 
Application),  424.530(a)(12) (Revoked Under Different Name, Numerical Identifier, or 
Business Identity),  424.530(a)(13) (Affiliation that Poses an Undue Risk),  424.530(a)(14) 
(Other Program Termination or Suspension), and denials involving MDPP suppliers, the 
contractor shall obtain approval of both the denial and the denial letter from PEOG via the 
ProviderEnrollmentRevocations@cms.hhs.gov mailbox prior to sending the denial letter.  The 
contractor shall also obtain prior PEOG approval of the denial and denial letter if otherwise 
required to do so in this chapter or another CMS directive (i.e., certain denial situations other 
than those described in this subsection 10.4.2.1(B) require prior PEOG approval).   
 
PEOG will notify the contractor of its determination (including, as applicable, whether a 
reapplication bar under  424.530(f) is to be imposed) and instruct the contractor as to how to 
proceed. Absent a CMS instruction or directive to the contrary, the denial letter shall be sent to  the provider via certified mail no later than 5 business days after PEOG concludes that the 
providers application should be denied.  The contractor shall not proceed with finalizing the 
denial until it receives the aforementioned guidance from PEOG.  If this guidance is delayed, the 
contractor shall carve the impacted application(s) out of its timeliness reporting; the contractor 
shall document and report the impacted application(s) in its Monthly Status Reports. 
 
C.   When Prior PEOG Approval of the Denial Unnecessary  Timeframe for Sending 
Letter  
 
Absent a CMS instruction or directive to the contrary, the denial letter shall be sent to the 
provider/supplier via certified mail no later than 5 business days after the contractor determines 
that the providers application should be denied.   
 
D.   No Denial Recommendation to State 
 
If the applicant is a certified provider or certified supplier and a denial reason is implicated, the 
contractor need not submit a recommendation for denial to the state/SOG Location.  Except as 
stated otherwise in this chapter, the contractor can simply: (1) deny the application (though, as 
explained in this chapter, some denials might require prior PEOG approval); (2) close out the 
PECOS record; (3) send a denial letter to the provider; and (4) copy the state and the SOG 
Location on said letter. 
 
E.   PECOS Entry 
 
All denied applications and all applicable denial reasons shall be entered into PECOS, including 
fingerprint and non-covered provider or supplier type denials.  For non-covered provider or 
supplier type denials, the contractor shall select the Other specialty/provider/supplier type 
option and input the type listed on the application. 
 
10.4.2.2 - Denial Reasons 
(Rev. 11808; Issued: 01-24-23; Effective: 01-01-23; Implementation: 01-03-23) 
 
A.  Denial Reason 1 Not in Compliance with Medicare Requirements (42 CFR 
424.530(a)(1)) 
 
The provider or supplier is determined not to be in compliance with the enrollment 
requirements in subpart P (of Part 424) or on the enrollment application applicable to its provider 
or supplier type, and has not submitted a plan of corrective action as outlined in 42 CFR part 
488.  Such non-compliance includes, but is not limited to, the following situations: 
 
i.   The provider or supplier does not have a physical business address or mobile unit where 
services can be rendered. 
 
ii.   The provider or supplier does not have a place where patient records are stored to determine 
the amounts due such provider or other person. 
 
iii.  The provider or supplier is not appropriately licensed. 
  iv.  The provider or supplier is not authorized by the federal/state/local government to perform 
the services that it intends to render. 
 
v.   The provider or supplier does not meet CMS regulatory requirements for the specialty that it 
seeks to enroll as. (See section 10.2.8 of this chapter for examples of suppliers that are not 
eligible to participate.) 
 
vi.   The provider or supplier does not have a valid social security number (SSN) or employer 
identification number (EIN) for itself, an owner, partner, managing organization/employee, 
officer, director, medical director, and/or authorized or delegated official. 
 
vii.   The applicant does not qualify as a provider of services or a supplier of medical and health 
services.  (For instance, the applicant is not recognized by any federal statute as a Medicare 
provider or supplier (see section 10.2.8 of this chapter))  An entity seeking Medicare payment 
must be able to receive reassigned benefits from physicians in accordance with the Medicare 
reassignment provisions in  1842(b)(6) of the Act (42 U.S.C. 1395u(b)). 
 
viii.   The provider or supplier does not otherwise meet general enrollment requirements. 
 
ix.   The provider or supplier does not meet standards specific to their supplier type (e.g., MDPP 
supplier standards outlined in 42 CFR  424.205(d)). 
 
(With respect to (v) above  and, as applicable, (iii), (iv) and (ix) - the contractors denial letter 
shall cite the appropriate statutory and/or regulatory citation(s) containing the specific 
licensure/certification/authorization requirement(s) for that provider or supplier type.  For a 
listing of some of these statutes and regulations, refer to section 10.2 et seq. of this chapter.) 
 
NOTE:  The contractor must identify in its denial letter the exact provision within said 
statute(s)/regulation(s) with which the provider/supplier is non-compliant. 
 
B.  Denial Reason 2 Excluded/Debarred from Federal Program (42 CFR  424.530(a)(2)) 
 
The provider or supplier, or any owner, managing employee, managing organization, officer, 
director, authorized or delegated official, medical director, supervising physician, or other health 
care or administrative or management services personnel (such as a billing specialist, accountant, 
or human resources specialist) furnishing services payable by a federal health care program, of 
the provider or supplier is 
 
(i) Excluded from Medicare, Medicaid, or any other federal health care program, as defined in 42 
CFR  1001.2, in accordance with section 1128, 1128A, 1156, 1842, 1862, 1867 or 1892 of the 
Social Security Act, or 
 
(ii) Debarred, suspended, or otherwise excluded from participating in any other Federal 
procurement or non-procurement program or activity in accordance with section 2455 of the 
Federal Acquisition Streamlining Act. 
 
(Unless stated otherwise in section 10.6.6 of this chapter or in another CMS directive, the 
contractor need not review the OIG exclusion list for any health care or administrative or  management services personnel who are not otherwise required to be reported on the enrollment 
application.) 
 
C.  Denial Reason 3  Felony Conviction (42 CFR  424.530(a)(3)) 
 
The provider, supplier, or any owner, managing employee, managing organization, officer, 
director, of the provider or supplier was, within the preceding 10 years, convicted (as that term is 
defined in 42 CFR  1001.2) of a federal or state felony offense that CMS determines to be 
detrimental to the best interests of the Medicare program and its beneficiaries.  Offenses include, 
but are not limited in scope and severity to: 
 
(i)  Felony crimes against persons, such as murder, rape, assault, and other similar crimes for 
which the individual was convicted, including guilty pleas and adjudicated pretrial diversions. 
 
(ii)  Financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud and 
other similar crimes for which the individual was convicted, including guilty pleas and 
adjudicated pretrial diversions. 
 
(iii)  Any felony that placed the Medicare program or its beneficiaries at immediate risk, such as 
a malpractice suit that results in a conviction of criminal neglect or misconduct. 
 
(iv) Any felonies outlined in section 1128 of the Social Security Act. 
 
While a reenrollment bar is established for revoked providers/suppliers, this does not preclude 
the contractor from denying reenrollment to a provider/supplier that was convicted of a felony 
within the preceding 10-year period or that otherwise does not meet all of the criteria necessary 
to enroll in Medicare. 
 
Note that if an MDPP coach meets the above felony requirements, this would not itself warrant a 
denial of the MDPP supplier under  424.535(a)(3).  This is because the coach, not the MDPP 
supplier, has the felony conviction.  The MDPP supplier could, however, be denied enrollment 
under  424.530(a)(1) (non-compliance with enrollment requirements) for having an ineligible 
coach. 
 
As explained in section 10.6.6 of this chapter, the contractor shall submit all felonies found on 
Form CMS-855 and CMS-20134 applications to PEOG for review via  
ProviderEnrollmentRevocations@cms.hhs.gov.  (See section 10.6.6 for more information.)  
 
D. Denial Reason 4 False or Misleading Information on Application (42 CFR  
424.530(a)(4)) 
 
The provider or supplier submitted false or misleading information on the enrollment 
application to gain enrollment in the Medicare program. 
 
E. Denial Reason 5 On-Site Review/Other Reliable Evidence that Requirements Not Met 
(42 CFR 424.530(a)(5)) 
  Upon on-site review or other reliable evidence, CMS determines that the provider or supplier:  
 
(i)  Is not operational to furnish Medicare-covered items or services; or 
(ii) Otherwise fails to satisfy any Medicare enrollment requirement. 
 
F. Denial Reason 6 Existing Overpayment at Time of Application (42 CFR  
424.530(a)(6)) 
 
1. Background 
 
Consistent with 42 CFR  424.530(a)(6), an enrollment application may be denied if the 
provider, supplier, or owner thereof has an existing Medicare overpayment that is equal to or 
exceeds a threshold of $1,500 and has not been repaid in full at the time the application was 
filed.  More specifically: 
 
(A) The enrolling provider, supplier, or owner (as defined in  424.502) thereof has an existing 
Medicare debt. 
 
(B)  The enrolling provider, supplier, or owner (as defined in  424.502) thereof was previously 
the owner of a provider or supplier that had a Medicare debt that existed when the latter's 
enrollment was voluntarily terminated, involuntarily terminated, or revoked, and all of the 
following criteria are met:  
 
(1)  The owner left the provider or supplier with the Medicare debt within 1 year before or after 
that provider or supplier's voluntary termination, involuntary termination, or revocation.  
 
(2)  The Medicare debt has not been fully repaid.  
 
(3)  CMS determines that the uncollected debt poses an undue risk of fraud, waste, or abuse.  In 
making this determination [under  424.530(a)(6)(ii)], CMS considers the following factors:   
 
(a)  The amount of the Medicare debt. 
 
(b)  The length and timeframe that the enrolling provider, supplier, or owner thereof was an 
owner of the prior entity. 
 
(c)  The percentage of the enrolling provider, supplier, or owner's ownership of the prior entity. 
 
(d)  Whether the Medicare debt is currently being appealed. 
 
(e)  Whether the enrolling provider, supplier, or owner thereof was an owner of the prior entity at 
the time the Medicare debt was incurred. 
 
In addition, a denial of Medicare enrollment under paragraph (a)(6) can be avoided if the 
enrolling provider, supplier, or owner thereof does either of the following: (1) satisfies the 
criteria set forth in  401.607 and agrees to a CMS-approved extended repayment schedule for 
the entire outstanding Medicare debt; or (2) repays the debt in full.   
  2.  Contractors Determination of Overpayment 
 
When processing a Form CMS-855A, CMS-855B, CMS-855I, CMS-855S, or CMS-20134 initial 
or change of ownership application (if applicable), the contractor shall determine  using a 
system generated monthly listing  whether the provider, supplier, or any owner listed in Section 
5 or 6 of the application has an existing or delinquent Medicare overpayment, as described in 
section 10.4.2.2(F)(1) above and  424.530(a)(6).  If such an overpayment exists, the contractor 
shall deny the application, using 42 CFR 424.530(a)(6) as the basis.  However, prior PEOG 
approval is required before proceeding with the denial.  The contractor shall under no 
circumstances deny an application under  424.530(a)(6) without receiving PEOG approval to do 
so. 
 
3.  Examples 
 
Example #1:  Dr. X, a sole proprietor, has a $70,000 overpayment.  Three months later, he joins 
Group Y and becomes a 50 percent owner thereof.  Group Y submits an initial enrollment 
application two months thereafter.  Group Ys enrollment could be denied because Dr. X is an 
owner.   
 
Example #2:  Dr. John Smiths practice (Smith Medicine) is set up as a sole proprietorship.  
He incurs a $50,000 overpayment.  He terminates his Medicare enrollment.  Six months later, he 
tries to enroll as a sole proprietorship; his practice is named JS Medicine.  A denial is 
warranted because  424.530(a)(6) applies to physicians and the $50,000 overpayment was 
attached to him as the sole proprietor. 
 
Example #3 - Same scenario as example #2, but assume that his new practice is an LLC of which 
he is only a 30 percent owner.  A denial is still warranted because he is an owner of the enrolling 
supplier and the $50,000 overpayment was attached to him. 
 
Example #4 - Jane Smith is a nurse practitioner in a solo practice.  Her practice (Smith 
Medicine) is set up as a closely-held corporation, of which she is the 100 percent owner.  Smith 
Medicine is assessed a $20,000 overpayment.  She terminates her Medicare enrollment.  Nine 
months later, she submits a Form CMS-855I application to enroll herself, Jane Smith as a new 
individual provider.  The business will be established as a sole proprietorship.  A denial is not 
warranted because the $20,000 overpayment was attached to Smith Medicine, not to Jane Smith. 
 
In each of these examples, however, denial could be avoided if (1) the party with the 
overpayment is on a Medicare-approved plan of repayment or (2) the overpayments in question 
are currently being offset or being appealed. 
 
4.  Additional Considerations Involving  424.530(a)(6)   
 
The contractor shall also observe the following with respect to  424.530(a)(6): 
 
a.   In determining whether an overpayment exists, the contractor need only review its own 
records; it need not contact other contractors to determine whether the person or entity has an 
overpayment in those contractor jurisdictions. 
  b.   The instructions in this section 10.4.2.2(F) apply only to (i) initial enrollments and (ii) new 
owners in a change of ownership. 
 
c.   The term owner under  424.502 means any individual or entity that has any partnership 
interest in, or that has 5 percent or more direct or indirect ownership of, the provider or supplier 
as defined in sections 1124 and 1124A(A) of the Act. 
 
d.   If the person or entity had an overpayment at the time the application was filed but repaid it 
in full by the time the contractor performed the review described in this section 10.4.2.2(F), the 
contractor shall not deny the application based on  424.530(a)(6). 
 
G.  Denial Reason 7 Medicare or Medicaid Payment Suspension (42 CFR  424.530(a)(7)) 
 
The provider, supplier or any owning and managing employee or organization of the provider 
or supplier is currently under a Medicare or Medicaid payment suspension at the time the denial 
is issued, as defined in  405.370 through 405.372. 
 
H.  Denial Reason 8 Home Health Agency (HHA) Capitalization (42 CFR  424.530(a)(8)) 
 
An HHA submitting an initial application for enrollment:  
 
a.   Cannot, within 30 days of a CMS or Medicare contractor request, furnish supporting 
documentation verifying that the HHA meets the initial reserve operating funds requirement in 
42 CFR  489.28(a); or 
 
b.   Fails to satisfy the initial reserve operating funds requirement in 42 CFR  489.28(a). 
 
I.   Denial Reason 9 Hardship Exception Denial and Fee Not Paid (42 CFR  
424.530(a)(9)) 
 
The institutional providers (as that term is defined in 42 CFR  424.502) hardship exception 
request is not granted, and the institutional provider does not submit the required application fee 
within 30 days of notification that the hardship exception request was not approved. 
 
(This denial reason should only be used when the institutional provider fails to submit the 
application fee after its hardship request was denied.  The contractor shall use  424.530(a)(1) as 
a basis for denial when the institutional provider: (a) does not submit a hardship exception 
request and fails to submit the application fee within the prescribed timeframes; or (b) submits 
the fee, but it cannot be deposited into a government-owned account.) 
 
J.   Denial Reason 10 Temporary Moratorium (42 CFR  424.530(a)(10)) 
 
The provider or supplier submits an enrollment application for a practice location in a 
geographic area where CMS has imposed a temporary moratorium.  (This denial reason applies 
to initial enrollment applications and practice location additions.) 
 
K.  Denial Reason 11 DEA Certificate/State Prescribing Authority Suspension or 
Revocation (42 CFR  424.530(a)(11))   
1. A physician or eligible professional's Drug Enforcement Administration (DEA) Certificate of 
Registration to dispense a controlled substance is currently suspended or revoked or is 
surrendered in response to an order to show cause; or  
 
2. The applicable licensing or administrative body for any state in which a physician or eligible 
professional practices has suspended or revoked the physician or eligible professional's ability to 
prescribe drugs, and such suspension or revocation is in effect on the date the physician or 
eligible professional submits his or her enrollment application to the Medicare contractor.   
 
(Except as otherwise stated in this chapter or in another CMS directive, the contractor need not 
verify whether an individuals DEA certificate was surrendered in response to a show cause 
order.) 
 
L.  Denial Reason 12 (42 CFR  424.530(a)(12) - Revoked Under Different Name, 
Numerical Identifier, or Business Identity) 
 
The provider or supplier is currently revoked under a different name, numerical identifier, or 
business identity, and the applicable reenrollment bar period has not expired.  In making its 
determination, CMS considers the following factors: 
 
(i) Owning and managing employees and organizations (regardless of whether they have been 
disclosed on the Form CMS-855 [or CMS-20134] application); 
(ii) Geographic location; 
(iii) Provider or supplier type; 
(iv) Business structure; or 
(v) Any evidence indicating that the two parties [the revoked provider/supplier and the newly-
enrolling provider/supplier] are similar or that the provider or supplier was created to circumvent 
the revocation or reenrollment bar. 
 
NOTE: With respect to (a)(12), PEOG  rather than the contractor  will make all determinations 
regarding whether a provider or supplier was revoked under a different name, numerical 
identifier or business identity. 
M.  Denial Reason 13 (42 CFR  424.530(a)(13) - Affiliation that Poses an Undue Risk) 
 
 
The provider or supplier has or has had an affiliation under 42 CFR  424.519 (specifically, the 
factors listed in 42 CFR  424.519(f)) that poses an undue risk of fraud, waste, and abuse to the 
Medicare program. 
 
An affiliation is defined as any of the following: 
 
(i)  A 5 percent or greater direct or indirect ownership interest that an individual or entity has in 
another organization. 
(ii) A general or limited partnership interest (regardless of the percentage) that an individual or 
entity has in another organization. 
(iii)  An interest in which an individual or entity exercises operational or managerial control 
over, or directly or indirectly conducts, the day-to-day operations of another organization  (including, for purposes of  424.519 only, sole proprietorships), either under contract or through 
some other arrangement, regardless of whether or not the managing individual or entity is a W2 
employee of the organization. 
(iv) An interest in which an individual is acting as an officer or director of a corporation. 
(v)  Any reassignment relationship under  424.80. 
 
NOTE: With respect to (a)(13), PEOG -- rather than the contractor  will make all 
determinations regarding whether a provider or supplier has an affiliation per 42 CFR  424.519 
that poses an undue risk of fraud, waste and abuse. 
 
N. Denial Reason 14 (42 CFR  424.530(a)(14)  Other Program Termination or 
Suspension) 
 
(1) The provider or supplier is currently terminated or suspended (or otherwise barred) from 
participation in a state Medicaid program or any other federal health care program; or (2) the 
provider or suppliers license is currently revoked or suspended in a state other than that in which 
the provider or supplier is enrolling.   
 
In determining whether a denial under  424.530(a)(14) is appropriate, CMS considers the 
following factors: 
 
a.  The reason(s) for the termination, suspension, or revocation;   
 
b.  Whether, as applicable, the provider or supplier is currently terminated or suspended (or 
otherwise barred) from more than one program (for example, more than one state's Medicaid 
program), has been subject to any other sanctions during its participation in other programs or by 
any other state licensing boards, or has had any other final adverse actions (as that term is 
defined in  424.502) imposed against it; and   
 
c.  Any other information that CMS deems relevant to its determination. 
 
NOTE: With respect to (a)(14), PEOG -- rather than the contractor  will make all 
determinations regarding whether a provider or supplier has an termination or suspension from 
another program. 
 
O.  Denial Reason 15 (42 CFR  424.530(a)(15)  Patient Harm) 
 
The physician or other eligible professional has been subject to prior action from a state 
oversight board, federal or state health care program, Independent Review Organization (IRO) 
determination(s), or any other equivalent governmental body or program that oversees, regulates, 
or administers the provision of health care with underlying facts reflecting improper physician or 
other eligible professional conduct that led to patient harm. In determining whether a denial is 
appropriate, CMS considers the following factors: 
 
(A) The nature of the patient harm 
(B) The nature of the physician's or other eligible professional's conduct  (C) The number and type(s) of sanctions or disciplinary actions that have been imposed against 
the physician or other eligible professional by a state oversight board, IRO, federal or state health 
care program, or any other equivalent governmental body or program that oversees, regulates, or 
administers the provision of health care. Such actions include, but are not limited to in scope or 
degree: (i) license restriction(s) pertaining to certain procedures or practices; (ii) required 
compliance appearances before state oversight board members; (iii) license restriction(s) 
regarding the ability to treat certain types of patients (for example, cannot be alone with 
members of a different gender after a sexual offense charge); (iv) administrative/monetary 
penalties; and (v) formal reprimand(s). 
(D) If applicable, the nature of the IRO determination(s). 
(E) The number of patients impacted by the physician's or other eligible professional's conduct 
and the degree of harm thereto or impact upon.  
Section 424.530(a)(15) does not apply to actions or orders pertaining exclusively to either of the 
following: (i) required participation in rehabilitation or mental/behavioral health programs; or (ii) 
required abstinence from drugs or alcohol and random drug testing. 
 
NOTE: With respect to (a)(15), PEOG -- rather than the contractor  will make all 
determinations regarding whether this provision applies.   
 
 
 
10.4.2.3  Additional Denial Policies 
(Rev. 11307; Issued: 03- 25-2022; Effective: 03-04-22; Implementation: 04-25-22) 
 
A.  Post-Denial Submission of Enrollment Application 
 
A denied provider may not submit a new enrollment application until: 
 
(i) If the initial denial was not appealed, the providers appeal rights have lapsed;  
 
(ii) If the initial denial was appealed, the provider has received notification that the determination 
was upheld; or 
 
(iii) The reapplication bar has expired, if applicable. 
 
The contractor shall return an application submitted before the aforementioned have occurred. 
 
B.   30-Day Effective Date of Denial 
 
A denial is effective 30 calendar days after the contractor sends its denial notice to the provider. 
 
As stated in 42 CFR  424.530(c), if the denial was due to adverse activity (e.g., exclusion, 
felony) of an owner, managing employee, an authorized or delegated official, medical director, 
supervising physician, or other health care or administrative or management personnel of the 
provider or supplier furnishing services payable by a federal health care program, the denial may  be reversed (with PEOG approval) if the provider or supplier submits proof that it has terminated 
its business relationship with that individual or organization within 30 days of the denial 
notification. 
 
C.   Denials - Changes of Information and Changes of Ownership (CHOWs) 
 
1.   Expiration of Timeframe for Reporting Changes  
 
If the contractor denies a change of information or CHOW submission and the applicable 90-day 
or 30-day period for reporting the change has expired, the contractor shall send an e-mail to the 
CMS MedicareProviderEnrollment@cms.hhs.gov mailbox notifying PEOG of the denial. PEOG 
will determine whether the providers Medicare billing privileges should be deactivated or 
revoked and will notify the contractor of its decision. 
 
2. Timeframe Not Yet Expired 
 
If the contractor denies a change of information or CHOW submission and the applicable 90-day 
or 30-day period for reporting the change has not yet expired, the contractor shall send the e-mail 
referenced in subsection (C)(1) above after the expiration of said time period unless the provider 
has resubmitted the change request/CHOW. 
 
3.  Second Rejection, Return, or Denial 
 
If, per subsection (C)(2) above, the provider resubmits the change of information or CHOW 
application and the contractor either denies it again, returns it, or rejects it, the contractor shall 
send the e-mail referenced in subsection (C)(1) above regardless of whether the applicable 
timeframe has expired.  PEOG will determine whether the providers Medicare billing privileges 
should be deactivated or revoked and will notify the contractor of its decision. 
 
 
D.  Reactivations  
 
If the contractor denies a reactivation application, the providers Medicare billing privileges shall 
remain deactivated or revoked. 
 
E. Revalidations 
 
If the contractor denies a revalidation application, the contractor shall  unless an existing CMS 
instruction or directive states otherwise - deactivate the providers Medicare billing privileges if 
the applicable time period for submitting the revalidation application has expired.  If it has not 
expired, the contractor shall deactivate the providers billing privileges after the applicable time 
period expires unless the provider has resubmitted the revalidation application.  If, per the 
previous sentence, the provider resubmits the application and the contractor denies it again, 
returns it, or rejects it, the contractor shall - unless an existing CMS instruction or directive states 
otherwise  revoke the providers billing privileges, assuming the applicable time period has 
expired. 
 
F.  Appeals of Denials    
For information regarding the provider enrollment appeals process, see section 10.6.18 of this 
chapter.   
 
G.  (A)(1) Versus (A)(5) 
 
In cases where denial is warranted because the provider/suppliers location is vacant, occupied 
by another party, closed during office hours, etc., or a state survey failure is involved, the 
contractor shall use  424.530(a)(5) (rather than  424.530(a)(1)) as the denial reason.  (This 
applies to both certified and non-certified providers/suppliers.)  No CAP rights are therefore 
involved. 
10.4.2.3.4  Denial Based on Survey Failure  
(Rev. 11574; Issued: 08-25-22; Effective: 06-24-22; Implementation: 09-27-22) 
 
(The instructions in this section 10.4.2.3.4 apply only if both of the following requirements are 
met: 
 
(i) The situation involves a certified provider/supplier initial enrollment denial based on the 
provider/suppliers failure of its state/accreditation survey (e.g., section 10.4.2.3.4 is inapplicable 
to revocations, changes of information involving a survey, etc.); and. 
 
(ii) The certified provider/supplier type in question has transitioned (as that term is described 
in this chapter). 
 
Except as otherwise stated, section 10.4.2.3.4 takes precedence over any other instruction in this 
chapter to the contrary.  (For instance, if a SNF fails its survey and the state notifies the 
contractor thereof, the contractor shall follow the instructions in this section 10.4.2.3.4 rather 
than those in section 10.2.1.14(B)(3)(a) of this chapter.)  All other denials (e.g., survey denials 
for non-transitioned providers; denials for transitioned providers for reasons other than a survey 
failure) shall be handled consistent with the instructions in this chapter.) 
 
A.  Traditional Process  Survey Failure 
 
The longstanding process for state/accreditation survey failures typically involved the following: 
 
(i) The SOG Location notifies the provider/supplier of the survey failure 
          
(ii) The provider/supplier is given up to two additional opportunities for resurvey within 6 
months of the SOG notification in (i) above   
 
(iii) As applicable, no provider agreement, tie-in notice (CMS-2007), final denial notice, etc. 
from the SOG Location is issued unless or until the provider/supplier passes or fails the 
remaining survey(s) or the aforementioned 6-month period expires 
 
(iv) Depending on the results of (iii), the SOG Location issues a tie-in approval/denial notice to 
the contractor 
  (v) The contractor finalizes the application 
 
(vi) The SOG Location handles any resulting reconsideration. 
 
Regarding paragraph (A)(ii) above: (1) the applicant may submit no more than two additional 
requests for survey/certification; and (2) no more than 6 months may elapse between the date of 
the SOG Locations first denial and the CMSs receipt of the second request.  Note, however, 
that isolated cases can arise when a subsequent survey is completed within the 6-month period 
but the SOG Location does not receive the results until after the 6-month period expires.  This is 
acceptable because the actual survey would have occurred timely.  Thus, references to a 6-
month period in this section 10.4.2.3.4 includes isolated instances where the SOG Location is 
awaiting survey results beyond the expiration of this period.   
 
B.  Revised Process for Transitioned Certified Providers/Suppliers 
 
Event 1  Provider/Supplier Fails Initial Survey 
 
(i)  The state notifies the SOG Location and the contractor (typically via the CMS-1539) of the 
survey failure and the specific requirements the provider/supplier failed. 
 
(ii) Within 5 business days of receiving this notification copy from the state, the contractor shall 
send to the provider/supplier the denial letter in section 10.7.5.1.1 of this chapter.  
(Notwithstanding any other instruction in this chapter to the contrary, this particular letter need 
not be sent via certified mail.)  The state, accreditation organization (if applicable), and SOG 
Location shall be copied on the letter. 
 
(iii) The letter shall include the reason(s) for the survey failure (from the CMS-1539) and 
reconsideration rights for said failure; the SOG Location will handle any reconsideration.   
 
(iv) The 6-month clock commences on the date of the letter in (B)(ii) above. 
 
(v) Once this letter is sent, no further action by the contractor is required at this time and the 
provider/supplier need not submit a new or revised application because of the survey failure.  
The enrollment application is not finalized but instead remains pending until the 
provider/supplier passes the survey or the six-month period has expired.  
 
Event 2  The 6-Month Period - Reconsiderations 
 
(i) If the provider/supplier submits a reconsideration and the survey failure is overturned because 
of a successful survey, the SOG Location will notify the provider/supplier thereof.  (The SOG 
Location will also notify the contractor of the reversal via a CMS-1539 (or other approval 
notice).)  The contractor shall follow the instructions in paragraph (i) in Event 3 below.   
 
(ii) If the survey failure is upheld on reconsideration, the SOG Location will notify the 
provider/supplier and the contractor thereof.  The contractor need not take further action at this 
time.  During the above-referenced 6-month period, the state will perform no more than two 
additional surveys.     
  Event 3  Final Decision  
 
The state or SOG Location will notify the contractor of the final outcome of the 6-month period 
(e.g., survey is finally passed, provider fails subsequent survey).  This could occur either before 
or after the exact date on which the 6-month period expired.  The contractor is not required to 
internally track this 6-month period but need only wait for the states or SOG Locations 
notification of the final outcome. 
 
(i) Notice of Approval 
 
If the state or SOG Location sends notice of its approval of the provider/supplier (e.g., 
subsequent survey passed; failure of the first survey was overturned on reconsideration), the 
contractor shall complete its processing of the application consistent with the instructions in this 
chapter regarding transitioned providers/suppliers.  (To illustrate, if the provider is an HHA, the 
contractor shall follow the instructions in section 10.2.1.6(B).)  In sending the appropriate 
approval letter, however, the contractor shall delete all references therein to provider agreement 
reconsiderations.  This is because the provider/supplier has no further appeals rights related to 
the provider agreement. 
  
(ii) Notice of Denial  
 
If the state or SOG Location sends notice of its denial of the provider/supplier (e.g., the provider 
failed a subsequent survey(s); the provider did not file a reconsideration request regarding the 
first failed survey and/or no second survey was performed), the contractor shall follow the 
current denial instructions in this chapter for transitioned providers/suppliers.   
 
10.4.3  Voluntary and Involuntary Terminations 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Voluntary Terminations of Certified Providers and Certified Suppliers 
 
For information regarding certified provider/supplier voluntary terminations, see section 10.6.1.3 
of this chapter.   
 
B.  Voluntary Terminations of Non-Certified Suppliers 
 
The contractor shall adhere to the following when processing voluntary terminations of non-
certified suppliers. 
 
1.  Timeframes  The contractor shall process such voluntary terminations in accordance with 
the timeframes in section 10.5 et seq. of this chapter.   
 
2.  Submission  Non-certified suppliers may only submit voluntary termination requests via the 
paper application process or PECOS.  They cannot do so via letter.   
 
3.  Reassignments/PTANs - When processing a voluntary termination of a reassignment, the 
contractor shall contact the group to confirm that: (1) the group member PTAN is being  terminated from all locations; and (2) if multiple group member PTANs exist for multiple group 
locations, each PTAN is terminated.  However, if a group has one PTAN with multiple 
addresses, the contractor need not contact the group to confirm the termination. 
 
4.  PECOS and Deactivations - The contractor shall identify the voluntary termination action in 
PECOS as a deactivation with a status reason of Voluntarily Withdrawal from the Medicare 
Program.  Per 42 CFR  424.540(a)(7), and unless stated otherwise in this chapter or in another 
CMS directive, the effective date of the deactivation (for system purposes) shall be the day after 
the date on which the supplier voluntarily withdrew from Medicare  
 
5.  Reassignments - When processing a voluntary termination of a reassignment, the contractor 
shall terminate non-certified suppliers effective the day after that which the supplier requested on 
its termination application.  (Note that this is different from a voluntary termination of the 
provider/supplier itself as addressed in subsection (B)(4) above.) 
 
6.  Special Payments - Upon receipt of a non-certified supplier voluntary termination request, the 
contractor may ask the supplier to complete the Special Payments portion of Section 4 of the 
Form CMS-855/20134 so that future payments can be sent thereto.  If the supplier has no special 
payments address already on file, the addition should be included in the same transaction as the 
termination (i.e., one transaction incorporating both items).  If the supplier wants to change its 
existing special payments address, the transaction should be treated as a separate change request 
(i.e., one termination and one change request).  The supplier is not required to submit a Form 
CMS-588 in conjunction with a termination. 
 
C.  Involuntary Terminations  Certified Providers/Suppliers 
 
In the event an instruction in section 10.6.1 et seq. of this chapter contradicts guidance in this 
section 10.4.3(C), the section 10.6.1 et seq. guidance takes precedence. 
 
1.  Notification from State or SOG Location 
 
If the contractor receives a notice from the state or SOG Location that involuntarily terminates a 
certified provider/suppliers Medicare participation because the provider/supplier no longer 
meets the conditions of participation, the contractor need not send a letter to the 
provider/supplier stating that its Medicare participation has been terminated.  The state or SOG 
Location will issue such a letter and afford appeal rights.  The contractor shall follow the 
applicable instructions in section 10.4.7 et seq. of this chapter with respect to revoking the 
provider/suppliers enrollment, since the provider/supplier is no longer compliant with Medicare 
enrollment regulations.  (NOTE: The contractor must identify in its revocation letter the exact 
provision within said statute(s)/regulation(s) with which the provider/supplier is non-compliant.) 
 
The contractor shall record the revocation in PECOS using the status reason of Non-
Compliance: Provider/Supplier Type Requirements Not Met. The contractor shall not identify 
the involuntary termination action in PECOS as a Deactivation with a status reason of 
Voluntarily Withdrawal from the Medicare Program. In addition, the contractor shall end-date 
the entitys enrollment record in PECOS in the same manner as it would upon receipt of a 
termination notice from the SOG Location. 
  2.  Revocation Letter 
 
Per subsection (C)(1) above, the contractor shall issue a revocation letter to the certified 
provider/supplier using 42 CFR  424.535(a)(1) as the legal basis for the revocation. The letter 
shall also contain the effective date of the revocation, appeal rights, and the length of the 
reenrollment bar as determined by CMS and indicated to the contractor.  (See section 10.7 et seq. 
of this chapter for the applicable revocation letter.)  The contractor shall e-mail a copy of the 
letter to the SOG Location using the same e-mail address it normally uses when communicating 
with the SOG Locations survey and certification staff. 
 
3.  Additional Information 
 
For more information on voluntary terminations, refer to: 
 
  Section 1866(b)(1) of the Social Security Act 
  42 CFR  489.52(b) 
  Pub. 100-07, chapter 3, section 3046 (SOM) 
 
10.4.4  Changes of Information 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  General Information 
 
Unless as stated otherwise in this chapter, the following apply: 
 
(i) The instructions in this section 10.4.4 apply to Part A and Part B enrollments. 
 
(ii) In the event an instruction in sections 10.6.1 et seq. or 10.6.22 et seq. of this chapter 
contradicts that in this section 10.4.4, the section 10.6.1 et seq. or 10.6.22 et seq. guidance takes 
precedence (e.g., transitioned certified provider/supplier change of information instructions in 
section 10.6.1.2 of this chapter).  
 
(iii) Except as otherwise specified in this chapter or another CMS directive, if an enrolled 
provider/supplier is adding, deleting, or changing information under its existing tax identification 
number, it must report the change using the applicable Form CMS-855 or CMS-20134.  
(Letterhead is impermissible.)  The provider/supplier shall: (a) furnish the changed data in the 
applicable section(s) of the form; and (b) sign and date the certification statement.   
 
(iv) The timeframes for reporting changes are generally addressed in  424.516. 
 
B.  Time Requirements to Report Changes of Information via a Form CMS-855/20134 
Application 
 
1.  Physicians/Non-Physicians/Groups 
 
Pursuant to  424.516(d), change of information requirements apply to physicians, non-physician 
practitioners, and physician and non-physician practitioner organizations (i.e., clinic/group  practices). These supplier types must report the following changes within 30 days: (1) a change 
of ownership; (2) adverse legal action; and (3) a change in practice location.  All other changes 
must be reported within 90 days. 
 
2.  DMEPOS Suppliers  
 
Per 42 CFR  424.57(c)(2) and 424.516(c), DMEPOS suppliers must report any change to their 
enrollment information within 30 days. 
 
3.  IDTFs 
 
Per 42 CFR  410.33(g)(2) and 424.516(b), IDTFs must report any change in adverse legal 
actions, ownership, location, and general supervision within 30 days.  All other changes must be 
reported within 90 days.   
 
4.  MDPP Suppliers  
 
Per 42 CFR  424.205(d)(5) and 424.516(e), an MDPP supplier must update its enrollment 
application within 30 days of any change of ownership, change to its coach roster (including due 
to coach ineligibility or because the coach is no longer an employee, contractor, or volunteer of 
the MDPP supplier), or change in final adverse action history.  All other changes must be 
reported within 90 days. 
 
5.  All Other Provider/Supplier Types  
 
Consistent with 42 CFR  424.516(e), all other provider/supplier types not specifically 
referenced in  424.516(b) through (e) are subject to the following reporting timeframes: 
 
(i)  Changes of ownership or control (including changes in authorized official(s) or delegated 
official(s))  30 days 
 
(ii) All other changes  90 days 
 
(In addition, and per  424.516(e)(3), an air ambulance supplier must report a revocation or 
suspension of its license or certification to the contractor within 30 days of the 
revocation/suspension.  The following FAA certifications must be reported: (a) specific pilot 
certifications including, but not limited to, instrument and medical certifications; and (b) 
airworthiness certification.)   
 
C.  Signatories and Notifications 
 
1.  Signer Not on Record - If the signer has never been reported in Section 6 of the Form CMS-
855 or CMS-20134, Section 6 must be completed in full with information about the individual.  
(This policy applies regardless of whether the provider/supplier already has a Form CMS-
855/20134 on file.)  The contractor shall conduct all required validations concerning the 
individual. 
  2.   Notifications  For changes of information that do not require state agency or SOG Location 
approval (e.g., Form CMS-855I changes, Form CMS-855B changes not involving ambulatory 
surgical centers or portable x-ray suppliers, minor Form CMS-855A/B certified provider/supplier 
changes), the contractor shall: 
 
(i)  Furnish written, e-mail, PCV, or fax confirmation to the provider that the change has been 
made; and  
 
(ii) Document PECOS (per sections 10.3 and 10.6.19 of this chapter) with the date and time the 
confirmation was made.  If, however, the transaction only involves an area code/ZIP code 
change, the contractor need not send confirmation to the provider that it has processed the 
change. 
 
3.  Confirmation of Change in Practice Location Address 
 
In cases where a provider submits a Form CMS-855 or Form CMS-20134 request to change its 
practice location address, the contractor shall contact the location currently associated with the 
provider in PECOS or MCS to verify that the provider/supplier is no longer there and did in fact 
move. 
 
D.  Change in Special Payments Address 
 
Note that the instructions in this subsection (D) are in addition to, and not in lieu of, those in 
section 10.6.23 and vice versa. 
 
1.  Submitted Change - If the provider/supplier submits a change to its special payments address, 
the contractor shall verify the change by contacting the individual physician/practitioner (Form 
CMS-855I changes), an authorized or delegated official (Form CMS-855A, Form CMS-855B, 
and Form CMS-20134 changes), or the contact person listed in Section 13 (for Form CMS-855A, 
Form CMS-855B, Form CMS-20134, and Form CMS-855I changes).  If the contractor cannot 
reach, as applicable, the individual physician/practitioner or an authorized or delegated official, it 
shall confirm the change with the contact person. 
 
2.  Revalidation - When processing a revalidation application, the contractor shall (unless 
another CMS directive instructs otherwise) follow the instructions in sections 10.4.4(D) and 
10.4.4(C)(3) above, respectively, if the practice location address or special payment address on 
the application is different from that currently associated with the provider in PECOS or MCS. 
 
E.  Provider or Supplier Changing Specialty Type 
 
With the exception of individual physicians and certain situations described in section 10.3 of 
this chapter, providers and suppliers who wish to change their enrolled provider/supplier type 
must terminate their current enrollment and submit an initial enrollment application (Screening 
and an application fee (if applicable) applies for the new enrollment.) 
 
F.  Changes Involving Complete Form CMS-855 or CMS-20134 Applications 
  A provider must submit a complete Form CMS-855 or CMS-20134 application if it (1) submits 
any change request and (2) does not have an established enrollment record in PECOS. (For 
purposes of this requirement, the term change request includes EFT changes.)  It is immaterial 
whether: (1) the provider or another party (e.g., local government changes street name) was 
responsible for triggering the changed data; or (2) the signer of the change request or EFT form 
already has a signature on file with the contractor. 
 
If the contractor receives a change request from a provider that is not in PECOS, the contractor 
shall develop for the entire application consistent with the procedures described in this chapter 
(i.e., the contractor shall treat the transaction as a request for additional information).  Consistent 
with existing policies for requesting additional data, the provider has 30 calendar days from the 
date of the contractors request to furnish a complete Form CMS-855 or CMS-20134.  During 
this period, the contractor should hold (i.e., not process) the change request until the entire 
application arrives; no L & T record shall be created in PECOS at this point. 
 
If the provider fails to submit a complete application within the aforementioned 30-day period, 
the contractor shall follow the instructions in section 10.4.1.4.3 of this chapter. 
 
If the provider submits the application, the contractor shall process it in accordance with the 
instructions in this chapter and all other applicable CMS directives.  This includes: 
 
(i)  Processing the complete application consistent with the timeframes for initial applications 
outlined in this chapter.  
 
(ii) Validate all data elements on the Form CMS-855 or CMS-20134 consistent with the 
instructions in this chapter pertaining to initial applications.  The contractor shall not approve the 
change request until it has verified all data on the complete Form CMS-855 or CMS-20134 
consistent with the instructions in this chapter. 
 
(iii) Creating a record in PECOS prior to approving the change request.  (The receipt date should 
be the date on which the complete application was received, not the date on which the initial 
change request was received.)  The transaction should be treated as an initial enrollment in 
PECOS; internally, the contractor shall treat it as a change of information.  As the complete 
application will presumably incorporate the changed data reported on the original Form CMS-
855 or CMS-20134 change request, the contractor shall not take two separate counts (one initial 
and one change request) for the transaction.  (NOTE: Any PECOS 2.0 policies or procedures that 
are contrary to those in this subparagraph (iii) take precedence over the latter.)  
 
G.  Incomplete or Unverifiable Changes of Information 
 
(The contractor shall follow the instructions in this section 10.4.4(G) if it cannot process the 
submitted change request to completion.)   
 
There can be instances where a provider has an enrollment record in PECOS and submits a 
change request but: (1) fails to timely respond to the contractors request for additional or 
clarifying information; or (2) the changed information cannot be validated.  The contractor in 
these situations shall reject the change request in accordance with section 10.4.1.4.3 of this 
chapter. Moreover, if the changed information is of such materiality that the contractor cannot  determine whether the provider still meets all enrollment requirements, the contractor shall refer 
the matter to its PEOG BFL for guidance.  Examples include but are not limited to: (i) change in 
the providers lone practice location; (ii) change in ownership; or (iii) change in EFT 
information. 
 
H.  Change of EFT Information 
 
(Note that the instructions in this subsection (H) are in addition to, and not in lieu, those in 
section 10.6.23 and vice versa.)  
 
If the provider submits a Form CMS-588 request to change the bank name, depository routing 
transit number, or depository account number, the contractor shall contact the individual 
physician/practitioner (for Form CMS-855I enrollees), an authorized or delegated official on 
record (for Form CMS-855A, CMS-855B, and Form CMS-20134 enrollees), or the Section 13 
contact person on record (for Form CMS-855A, Form CMS-855B, Form CMS-20134 and Form 
CMS-855I enrollees) to verify the change.  If the contractor cannot reach, as applicable, the 
individual physician/practitioner or an authorized or delegated official, it shall confirm the 
change with the contact person. 
 
I.  Special Instructions for Certified Providers, ASCs, and Portable X-ray Suppliers 
 
1.  Timeframe for State Review 
 
In situations where state and/or SOG Location review of the change of information is required 
(see sections 10.6.1.2 and 10.6.22.1), the contractor may (via any means) advise the provider that 
it may take several months for the request to be approved.   
 
2.  Post-Recommendation Changes 
 
If an applicant submits a change request after the contractor recommends approval of the 
providers initial Form CMS-855 application but before the state or SOG Location (as 
applicable) notifies the contractor that, respectively, it recommends approval of or approves the 
initial application, the contractor shall process the newly-submitted data as a separate change of 
information.  The contractor shall not take the changed information/corrected pages and, 
immediately upon receipt, send them directly to the state/SOG Location for incorporation into 
the existing application.   
 
In entering the change request into PECOS, the contractor shall use the date on which it received 
the change request in its mailroom as the actual receipt date in PECOS; the contractor shall not 
use the date on which the contractor received the aforementioned state/SOG Location 
approval/recommendation. The contractor shall explain the situation in PECOS.  
 
J.  Critical Access Hospital (CAH) Addition of New Provider-Based Locations 
 
Regulations found at 42 CFR  485.610(e)(2) and in the State Operations Manual state that the 
CAHs provider-based location must meet certain distance requirements from the main campus 
of another hospital or CAH.  
  The contractor shall contact the appropriate SOG Location while processing the Form CMS-
855A to verify that the CAHs new provider-based location is more than 35 miles (15 miles in 
the case of mountainous terrain or an area with only secondary roads) from the main campus of 
another hospital or CAH.  The contractor may not make a recommendation for approval without 
receiving a response from the SOG Location.   
 
If the SOG Location finds that CAHs new provider-based location meets the distance 
requirements, the contractor shall continue processing the application normally.  If the SOG 
Location determines that the location does not meet the distance requirements, the contractor 
shall reject the application and issue to the CAH the applicable rejection letter outlined in section 
10.7 et seq.  
 
The SOG Location will provide the CAH with three options if the location does not meet the 
distance requirements: 
 
1. The CAH keeps the new provider-based location, which will cause an involuntary termination 
in 90 days (as outlined in the Pub. 100-07, chapter 3, section 3012). 
2. The CAH terminates the new provider-based location and continue its enrollment as a CAH. 
3. The CAH keeps the new provider-based location but converts to a hospital (as outlined in Pub. 
100-07, chapter 2, sections 2256G and 2256H). 
 
For each option, the contractor shall keep the CAHs enrollment in an approved status in 
PECOS.  For Option #1 above, the contractor will receive notice from the SOG Location of the 
termination, which will lead to revocation of the CAHs enrollment. For Option #2, the CAHs 
enrollment remains approved and the contractor shall expect no further communication from the 
SOG Location. If the CAH chooses Option #3 to convert to a hospital, the contractor will receive 
a Form CMS-855A to terminate the CAHs enrollment and a new Form CMS-855A to enroll as a 
hospital. 
 
10.4.5  Revalidations 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
Consistent with section 6401(a) of the Patient Protection and the Affordable Care Act (ACA), all 
existing providers and suppliers are required to revalidate their enrollment information under 
new enrollment screening criteria. Providers and suppliers are normally required to revalidate 
their Medicare enrollment every 5 years (every 3 years for DMEPOS suppliers). However, CMS 
reserves the right to perform off-cycle revalidations as deemed necessary. 
 
Except as otherwise stated in this chapter or another CMS directive, the contractor shall follow 
the guidance in sections 10.4.5 through 10.4.5.3 of this chapter when processing revalidation 
applications.  This guidance takes precedence over all other instructions in this chapter 
concerning revalidation processing unless, again, another CMS directive specifies otherwise.  
The contractor shall note, however, that some of the instructions in section 10.4.5 et seq. may not 
apply to PECOS revalidation applications.  This is because, as stated in section 10.3(C) of this 
chapter: 
  (1) PECOS automatically handles revalidation tracking and revalidation requests and prevents 
the submission of PECOS revalidation applications outside of the revalidation window.  
(2) PECOS establishes timeframes and then queues mailings based on revalidation history and 
enrollment dates (although CMS can modify timeframes and request off-cycle revalidations 
at any time; this includes those for large group revalidations.)  All PECOS revalidation 
requests will be staggered so that revalidations are submitted and processed within 7 months 
of the providers due date.  This will eliminate the potential for unsolicited revalidation 
applications submitted outside of the 7-month window and permit a more structured and 
streamlined revalidation process. 
(3) Failure to respond to a revalidation request would result in an automatic pend, deactivation, 
etc.   
 
Accordingly, the contractor can disregard those instructions in section 10.4.5 et seq. that 
obviously do not apply to a particular situation.   
 
10.4.5.1  Revalidation Solicitations 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Background  
 
Under previous practice, CMS identified the providers and suppliers required to revalidate 
during each cycle.  CMS communicated when new lists became available through the 
appropriate channels, at which time the contractor obtained the list from the CGI Share Point 
Ensemble website.  With the advent of PECOS 2.0, PECOS will automatically: (i) determine 
when a provider/supplier is due to periodically revalidate its enrollment; and (ii) send a 
revalidation notice to the provider/supplier.  Note that this new process of revalidation 
solicitation applies both to providers/suppliers that currently submit applications via (or 
otherwise utilize) PECOS or via paper.  For the former group, solicitations will be sent via the 
PCV.  For the latter, solicitations will be e-mailed via PECOS, and the affected provider/supplier 
may submit its revalidation application via paper; it is not required to use PECOS. 
 
B.  Sending Revalidation Letters 
 
Based on the due date identified in PECOS, PECOS will send a revalidation notice (using the 
applicable letter in section 10.7 et seq. of this chapter) between 90 to 105 days prior to the 
provider/suppliers revalidation due date. The initial revalidation letter will include a generic 
provider enrollment signature.   
 
C.  Interaction with Change Request 
 
If the contractor receives a change of information (COI) application from the provider after 
PECOS has mailed to the provider a revalidation notice, the contractor shall ensure that the 
received revalidation application contains the changed information.   
 
If the contractor receives paper revalidation and COI applications concurrently, the contractor 
shall merge the two applications and process accordingly.  If the two applications were PECOS 
applications, they should be processed as two separate transactions.   
If the provider submits an application marked as a revalidation but that only includes enough 
information to be considered a COI, the contractor shall (1) develop for a complete application 
containing the missing data elements and (2) treat it as a revalidation. 
 
D.  Interaction with a Change of Ownership (CHOW) 
 
PECOS will not commence revalidation action regarding a provider/supplier that is undergoing a 
CHOW that: (1) the contractor is currently processing; or (2) is pending review with the state 
agency.   
 
E.  Reassignment Applications Received After Revalidation Letter Mailed 
 
If a reassignment application has been received after a revalidation letter has been sent to the 
affected provider/supplier, the contractor shall process the reassignment application.  The 
supplier need not report the newly established reassignment/employment arrangement on the 
revalidation application, and the contractor shall not develop for this information; this is because 
the arrangement was established after the revalidation notice was issued.  However, the 
contractor shall maintain the reassignment/employment arrangement information in the 
enrollment record when processing the revalidation application; this information shall not be 
overridden.  If the supplier fails to respond to the revalidation request, all reassignments shall be 
end-dated, including the newly established reassignment.  Consider the following illustration: 
 
EXAMPLE: Dr. Doe submits a Form CMS-855R application to add a new reassignment to 
Browns Medical Center after receiving a revalidation request. He submits his revalidation 
application to his contractor but does not include the reassignment for Browns Medical Center 
because the contractor is still processing the Form CMS-855R and has not yet approved the 
reassignment.  The contractor finalizes the reassignment changes and then proceeds with 
processing the revalidation application. The contractor shall not develop for the new 
reassignment to Browns Medical Center and shall maintain the reassignment in the providers 
enrollment record when processing the revalidation application. 
 
F.  Revalidation Extension Requests 
 
The contractor shall only accept extension requests from a provider that was not given the full 7 
months advance notice prior to their revalidation due date.  The contractor shall not accept 
extension requests from providers for any other reason. 
 
The provider/supplier may submit its request in writing (fax/e-mail/PCV permissible) or via 
phone, though the individual provider, authorized/delegated official, or appropriate contact person 
shall make the request.  (See section 10.3 of this chapter for information regarding contact 
persons for PECOS applications.) 
 
G.  Additional Letter Data 
 
In addition to the PCV e-mailing revalidation correspondence, the contractor  in any 
circumstance required per this chapter -- shall print and mail the following PCV-generated  letters: (1) revalidation notification letters (e.g., the first letter came back as undeliverable (see 
subsection (B)(2) above)); (2) pend letters; and (3) deactivation letters.  
 
(NOTE: As a general rule, the PCV can, among other things: (1) automatically send emails (e.g., 
revalidation); (2) send e-mails upon request (e.g., development); (3) generate letters/store letters; 
(4) send letters to a print queue; and (5) accept document uploads,) 
 
10.4.5.2  Non-Responses to Revalidation and Extension Requests 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Phone Calls 
 
The contractor may (but is not required to) continue to contact providers via telephone, e-mail, or 
the PCV to communicate non-receipt of revalidation applications.  The contractor shall 
document in PECOS all such communications with the provider. 
 
B.  Pend Status and Deactivation Actions 
 
PECOS will automatically pend (i.e., hold payment to) a provider/supplier that fails to respond to 
a revalidation request within the required timeframe.  The pend will last until the final 
disposition of the application, and PECOS will notify the provider/supplier of the pend.  If the 
provider does not submit the revalidation within this period, PECOS will automatically 
deactivate the provider and notify the contractor thereof.  Within 10 business days of receiving 
this notification, the contractor shall send the appropriate deactivation letter to the provider using 
the procedures in this chapter.  The deactivation basis is 42 CFR  424.540(a)(3).  Per  
424.540(d)(1)(ii)(A), the deactivation effective date shall be the date on which PECOS 
deactivated the provider (that is, the date on which the provider became non-compliant).  
 
No later than 5 business days after sending the aforementioned deactivation letter --- and if the 
deactivated supplier is a physician  the contractor shall search his/her associate record to 
determine if he/she serves as a supervising physician on any independent diagnostic testing 
facility (IDTF) enrollment.  If he/she does, the contractor shall disassociate him/her as the 
supervising physician for that entity.  If he/she is the only supervising physician on file for the 
IDTF, the contractor shall develop for an active supervising physician to bring the IDTF into 
compliance. The contractor shall give the IDTF 30 days to respond. Failure to provide an active 
supervising physician in the designated timeframe shall result in revocation of the IDTFs billing 
privileges for non-compliance with the IDTF standards. 
 
 
10.4.5.3  Receipt and Processing of Revalidation Applications 
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
The provider may submit its revalidation application via paper or PECOS, though the latter is 
encouraged so as to allow for more expedited processing. 
 
For paper applications, the contractor shall input the relevant data in PECOS consistent with 
longstanding practice and with the policies in this chapter, including those in section 10.3. 
  Note that some of the instructions in this section 10.4.5.3 et seq. may be inapplicable to PECOS 
(e.g., developing for missing sections of the Form CMS-855 revalidation application). 
 
A.  General Situations 
 
1.  Unsolicited Applications 
 
An unsolicited revalidation application is one received outside of the PECOS revalidation 
request addressed in section 10.4.5.1.  The contractor shall return such applications using the 
applicable sample return letter in section 10.7 et seq. within 20 business days of receipt.  If the 
application was received more than 7 months prior to the provider/suppliers revalidation due 
date, the contractor shall use  424.526(a)(8) as the return basis.  If  424.526(a)(8) does not 
apply to the situation, the contractor shall use  424.526(a)(7) as the basis, for the application 
was inapplicable to or not needed for the transaction involved. 
 
If applicable, the contractor shall also submit a request to CMS to have the application fee 
returned to the provider. 
 
2.  Signatures 
 
The contractor may only accept revalidation applications signed by the individual provider or the 
authorized or delegated official. 
 
3.  Sub-Units 
 
Any certified provider sub-unit that has a separate provider agreement must revalidate on a 
separate Form CMS-855A.  It cannot revalidate via the main providers Form CMS-855A. If the 
sub-unit has a separate CMS Certification Number (CCN) but not a separate provider agreement 
(e.g., hospital psychiatric unit, HHA branch), the sub-unit can disclose the revalidation on the 
main providers Form CMS-855A; this is because the sub-unit is a practice location of the main 
provider and not a separately enrolled entity. Separate fees, too, are not required. 
 
4.  Collapse of PTANs 
 
If the provider requests to collapse its PTANs per a revalidation, the contractor shall process said 
requests if appropriate (based on payment localities, etc.). 
 
5.  Voluntary Withdrawal 
 
(This subsection (A)(5) does not apply to certified providers/suppliers.  See section 10.6.1.3 of 
this chapter for instructions concerning certified provider/supplier voluntary terminations.) 
 
If a non-certified supplier wishes to voluntarily withdraw from Medicare (including deactivating 
all active PTANs), the contractor shall accept this request via phone, U.S. mail, or fax from the 
individual supplier or the authorized/delegated official (on letterhead); the contractor shall not 
require the non-certified supplier to complete a Form CMS-855 or CMS-20134 application. If  the contractor makes the request via telephone, the contractor shall document the telephone 
conversation in PECOS and take the appropriate action in PECOS. 
 
B.  Development Required 
 
(Note that some of the instructions in this subsection (B) will be inapplicable to PECOS 
applications. See section 10.3 for more information.) 
 
1.  General Instructions 
 
If a revalidation application requires development (e.g., missing application fee, clarification or 
documentation needed, missing reassignments), the contractor shall notify the provider via mail, 
telephone, the PCV, fax, or e-mail.  The contractor shall develop for all of the required 
information in one development request.  The provider has 30 days to respond to the contractors 
request.  For paper applications, the provider may submit the information via mail, fax, or e-mail 
containing scanned documentation; this includes missing signatures and dates.  For PECOS 
applications, the provider must submit the information via PECOS.  (Note that the provider may 
submit a full Form CMS-855I or Sections 1, 2, 4, & 15 of the Form CMS-855I to report missing 
reassignments any time prior to their revalidation due date; this includes post-revalidation 
application approval.) 
 
If the contractor can verify licensure and/or educational requirements (e.g., non-physician 
practitioners degree or diploma) online, the contractor shall not require the provider to submit 
this documentation.  If the supporting documentation currently exists in the providers file, the 
provider need not submit that documentation again with their revalidation application; the 
contractor may utilize the existing documentation for verification.  Residency information is not 
required as part of a revalidation.  In addition, the contractor need not develop for data that is 
missing or needs clarification on the providers revalidation application if the provider accurately 
disclosed (meaning no clarification is needed) the information (1) elsewhere on the application 
or (2) in the supporting documentation submitted with the application, though with the exception 
of the following items: 
 
(i)  Adverse legal action data 
(ii) LBN 
(iii) Tax identification number (TIN) 
(iv) NPI-legacy number combinations 
(v) Supplier/Practitioner type 
(vi) DBA name 
(vii) Effective dates of sale/transfer/consolidation or indication of acceptance of assets/liabilities 
 
The contractor shall not require providers to include the PTAN(s) in Section 2 or 4 of the 
revalidation application---provided that the provider included the information needed (NPI, TIN, 
LBN, DBA, etc.) for the contractor to appropriately make the association.  If the PTAN was not 
submitted but is needed to make the connection, the contractor shall use the shared systems, 
PECOS, or its provider file(s) as a resource before developing with the provider. 
  The contractor shall not develop for the EFT form if the provider has the 05/10 or 09/13 version 
of the Form CMS-588 on file.  If provider submits an EFT form with a bank letter or voided 
check, the contractor may verify that the LBN matches and develop to process the application 
accordingly.  Note that the instructions in section 10.6.23 apply to revalidations. 
 
If the supporting documentation currently exists in the providers file, the provider need not 
submit that documentation again during the enrollment process. The contractor shall utilize the 
existing documentation for verification. Documentation submitted with a previously submitted 
enrollment application (or documentation currently uploaded in PECOS) qualifies as a 
processing alternative, unless stated otherwise in this chapter or any CMS directive.  In addition, 
per the instructions in this chapter, the contractor shall document in PECOS that it found the 
missing information elsewhere in the enrollment package, with previously submitted 
applications, or with documentation currently uploaded in PECOS. (This excludes information 
that the contractor must verify at the current point in time (e.g., a license without a primary 
source verification method).)  In addition, the contractor shall not utilize information submitted 
along with opt-out applications for enrollment application processing or vice-versa. 
 
If a revalidation response is received for a single reassignment within an enrollment record that 
has multiple reassignments, the contractor shall develop with the contact person (or the 
individual provider if a contact is not listed) for the remaining reassignments not accounted for. 
If no response is received within 30 days, the contractor shall revalidate the single reassignment 
and deactivate the reassignments within the enrollment records that were not revalidated.  
 
If other missing information is not received within 30 days, the contractor shall deactivate the 
provider within 25 days after the development due date and notify the provider of the 
deactivation using the applicable sample letter in section 10.7 et seq. of this chapter.  After 
deactivation, the provider must submit an entirely new application in order to reactivate their 
PTANs. The contractor may use any supporting documentation received (if needed) for 
subsequent application submissions. 
 
The deactivation date shall be consistent with the latter of: (1) the revalidation due date; or (2) 
the date on which the deactivation occurred due to non-response or incomplete response to a 
development request for all provider business structures (e.g., organizations, sole proprietors, 
sole owners, etc.).   
 
2.  Illustrations 
 
Consider the following examples that address the instructions in section 10.4.5.3(B)(1): 
 
SCENARIO #1 - PECOS issues a revalidation notice to the provider and includes reassignments 
and/or employment arrangements for Groups A, B & C.  The provider submits the revalidation 
application but only addresses the reassignment for Group A.  The contractor develops with the 
contact person for the missing reassignments and/or employment arrangements for Groups B & 
C.  The provider responds with the reassignment information for Groups B & C prior to the 
development due date. Since the revalidation application remains in progress, the provider may 
submit a full Form CMS-855I or Sections 1, 2, 4, & 15 of the Form CMS-855I to report the 
missing reassignment information (even post-revalidation application approval).  Here, the  contractor processes the revalidation application to completion, and the provider experiences no 
break in billing. 
 
SCENARIO #2 - The contractor issues a revalidation notice to the provider and includes 
reassignments and/or employment arrangements for Groups A, B & C.  The provider submits the 
revalidation application to the contractor but only addresses the reassignment for Group A.  The 
contractor develops with the contact person for the missing reassignments and/or employment 
arrangements for Groups B & C.  No response is received within 30 days, and the revalidation 
due date has passed.  In this situation, Group As reassignment is revalidated, and the contractor 
shall deactivate Group B & Cs reassignments and/or employment arrangements effective with 
the date on which the contractor took deactivation action due to non-response or incomplete 
response to a development request. The approval letter shall identify the reassignments and/or 
employment arrangements that were revalidated and those that were terminated with the 
effective date of the reassignment or termination.  The provider must submit a full application 
(Form CMS-855R) to reactivate the reassignment.  The reactivation effective date is based on the 
receipt date of the CMS-855R.   
 
In Scenario #2, therefore: (i) the provider experiences a break in billing but the contractor only 
deactivates the non-response reassignments and/or employment arrangements; and (ii) the 
contractor revalidates the other reassignments and/or employment arrangements.)   
 
Contractor-initiated development letters, however, shall include a provider enrollment analysts 
name and phone number for provider contacts.  
 
C.  Revalidation Received after a Pend is Applied 
 
If the contractor receives a revalidation application after applying a pend, it shall remove the 
pend within 15 business days of receiving the revalidation application, even though the 
submitted application has not been processed to completion. This will release all held paper 
checks, SPRs, and EFT payments. 
 
The contractor shall process the revalidation application using current processing instructions 
and mail, fax, or e-mail (via the PCV for PECOS applications) a decision letter to the provider to 
notify the latter that the contractor has processed the revalidation application. 
 
D.  Revalidation Received After a Deactivation Occurs 
 
1.  General Guidance 
 
The contractor shall require a deactivated provider to submit a new, full application to reactivate 
their enrollment record.  The contractor shall process the application as a reactivation.  The 
provider shall maintain their original PTAN; however, the contractor shall reflect a gap in 
coverage (between the deactivation and the reactivation) on the existing PTAN using A/R codes in 
MCS and based on the applications receipt date.  The provider will not receive reimbursement 
for dates of service in which they were non-compliant with Medicare requirements (deactivated 
for non-response to revalidation).  The contractor shall reactivate group members (with the group 
enrollment) who had their reassignment associations terminated when the contractor deactivated  the group. The effective dates assigned to the reassigned providers should align with the groups 
effective date per standard reactivation instructions. 
 
2.  Certified Providers and Certified Suppliers 
 
Unless CMS instructs otherwise, the contractor shall allow a certified provider/supplier to 
maintain its original PTAN and effective date when the reactivation application is processed.  (As 
stated in  424.540(c), a deactivation does not terminate a certified provider/supplier agreement.)  
In addition, when processing the revalidation application after a deactivation occurs, the 
contractor shall not require the deactivated certified provider/supplier to obtain a new state 
survey or accreditation as a condition of revalidation. 
 
E.  Finalizing the Revalidation Application 
 
Prior to processing the revalidation application to completion, the contractor shall:  
 
(i) Ensure that a site visit (if applicable to the provider in question) occurs.   
 
(ii) Ensure that the provider meets all applicable federal regulatory requirements regarding 
licensure, certification, and/or educational requirements. 
 
(iii) Revalidate the providers information based on the data in PECOS. 
 
(iv) Verify the practice locations, although the contractor need not contact each location 
separately. The contractor shall: (1) verify the location(s) by contacting the contact person listed 
on the application; and (2) note the validation accordingly in the contractors verification 
documentation per the instructions in this chapter. 
 
(v) Ensure that the appropriate record type and finalization status are identified in PECOS. 
 
(vi) Ensure that an enrollment record is not marked as revalidated in PECOS if responses have 
been received for some PTANs but not all PTANs have been addressed (meaning that no action 
has been taken on the non-response PTANs, e.g., end-dated). If all PTANs have been addressed 
(e.g., revalidated, end-dated), the enrollment can be marked as revalidated. 
 
(vii) Ensure that PECOS and the claims systems remain consistent. The contractor shall not 
directly update the shared systems without first updating PECOS when processing a revalidation 
(unless instructed otherwise in another CMS directive). 
 
(viii) When processing is complete, issue an approval letter to the contact person (or the provider 
if no contact person is listed) via mail, fax, the PCV, or e-mail.  (For PECOS If the provider has 
reassignments that were terminated due to non-response, the approval letter shall contain the 
reassignments that were terminated due to non-response and the effective date of termination 
(i.e., the revalidation due date or the development due date). 
 
F.  Revalidation Reporting 
  Unless CMS requests it, the contractor need no longer submit reports to CMS regarding its 
revalidation activities, for the revalidation data is captured in PECOS.   
 
10.4.6  Reactivations  
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Form CMS-855 or CMS-20134 Reactivations  Screening Levels 
 
1.  Limited  
 
The contractor shall process reactivation applications from providers in the limited level of 
categorical screening in accordance with existing instructions.  
 
2.  Moderate  
 
The contractor shall process reactivation applications from providers in the moderate level of 
categorical screening (including existing HHAs and DMEPOS suppliers) in accordance with the 
screening procedures for this category. A site visit is thus needed prior to the contractors final 
decision regarding the application.  
 
 
 
 
3.  High  
 
The contractor shall process reactivation applications from providers in the high level of 
categorical screening in accordance with the screening procedures for this category. A site visit 
is thus needed prior to the contractors final decision regarding the application. 
 
B.  Form CMS-855B and CMS-855I Non-Certified Supplier Reactivations 
 
If the contractor approves a Part B non-certified suppliers reactivation application, the 
reactivation effective date shall be the date the contractor received the application that was 
processed to approval.  In addition, upon reactivating a Part B non-certified supplier, the 
contractor shall issue a new PTAN; for PECOS applications (and as indicated in section 10.3 of 
this chapter), PECOS will automatically issue a new PTAN.  
 
C.  Form CMS-855A or CMS-855B Certified Provider or Supplier Reactivations 
 
With the exception of HHAs, reactivation of a certified provider/supplier does not require a new 
state survey, provider agreement, or participation agreement. Per 42 CFR  424.540(b)(3)(i), an 
HHA must undergo a new state survey or obtain accreditation by an approved accreditation 
organization before it can be reactivated.  
 
D.  Reactivations - Deactivation for Reasons Other Than Non-Submission of a Claim  
  To reactivate its billing privileges, the provider or supplier must submit a complete Medicare 
enrollment application if the provider or supplier was deactivated: (i) for failing to timely notify 
the contractor of a change of information; or (ii) under  424.540(a)(4) and (a)(5).   
 
E.  Reactivation Effective Date 
 
Per 42 CFR  424.540(d)(2), the effective date of a reactivation of billing privileges under this 
section is the date on which the contractor received the providers or suppliers reactivation 
submission that the contractor processed to approval.  Under 42 CFR  424.540(e), however, the 
provider or supplier may not receive payment for services or items furnished while deactivated.  
This means that the contractor shall not add a retroactive back-billing period (e.g., 30 days) to 
the reactivation effective date.  To illustrate, suppose the contractor establishes a reactivation 
effective date under  424.540(d)(2) of October 30, the date the contractor received the 
ultimately approved reactivation submission.  The contractor under  424.540(e) cannot establish 
an effective date earlier than October 30 to allow for additional retroactive billing. 
 
F.  Miscellaneous Policies 
 
1.  Previous Withdrawn Status 
 
A provider that voluntarily withdraws (or, in the case of a certified provider/supplier, 
voluntarily or involuntarily withdraws from Medicare enrollment) is ineligible for 
reactivation. Such a provider must complete an initial enrollment application and, if 
applicable, pay an application fee.    
 
2.  Deactivation for Non-Billing 
 
For providers deactivated for non-billing, the provider must submit a complete Form CMS-855 
or CMS-20134 enrollment application via paper or PECOS Web. 
 
 
3.  Contractor Timeliness Standards 
 
For Form CMS-855 or CMS-20134 reactivation applications, the timeliness requirements in 
section 10.5 et seq. of this chapter pertaining to initial enrollment applications apply.  Except as 
otherwise stated in this chapter or another CMS directive, the contractor shall validate all of the 
information on the application as it would with an initial application. 
 
10.4.7  Revocations  
(Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) 
   
In executing the instructions in section 10.4.7 et seq. of this chapter, the contractor shall also 
adhere to: 
 
(i)  All supplemental and any superseding instructions in section 10.6.6 of this chapter 
concerning final adverse actions (e.g., referrals to PEOG);  
    (ii) The letter formats and verbiage in section 10.7 et seq. of this chapter;  
 
(iii) The PECOS 2.0 instructions in section 10.3 of this chapter; and 
 
(iv) Any other directive that, per CMS, explicitly pre-empts any instruction(s) in section 10.4.7 et 
seq. of this chapter.   
 
If any instruction in categories (i) through (iv) above conflict with that in section 10.4.7 et seq., 
the instruction in (i), (ii), (iii), or (iv) applies.  In addition, the contractor shall adhere to any 
instruction in (i), (ii), (iii), or (iv) above that addresses a revocation-related matter not discussed 
in section 10.4.7 et seq. 
 
 
10.4.7.1  Revocations  Background and General Requirements  
(Rev. 11020; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21) 
 
A.   Introduction 
 
Medicare revokes currently enrolled providers/suppliers Medicare billing privileges and 
corresponding provider/supplier agreements pursuant to federal regulations at 42 CFR  424.535.  
(A Medicare revocation is a termination as defined at 42 CFR  455.101.)  A revocation of 
Medicare billing privileges does not affect a providers ability to submit claims to non-Medicare 
payers using their NPI. 
 
If the contractor determines that a providers billing privileges should be revoked or receives 
information from PEOG that a providers billing privileges should be revoked, it shall undertake 
activities to process the revocation, apply the revocation in PECOS, notify the provider, and 
afford appeal rights.  This section 10.4.7.1 includes, but is not limited to, information concerning 
the contractors responsibilities to: 
 
(i)  Prepare a draft revocation letter; 
 
(ii) E-mail the letter to the appropriate PEOG mailbox with additional pertinent information 
regarding the basis for revocation; 
 
(iii) Receive PEOGs determination and follow PEOGs instructions regarding the case; 
 
(iv) If PEOG authorizes the revocation: (a) revoke the providers billing privileges effective on 
the appropriate date; (b) establish the applicable reenrollment bar; (c) update PECOS with the 
appropriate reenrollment bar length; (d) assess an overpayment, as applicable; and (e) send the 
revocation letter (including affording appeal rights) to the provider via certified mail. 
 
B.  Administrative Requirements 
 
This section 10.4.7.1(B) addresses (in greater specificity than section 10.4.7.1(A)) certain 
contractor administrative activities pertaining to revocations.  As stated in section 10.4.7.1(A), 
however, the contractor shall take into account the instructions in sections 10.6.6 and 10.7 et seq.   
1.  Processing Timeframes  
 
If the contractor receives approval from PEOG (or receives an unrelated request from PEOG) to 
revoke a providers billing privileges, the contractor shall complete all steps associated with the 
revocation no later than five (5) business days from the date it received PEOGs 
approval/request.  The contractor shall notify PEOG that it has completed all revocation steps no 
later than three (3) business days after completion.  
 
2.  Revocation Letters - Contents 
 
i.   General Information 
 
When the contractor discovers a basis for revoking a providers enrollment under 42 CFR  
424.535 - and, if applicable under section 10.6.6 of this chapter or another CMS directive, 
receives PEOGs approval for the revocation - the contractor shall revoke billing privileges and 
notify the provider by letter.  The revocation letter shall contain: 
 
(a) A legal (i.e., regulatory, such as  424.535(a)(3) or 424.535(a)(9)) basis for each reason for 
revocation (the contractor shall not use provisions from this chapter as the basis for revocation);  
 
(b) A clear explanation of why Medicare billing privileges are being revoked, including the facts 
or evidence that the contractor used in making its determination; 
 
(c) An explanation of why the provider does not meet the applicable enrollment criteria;  
 
(d) The effective date of the revocation; 
 
(e) Procedures for submitting a CAP (if revoked under  424.535(a)(1));  
 
(f) Complete and accurate information about the providers appeal rights; 
 
(g) Any other information contained in or required by the applicable model letter in section 10.7 
et seq. 
 
ii.   One Letter Per Enrollment 
 
The contractor shall issue a unique revocation letter per enrollment.  For example, regarding 
revocation letters for solely owned organizations, when revoking a physician/non-physician 
practitioners billing privileges and those of his/her solely owned organization, the contractor 
shall issue two revocation letter: one for the individual and the other for the solely owned 
organization.  The contractor shall not issue one letter to convey revoked Medicare billing 
privileges for both the individual and the solely owned organization.   
 
3.  Revocation Letters  PEOG Approval 
  Using the guidance in this section 10.4.7.1(B) et seq., section 10.6.6, and section 10.7 et seq., the 
contractor shall determine whether it must submit its draft revocation letter to PEOG for 
approval prior to sending it to the provider.   
 
i.   Prior PEOG Approval Required  
 
If prior PEOG approval of the letter is required, the contractor shall submit the letter to the 
appropriate PEOG mailbox for PEOG review.  PEOG will examine the letter for technical 
correctness and determine matters such as: (1) whether the revocation affects the revoked 
providers other locations; (2) the length and application of the reenrollment bar; and (3) the 
revocation effective date.  PEOG will notify the contractor of the outcome of its review and 
instruct the contractor how to proceed.  
 
The contractor shall not begin finalizing the revocation until it receives guidance from PEOG.   
 
The contractor may not alter an approved revocation letter; if it needs to revise said letter, the 
contractor shall submit the letter to PEOG for a new review via the process described above.  
 
Unless CMS has directed otherwise, the contractor shall document and report the impacted 
application/enrollment in its Monthly Status Reports. 
 
ii.   When PEOG Approval of Revocation Letter is Unnecessary 
 
The contractor need not obtain prior PEOG approval of the revocation and the revocation letter if 
the revocation involves any of the following situations:  
 
    424.535(a)(1) (except as otherwise required in this chapter or another CMS directive)  
 
    424.535(a)(6)  
 
    424.535(a)(11) 
 
4.   Issuing the Revocation Letter to the Provider 
 
The contractor shall send revocation letters by USPS certified mail.  (The contractor may e-mail 
a follow-up copy of the letter after issuing it via USPS certified mail.)  The contractor shall date 
and mail the letter on the same business day. 
 
10.4.7.2  Revocation Effective Dates and Miscellaneous Policies 
(Rev. 11307; Issued: 03- 25-2022; Effective: 03-04-22; Implementation: 04-25-22) 
 
A.  Effective Dates 
 
The contractor shall apply a revocation effective date based upon federal regulations at  
424.535(g).  In general, and as discussed below, these dates are either prospective or retroactive.   
 
1.  Revocations with Retroactive Effective Dates   
The following revocation reasons require a retroactive effective date under  424.535(g):  
 
(1) Federal exclusion or debarment;  
(2) Felony conviction as described in 42 CFR  424.535(a)(3) and 1001.2;  
(3) License suspension or revocation; or  
(4) Determination that the provider or supplier is no longer operational  
 
A revocation based upon any of these reasons is effective with the date of the exclusion, 
debarment, felony conviction, license suspension or revocation, or the date that CMS or the 
contractor determined that the provider is no longer operational.  To illustrate, for a revocation 
involving a licensure revocation/suspension, the revocation effective date (and the date listed on 
the revocation letter) shall be the date of the actual license revocation/suspension. 
 
2.  Revocations with Prospective Effective Dates 
 
The contractor shall use a prospective effective date (i.e., the date that is 30 days after CMS or 
the CMS contractor mails notice of its determination to the provider) for revocations not based 
upon one of the four reasons listed in  424.535(g) and section 10.4.7.2(B) above (e.g.,  
424.535(a)(8) -- abuse of billing).   
 
3.  Revocations Based Upon More than One Reason 
 
When a revocation involves more than one reason, the contractor shall determine whether any of 
the grounds require a retroactive effective dates (listed in  424.535(g) and section 10.4.7.2(B) 
above; if a retroactive date is indeed implicated, the contractor shall apply the appropriate 
retroactive date.  
 
B.  (A)(1) Versus (A)(5) 
In cases where a revocation is warranted because the provider/suppliers location is vacant, 
occupied by another party, closed during office hours, etc., or a state survey failure is involved, 
the contractor shall use  424.535(a)(5) (rather than  424.535(a)(1)) as the revocation reason.  
(This applies to both certified and non-certified providers/suppliers.)  No CAP rights are 
therefore involved. 
 
10.4.7.3  Revocation Reasons 
(Rev. 11808; Issued: 01-24-23; Effective: 01-01-23; Implementation: 01-03-23) 
 
Sections 10.4.7.3(A) through (T) list the revocation reasons in 42 CFR  424.535.  Section 
10.4.7.3(U) discusses extensions of revocations per 42 CFR  424.535(i). 
 
A.  Revocation Reason 1  Noncompliance (42 CFR  424.535(a)(1)) 
 
The provider or supplier is determined not to be in compliance with the enrollment 
requirements in subpart P (of Part 424) or in the enrollment application applicable to its provider 
or supplier type, and has not submitted a plan of corrective action as outlined in 42 CFR Part  488.  The provider or supplier may also be determined not to be in compliance if it has failed to 
pay any user fees as assessed under part 488 of this chapter. 
 
Noncompliance includes, but is not limited to: (1) the provider/supplier no longer has a physical 
business address or mobile unit where services can be rendered; (2) the provider/supplier does 
not have a place where patient records are stored to determine the amounts due such provider or 
other person; and/or (3) the provider/supplier no longer meets or maintains general enrollment 
requirements.  Noncompliance also includes situations when the provider/supplier has failed to 
pay any user fees as assessed under 42 CFR Part 488. 
 
Other situations (some of which were mentioned in the previous paragraph) in which  
424.535(a)(1) may be used as a revocation reason include, but are not limited to, the following: 
 
  The provider or supplier does not have a physical business address or mobile unit where 
services can be rendered. 
 
  The provider or supplier does not have a place where patient records are stored to determine 
the amounts due such provider or other person. 
 
  The provider or supplier is not appropriately licensed.  
 
  The provider or supplier is not authorized by the federal/state/local government to perform 
the services that it intends to render. 
 
  The provider or supplier does not meet CMS regulatory requirements for the specialty that it 
is enrolled as. 
 
  The provider or supplier does not have a valid social security number (SSN) or employer 
identification number (EIN) for itself, an owner, partner, managing organization/employee, 
officer, director, medical director, and/or authorized or delegated official. 
 
  The provider or supplier fails to furnish complete and accurate information and all supporting 
documentation within 60 calendar days of the provider/suppliers notification from CMS or 
its contractor to submit an enrollment application and supporting documentation, or resubmit 
and certify to the accuracy of its enrollment information.  (This revocation reason will not 
apply if CMS has instructed the contractor to use deactivation reason  424.540(a)(3) in lieu 
thereof.) 
 
  The provider or supplier does not otherwise meet general enrollment requirements. 
 
(Concerning the last bullet above  and, as applicable, bullets 3, 4 and 5  the contractors 
revocation letter shall cite the appropriate statutory and/or regulatory citation(s) containing the 
specific licensure/certification/authorization requirement(s) for that provider/supplier type.) 
 
Special Instructions Regarding Certified Providers/Suppliers  The SOG Location may 
involuntarily terminate a certified provider/supplier if the latter no longer meets CMS 
requirements, conditions of participation, or conditions of coverage. When this occurs, CMS  terminates the provider'/suppliers provider agreement and notifies the contractor thereof.  Upon 
receipt of the CMS notice (and except as otherwise stated in this chapter), the contractor shall 
follow the revocation procedures in this chapter (including, as applicable, those in section 
10.6.6)), using  424.535(a)(1) as the revocation basis; the contractor shall not process the 
involuntary termination as a deactivation based upon a voluntary withdrawal from Medicare.  
 
Note that the contractor need not (but certainly may) contact the SOG Location to obtain further 
details of the termination.  
 
B.  Revocation Reason 2  Provider or Supplier Conduct (42 CFR  424.535(a)(2)) 
 
The provider or supplier, or any owner, managing employee, managing organization, officer, 
director, authorized or delegated official, medical director, supervising physician, or other health 
care or administrative or management personnel furnishing services payable by a federal health 
care program, of the provider or supplier is: 
 
(i) Excluded from the Medicare, Medicaid, and any other federal health care program, as defined 
in 42 CFR  1001.2, in accordance with section 1128, 1128A, 1156, 1842, 1862, 1867 or 1892 of 
the Act. 
 
(ii) Is debarred, suspended, or otherwise excluded from participating in any other federal 
procurement or non-procurement program or activity in accordance with the FASA 
implementing regulations and the Department of Health and Human Services non-procurement 
common rule at 45 CFR part 76. 
 
If the contractor finds an excluded party (and unless section 10.6.6 states otherwise, in which 
case the latter section takes precedence), the contractor shall notify its PEOG BFL immediately.  
PEOG will notify the Contracting Officers Representative (COR) for the appropriate Unified 
Program Integrity Contractor (UPIC).  The COR will, in turn, contact the OIG for further 
investigation. 
 
C.  Revocation Reason 3  Felony Conviction (42 CFR  424.535(a)(3)) 
 
The provider, supplier, or any owner, managing employee, managing organization, officer, or 
director of the provider or supplier was, within the preceding 10 years, convicted (as that term is 
defined in 42 CFR 1001.2) of a federal or state felony offense that CMS determines to be 
detrimental to the best interests of the Medicare program and its beneficiaries.  [Under  
424.535(a)(3)(ii),] [o]ffenses include, but are not limited in scope and severity to: 
 
  Felony crimes against persons, such as murder, rape, assault, and other similar crimes for 
which the individual was convicted, including guilty pleas and adjudicated pretrial 
diversions. 
  Financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud and 
other similar crimes for which the individual was convicted, including guilty pleas and 
adjudicated pretrial diversions. 
  Any felony that placed the Medicare program or its beneficiaries at immediate risk, such as a 
malpractice suit that results in a conviction of criminal neglect or misconduct.    Any felonies that would result in mandatory exclusion under section 1128(a) of the Act. 
 
[Under  424.535(a)(3)(iii),] revocations based on felony convictions are for a period to be 
determined by the Secretary, but not less than 10 years from the date of conviction if the 
individual has been convicted on one previous occasion for one or more offenses. 
 
The expiration of a reenrollment bar issued pursuant to 42 CFR  424.535(c) does not preclude 
CMS or its contractors from denying reenrollment to a provider that (i) was convicted of a felony 
within the preceding 10-year period or (ii) otherwise does not meet all criteria necessary to enroll 
in Medicare. 
 
D.   Revocation Reason 4  False or Misleading Information on Application (42 CFR  
424.535(a)(4)) 
 
The provider or supplier certified as true misleading or false information on the enrollment 
application to be enrolled or maintain enrollment in the Medicare program. (Offenders may be 
subject to either fines or imprisonment, or both, in accordance with current laws and 
regulations.) 
 
E.  Revocation Reason 5 - On-Site Review/Other Reliable Evidence that Requirements Not 
Met (42 CFR  424.535(a)(5)) 
 
Upon on-site review or other reliable evidence, CMS determines that the provider or supplier:  
 
(i)  Is not operational to furnish Medicare-covered items or services; or 
(ii) Otherwise fails to satisfy any Medicare enrollment requirement.  
 
F.  Revocation Reason 6 - Hardship Exception Denial and Fee Not Paid (42 CFR 
424.535(a)(6)) 
 
(i)  An institutional provider does not submit an application fee or hardship exception request 
that meets the requirements set forth in  424.514 with the Medicare revalidation application; or 
 
(ii) The hardship exception is not granted and the institutional provider does not submit the 
applicable application form or application fee within 30 days of being notified that the hardship 
exception request was denied. 
 
(iii) Either of the following occurs: 
 
  CMS is not able to deposit the full application amount into a government-owned account; or 
 
  The funds are not able to be credited to the United States Treasury; 
 
(iv) The provider or supplier lacks sufficient funds in the account at the banking institution 
whose name is imprinted on the check or other banking instrument to pay the application fee; or 
  (v) There is any other reason why CMS or its Medicare contractor is unable to deposit the 
application fee into a government-owned account. 
 
G.  Revocation Reason 7  Misuse of Billing Number (42 CFR  424.535(a)(7)) 
 
The provider or supplier knowingly sells to or allows another individual or entity to use its 
billing number.  This does not include those providers or suppliers that enter into a valid 
reassignment of benefits as specified in 42 CFR  424.80 or a change of ownership as outlined in 
42 CFR  489.18. 
 
H.  Revocation Reason 8  Abuse of Billing Privileges (42 CFR  424.535(a)(8)) 
 
Abuse of billing privileges includes either of the following: 
 
(i) The provider or supplier submits a claim or claims for services that could not have been 
furnished to a specific individual on the date of service.  These instances include but are not 
limited to the following situations: 
 
  Where the beneficiary is deceased. 
 
  The directing physician or beneficiary is not in the state or country when services were 
furnished. 
 
  When the equipment necessary for testing is not present where the testing is said to have 
occurred.  
 
(ii) CMS determines that the provider or supplier has a pattern or practice of submitting claims 
that fail to meet Medicare requirements.  In making this determination, CMS considers, as 
appropriate or applicable, the following factors:  
 
  The percentage of submitted claims that were denied during the period under consideration. 
 
  Whether the provider or supplier has any history of final adverse actions (as that term is 
defined in  424.502) and the nature of any such actions. 
 
  The type of billing non-compliance and the specific facts surrounding said non-compliance 
(to the extent this can be determined). 
 
  Any other information regarding the provider or supplier's specific circumstances that CMS 
deems relevant to its determination. 
 
(NOTE: Concerning (a)(8), PEOG -- rather than the contractor -- will (1) make all 
determinations regarding whether a provider has a pattern or practice of submitting non-
compliant claims; (2) consider the relevant factors; and (3) accumulate all information needed to 
make such determinations.) 
 
I.  Revocation Reason 9  Failure to Report (42 CFR  424.535(a)(9))   
The provider or supplier failed to comply with the reporting requirements specified in 42 CFR  
424.516(d) or (e),  410.33(g)(2), or  424.57(c)(2) [which pertain to the reporting of changes in 
adverse actions and practice locations]. 
 
With respect to  424.535(a)(9) (and except as otherwise stated in section 10.6.6): 
 
  If the provider reports a change in practice location more than 30 days after the effective date 
of the change, the contractor shall not pursue a revocation on this basis.  However, if the 
contractor independently determines  through an on-site inspection under 42 CFR  
424.535(a)(5)(ii) or via another verification process - that the providers address has changed 
but the provider has not notified the contractor thereof within the aforementioned 30-day 
timeframe, the contractor may pursue a revocation (e.g., seeking PEOGs approval to 
revoke).  
 
  If an IDTF reports a change in ownership, change of location, change in general supervision 
or change in adverse legal action more than 30 days after the effective date of the change, the 
contractor may pursue a revocation on this basis (e.g., seeking PEOGs approval to revoke). 
 
  If a DMEPOS supplier reports a change of information more than 30 days after the effective 
date of the change, the contractor may pursue a revocation on this basis (e.g., seeking 
PEOGs approval to revoke). 
 
J.  Revocation Reason 10  Failure to Document or Provide CMS Access to Documentation 
(42 CFR  424.535(a)(10)) 
 
The provider or supplier did not comply with the documentation requirements specified in 42 
CFR  424.516(f). A provider that furnishes any covered ordered, certified, referred, or 
prescribed Part A or B services, items or drugs is required to maintain documentation for 7 
years. 
 
K.  Revocation Reason 11 - Home Health Agency (HHA) Capitalization (42 CFR  
424.535(a)(11)) 
 
An HHA fails to furnish - within 30 days of a CMS or contractor request - supporting 
documentation verifying that the HHA meets the initial reserve operating funds requirement 
found in 42 CFR  489.28(a). 
 
L.  Revocation Reason 12  Other Program Termination (42 CFR  424.535(a)(12)) 
 
The provider or supplier is terminated, revoked, or otherwise barred from participation in a 
particular State Medicaid Agency or any other federal health care program.  Under  
424.535(a)(12)(ii), Medicare may not revoke [a provider/suppliers Medicare billing privileges] 
unless and until the provider or supplier has exhausted all applicable appeal rights or the 
timeframe for filing an appeal has expired without the provider or supplier filing an appeal.    In making its determination, CMS considers the following factors listed in 42 CFR  
424.535(a)(12):  
(A) The reason(s) for the termination or revocation;  
(B) Whether the provider or supplier is currently terminated, revoked, or otherwise barred from 
more than one program (for example, more than one state's Medicaid program) or has been 
subject to any other sanctions during its participation in other programs; and;  
(C) Any other information that CMS deems relevant to its determination. 
 
M.  Revocation Reason 13 - Prescribing Authority (42 CFR  424.535(a)(13)) 
 
(i) The physician or eligible professional's Drug Enforcement Administration (DEA) Certificate 
of Registration is suspended or revoked or is surrendered in response to an order to show cause; 
or  
 
(ii) The applicable licensing or administrative body for any state in which the physician or 
eligible professional practices suspends or revokes the physicians or other eligible professional's 
ability to prescribe drugs. 
 
N.  Revocation Reason 14  Improper Prescribing Practices (42 CFR  424.535(a)(14))  
 
CMS determines that the physician or other eligible professional has a pattern or practice 
of prescribing Part B or D drugs that falls into one of the following categories: 
 
(i)  The pattern or practice is abusive or represents a threat to the health and safety of 
Medicare beneficiaries or both.  In making this determination, CMS considers the 
following factors: 
(A) Whether there are diagnoses to support the indications for which the drugs were prescribed;  
(B) Whether there are instances when the necessary evaluation of the patient for whom the drug 
was prescribed could not have occurred (for example, the patient was deceased or out of state at 
the time of the alleged office visit);  
(C) Whether the physician or eligible professional has prescribed controlled substances in 
excessive dosages that are linked to patient overdoses;  
(D) The number and type(s) of disciplinary actions taken against the physician or eligible 
professional by the licensing body or medical board for the State or States in which he or she 
practices, and the reason(s) for the action(s);  
(E) Whether the physician or eligible professional has any history of final adverse actions (as 
that term is defined in  424.502);   (F) The number and type(s) of malpractice suits that have been filed against the physician or 
eligible professional related to prescribing that have resulted in a final judgment against the 
physician or eligible professional or in which the physician or eligible professional has paid a 
settlement to the plaintiff(s) (to the extent this can be determined);  
(G) Whether any State Medicaid program or any other public or private health insurance 
program has restricted, suspended, revoked, or terminated the physician or eligible professional's 
ability to prescribe medications, and the reason(s) for any such restriction, suspension, 
revocation, or termination; and  
(H) Any other relevant information provided to CMS. 
(ii) The pattern or practice of prescribing fails to meet Medicare requirements.  In making 
this determination, CMS considers the following factors: 
 
(A) Whether the physician or eligible professional has a pattern or practice of prescribing 
without valid prescribing authority.  
(B) Whether the physician or eligible professional has a pattern or practice of prescribing for 
controlled substances outside the scope of the prescriber's DEA registration.  
(C) Whether the physician or eligible professional has a pattern or practice of prescribing drugs 
for indications that were not medically accepted - that is, for indications neither approved by the 
FDA nor medically accepted under section 1860D-2(e)(4) of the Act - and whether there is 
evidence that the physician or eligible professional acted in reckless disregard for the health and 
safety of the patient.   
 
(NOTE: Concerning (a)(14), PEOG -- rather than the contractor -- will (1) make all 
determinations regarding whether a provider/supplier has a pattern or practice of prescribing Part 
B or D drugs; (2) consider the relevant factors; and (3) accumulate all information needed to 
make such determinations.) 
 
O.  Revocation Reason 17  Debt Referred to the United States Department of Treasury (42 
CFR  424.535(a)(17)) 
 
The provider or supplier has an existing debt that CMS appropriately refers to the United States 
Department of Treasury.  In determining whether a revocation is appropriate, CMS considers 
the following factors: 
(i) The reason(s) for the failure to fully repay the debt (to the extent this can be determined);  
(ii) Whether the provider or supplier has attempted to repay the debt (to the extent this can be 
determined);  
(iii) Whether the provider or supplier has responded to CMS' requests for payment (to the extent 
this can be determined);   (iv) Whether the provider or supplier has any history of final adverse actions or Medicare or 
Medicaid payment suspensions;  
(v) The amount of the debt; and  
(vi) Any other evidence that CMS deems relevant to its determination. 
(NOTE: With respect to (a)(17), PEOG  rather than the contractor  will make all 
determinations regarding whether a provider/supplier has an existing debt that has been referred 
to the Department of Treasury.) 
 
P.  Revocation Reason 18  Revoked Under a Different Name, Numerical Identifier or 
Business Identity (42 CFR  424.535(a)(18))  
 
The provider or supplier is currently revoked [from Medicare] under a different name, 
numerical identifier, or business identity, and the applicable reenrollment bar period has not 
expired.  In making its determination, CMS considers the following factors: 
 
(i) Owning and managing employees and organizations (regardless of whether they have been 
disclosed on the Form CMS-855 [or CMS-20134] application); 
 
(ii) Geographic location; 
 
(iii) Provider or supplier type; 
 
(iv) Business structure; or 
 
(v) Any evidence indicating that the two parties [the revoked provider or supplier and newly 
enrolling provider or supplier] are similar or that the provider or supplier was created to 
circumvent the revocation or reenrollment bar. 
 
(NOTE: Concerning (a)(18), PEOG  rather than the contractor  will make all determinations 
regarding whether a provider/supplier was revoked under a different name, numerical identifier, 
or business identity.) 
 
Q.  Revocation Reason 19  Affiliation that Poses an Undue Risk (42 CFR  424.535(a)(19))  
 
1.  Specific Reason 
 
The provider or supplier has or has had an affiliation under 42 CFR  424.519 that poses an 
undue risk of fraud, waste and abuse to the Medicare program.  In making this determination, 
CMS considers the following factors listed in 42 CFR  424.519(f)(1) through (6):  
(1) The duration of the affiliation 
(2) Whether the affiliation still exists and, if not, how long ago it ended  (3) The degree and extent of the affiliation 
(4) If applicable, the reason for the termination of the affiliation 
(5) Regarding the affiliated provider/supplier's disclosable event [under  424.519(b)]: 
(i) The type of disclosable event. 
(ii) When the disclosable event occurred or was imposed. 
(iii) Whether the affiliation existed when the disclosable event occurred or was imposed. 
(iv) If the disclosable event is an uncollected debt: (A) the amount of the debt; (B) whether the 
affiliated provider or supplier is repaying the debt; and (C) to whom the debt is owed. 
(v) If a denial, revocation, termination, exclusion, or payment suspension is involved, the reason 
for the disclosable event. 
 
(6) Any other evidence that CMS deems relevant to its determination. 
 
2.  Definition of Affiliation 
 
For purposes of  424.519 only, 42 CFR  424.502 defines affiliation as: 
 
  A 5 percent or greater direct or indirect ownership interest that an individual or entity has in 
another organization. 
 
  A general or limited partnership interest (regardless of the percentage) that an individual or 
entity has in another organization. 
 
  An interest in which an individual or entity exercises operational or managerial control over, 
or directly or indirectly conducts, the day-to-day operations of another organization 
(including, for purposes of [ 424.519 only], sole proprietorships), either under contract or 
through some other arrangement, regardless of whether or not the managing individual or 
entity is a W2 employee of the organization. 
 
  An interest in which an individual is acting as an officer or director of a corporation. 
 
  Any reassignment relationship under  424.80. 
 
(NOTE: Concerning (a)(19), PEOG -- rather than the contractor -- will make all determinations 
regarding whether a provider/supplier has an affiliation per  424.519 that poses an undue risk of 
fraud, waste, and abuse.) 
 
R.  Revocation Reason 20  Billing from a Non-Compliant Location (42 CFR  
424.535(a)(20))  
  CMS may revoke a provider's or supplier's Medicare enrollment or enrollments, even if all of 
the practice locations associated with a particular enrollment comply with Medicare enrollment 
requirements, if the provider or supplier billed for services performed at or items furnished from 
a location that it knew or should have known did not comply with Medicare enrollment 
requirements.  In determining whether and how many of the provider/supplier's enrollments 
(involving the non-compliant location or other locations) should be revoked, CMS considers the 
following factors [enumerated in  424.535(a)(20)(i) through (vii)]:  
 
   The reason(s) for and the specific facts behind the locations non-compliance; 
   The number of additional locations involved; 
   The provider or suppliers possibly history of final adverse actions or Medicare or    
       Medicaid payment suspensions; 
   The degree of risk the locations continuance poses to the Medicare Trust Funds; 
   The length of time that the location was considered non-compliant; 
   The amount that was billed for services performed at or items furnished from the non-   
       compliant location; and, 
   Any other evidence that CMS deems relevant to its determination. 
 
(NOTE: Concerning (a)(20), PEOG  rather than the contractor  will make all determinations 
regarding whether a provider/supplier has performed services or furnished items from a location 
that did not comply with Medicare enrollment requirements.) 
 
S.  Revocation Reason 21  Abusive Ordering, Certifying, Referring, or Prescribing of Part 
A or B Services, Items or Drugs (42 CFR  424.535(a)(21))  
 
The physician or eligible professional has a pattern or practice of ordering, certifying, referring 
or prescribing Medicare Part A or B services, items or drugs that is abusive, represents a threat to 
the health and safety of Medicare beneficiaries, or otherwise fails to meet Medicare 
requirements.  In making its determination, CMS considers the following factors [enumerated in 
 424.535(i) through (ix)]: 
 
  Whether the physician or eligible professionals diagnosis supports the order, certification, 
referral or prescription in question; 
  Whether there are instances where the necessary evaluation of the patient for whom the 
order, certification, referral or prescription could have not occurred (for example: the patient 
was deceased or out of state at the time of the alleged office visit); 
  The number and types of disciplinary actions taken against the physician or eligible 
professional by the licensing body or medical board for the state(s) in which he or she 
practices and the reason(s) for the action(s); 
  Whether the physician or eligible professional has any history of final adverse actions (as 
defined by 42 CFR  424.502); 
  The length of time over which the pattern or practice has continued; 
  How long the physician or eligible professional has been enrolled in Medicare; 
  The number of type(s) of malpractice suits that have been filed against the physician or 
eligible professional related to ordering, certifying, referring or prescribing that resulted in a 
final judgement against the physician or eligible professional or the physician or eligible 
professional paid a settlement to the plaintiff(s) (to the extent this can be determined);    Whether any State Medicaid Agency (SMA) or other public health insurance program has 
restricted, suspended, revoked or terminated the physicians or eligible professionals ability 
to practice medicine and reason for any such restriction, suspension, revocation or 
termination; and 
  Any other information that CMS deems relevant to its determination. 
 
(NOTE: Concerning (a)(21), PEOG  rather than the contractor  will make all determinations 
regarding whether a physician or eligible professional has a pattern or practice of ordering, 
certifying, referring or prescribing Medicare Part A or B services, items, or drugs that is abusive, 
threatening to the safety of Medicare beneficiaries, or fails to meet Medicare requirements). 
 
T.  Revocation Reason 22  Patient Harm (42 CFR  424.535(a)(22))  
 
The physician or other eligible professional has been subject to prior action from a state 
oversight board, federal or state health care program, Independent Review Organization (IRO) 
determination(s), or any other equivalent governmental body or program that oversees, regulates, 
or administers the provision of health care with underlying facts reflecting improper physician or 
other eligible professional conduct that led to patient harm.  In determining whether a revocation 
is appropriate, CMS considers the following factors [enumerated in  424.535(a)(22)(i)(A) 
through (E)): 
(A) The nature of the patient harm. 
(B)  The nature of the physician's or other eligible professional's conduct. 
(C)  The number and type(s) of sanctions or disciplinary actions that have been imposed against 
the physician or other eligible professional by the state oversight board, IRO, federal or state 
health care program, or any other equivalent governmental body or program that oversees, 
regulates, or administers the provision of health care.  Such actions include, but are not limited to 
in scope or degree: 
(i)  License restriction(s) pertaining to certain procedures or practices. 
(ii) Required compliance appearances before State medical board members. 
(iii) License restriction(s) regarding the ability to treat certain types of patients (for example, 
cannot be alone with members of a different gender after a sexual offense charge).  
(iv) Administrative or monetary penalties. 
(v) Formal reprimand(s). 
(D) If applicable, the nature of the IRO determination(s). 
(E) The number of patients impacted by the physician/other eligible professional's conduct and 
the degree of harm thereto or impact upon. 
(Per 42 CFR  424.535(a)(22)(ii), paragraph (a)(22) does not apply to actions or orders 
pertaining exclusively to either of the following:    Required participation in rehabilitation or mental/behavioral health programs; or 
  Required abstinence from drugs or alcohol and random drug testing.) 
U.  Extension of Revocation  
 
If a providers Medicare enrollment is revoked under  424.535(a), CMS may revoke any and all 
of the providers Medicare enrollments, including those under different names, numerical 
identifiers or business identities and those under different types.  In determining whether to 
revoke a providers other enrollments, CMS considers the following factors: 
  
(i) The reason for the revocation and the facts of the case;  
 
(ii) Whether any final adverse actions have been imposed against the provider or supplier 
regarding its other enrollments;  
 
(iii) The number and type(s) of other enrollments; and  
 
(iii)  Any other information that CMS deems relevant to its determination.  
 
10.4.7.4  Reenrollment Bar  
(Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
If any inconsistency exists between an instruction in this section 10.4.7.4 and a directive in 
section 10.6.6, the latter instruction takes precedence.  In addition, the contractor shall adhere to 
any instruction in section 10.6.6 that addresses a reenrollment bar matter not discussed in section 
10.4.7.4. 
 
A.  Background 
 
As stated in 42 CFR  424.535(c), if a provider/supplier has their billing privileges revoked, they 
are barred from participating in the Medicare program from the effective date of the revocation 
until the end of the reenrollment bar.  The reenrollment bar begins 30 days after CMS or its 
contractor mails notice of the revocation and lasts a minimum of 1 year, but not greater than 10 
years, depending on the severity of the basis for revocation. In addition, CMS may impose a 
reenrollment bar of up to 20 years if the provider/supplier is being revoked from Medicare for 
the second time. 
 
Per  424.535(c), the reenrollment bar does not apply if the revocation: (i) is based on  
424.535(a)(1); and (ii) stems from a provider/suppliers failure to respond timely to a 
revalidation request or other request for information.  If both of these conditions are met, no 
reenrollment bar will be applied.  
 
The contractor shall update PECOS to reflect that the individual cannot participate in Medicare 
for the applicable length of the reenrollment bar. Except as otherwise stated in this chapter, 
PEOG (rather than the contractor) determines reenrollment bars that exceed 3 years. 
  In addition, CMS may add up to 3 more years to the provider/supplier's reenrollment bar if it 
determines that the provider/supplier is attempting to circumvent its existing reenrollment bar. 
 
B.  Establishment of Length 
 
The following serves merely as general, non-binding guidance regarding the establishment of the 
length of reenrollment bars.  It is crucial to note that every situation must and will be judged on 
its own merits, facts, and circumstances. It should not be assumed that a particular timeframe 
will always be applied to a specific revocation reason in all cases.  CMS retains the discretion to 
apply a reenrollment bar period that is different from that indicated below (though which in no 
case will be greater than 10 to 20 years).   
 
   424.535(a)(1) (Noncompliance) -- For licensure issues, 1 year if no billing after loss of 
license 
  424.535(a)(6) (Grounds Related to Screening)  1 year 
  424.535(a)(11) (Initial Reserve Operating Funds)  1 year 
 
The following revocation reasons will receive reenrollment bar lengths per CMS discretion: 
 
  424.535(a)(17) (Debt Referred to the United States Department of Treasury) 
  424.535(a)(18) (Revoked Under a Different Name, Numerical Identifier or 
Business Identity) 
  424.535(a)(19) (Affiliation that Poses an Undue Risk) 
  424.535(a)(20) (Billing from a Non-Compliant Location, 424.535(a)(21) 
(Abusive Ordering, Certifying, Referring, or Prescribing of Part A or B Services, 
Items or Drugs)  
  424.535(a)(22) (Patient Harm) will receive reenrollment bar lengths per CMS 
discretion. 
 
C.  Applicability of Bar 
 
1.  Revocation Reasons Other Than  424.535(a)(1), (a)(5), (a)(6), (a)(9), (a)(10), and (a)(11) 
 
In general, and unless stated otherwise above, any reenrollment bar at a minimum applies to: (1) 
all practice locations under the providers PECOS or legacy enrollment record; and (2) any effort 
to reestablish any of these locations (i) at a different address and/or (ii) under a different business 
or legal identity, structure, or TIN.  If the contractor receives an application and is unsure 
whether a revoked provider is attempting to reestablish a revoked location, it shall contact its 
PEOG BFL for guidance.  Instances where the provider might be attempting to do so include - 
but are not limited to  the following: 
 
SCENARIO 1 - John Smith was the sole owner of Group Practice X, a sole proprietorship. Six 
months after X was revoked under  424.535(a)(9), the contractor receives an initial application 
from Group Practice Medicine, LLC, of which John Smith is the sole owner/member. 
 
SCENARIO 2 - Jack Jones and Stan Smith were 50 percent owners of World Home Health 
Agency, a partnership.  One year after World Home Health was revoked under  424.535(a)(7),  the contractor receives an initial application from XYZ Home Health, a corporation owned by 
Jack Jones and his wife, Jane Jones. 
 
SCENARIO 3 - John Smith was the sole owner of XYZ Medical Supplies, Inc.  XYZs lone 
location was at 1 Jones Street.  XYZs billing privileges were revoked after it was determined 
that the site was non-operational.  Nine months later, the contractor receives an initial application 
from Johnson Supplies, LLC.  The entity has two locations in the same city in which 1 Jones 
Street is located.  John Smith is listed as a 75 percent owner. 
 
2.  Revocation Reasons  424.535(a)(1), (a)(5), (a)(6), (a)(9), (a)(10), and (a)(11) 
 
For these revocation reasons, any reenrollment bar applies only to the specific enrollment that 
was the subject of the reenrollment bar.    
 
D.  Discussing Provider Enrollment Appeals Process in Revocation Letter 
 
(If a conflict exists between the instructions in this section 10.4.7.4(D) and those in either (i) 
those in section 10.6.18 or (ii) the language in the applicable model letter in section 10.7 et seq., 
the guidance in section 10.6.18 or the model letter takes precedence.)   
 
In the revocation letter, the contractor shall include information concerning the providers appeal 
rights.  The following table summarizes where the provider must send a corrective action plan 
(CAP) and/or reconsideration request.   
 
 
    CAP requests should be sent to:  Reconsideration request 
should be sent to: 
Revocation  Institutional*  Non-institutional       Institutional*  -Non-
Regulation      Institutional 
424.535(a)(1)   Alone or in       MAC  CMS  MAC 
related to an  combination: 
enrollment  CMS 
requirement (i.e., 
425.516) 
424.535(a)(1)  CAP rights (to  CAP rights (to the  CMS  MAC 
Licensure  CMS)  MAC) 
424.535(a)(1) DME or  CAP rights (to  CAP rights (to the  CMS  MAC 
IDTF   CMS)  MAC) 
424.535(a)(2)   No CAP rights   No CAP rights  CMS  CMS 
Exclusion 
424.535(a)(2)   No CAP rights   No CAP rights  CMS  CMS 
Debarment 
424.535(a)(3)   No CAP rights   No CAP rights  CMS  CMS 
424.535(a)(4)   No CAP rights   No CAP rights  CMS  CMS 
424.535(a)(5)   No CAP rights   No CAP rights  CMS  MAC 
424.535(a)(6)   No CAP rights   No CAP rights  CMS  MAC 
424.535(a)(7)   No CAP rights   No CAP rights  CMS  CMS 
424.535(a)(8)   No CAP rights   No CAP rights  CMS  CMS  424.535(a)(8)   No CAP rights   No CAP rights  CMS  CMS 
424.535(a)(9)   No CAP rights   No CAP rights  CMS  MAC 
424.535(a)(10)   No CAP rights   No CAP rights  CMS  CMS 
424.535(a)(11)   No CAP rights   No CAP rights  CMS  CMS 
424.535(a)(12)   No CAP rights   No CAP rights  CMS  CMS 
424.535(a)(13)   No CAP rights   No CAP rights  CMS  CMS 
424.535(a)(14)   No CAP rights   No CAP rights  CMS  CMS 
424.535(a)(17)   No CAP rights   No CAP rights  CMS  CMS 
424.535(a)(18)   No CAP rights   No CAP rights  CMS  CMS 
424.535(a)(19)   No CAP rights   No CAP rights  CMS  CMS 
424.535(a)(20)   No CAP rights   No CAP rights  CMS  CMS 
424.535(a)(21)   No CAP rights   No CAP rights  CMS  CMS 
424.535(a)(22)   No CAP rights   No CAP rights  CMS  CMS 
 
*    Institutional providers: 
 
  Ambulance Service Supplier 
  Ambulatory Surgery Centers 
  CLIA Labs 
  Community Mental Health Center 
  Comprehensive Outpatient Rehabilitation Facilities (CORFs) 
  Critical Access Hospitals 
  End Stage Renal Disease (ESRDs) 
  Federally Qualified Health Careers (FQHCs) 
  Histocompatibility Laboratories 
  Home Health Agencies 
  Hospices 
  Hospitals and Hospital Units 
  Independent Diagnostic Testing Facilities (IDTFs) 
  Intensive Cardiac Rehabilitation 
  Indian Health Service Facility 
  Mammography Screening Centers 
  Mass Immunization/Flu Roster Billers 
  Medicare Diabetes Prevention Programs (MDPPs) 
  Opioid Treatment Centers (OTPs) 
  Organ Procurement Organizations (OPOs) 
  Outpatient Physical Therapy/Outpatient Speech Pathology Services (OPT/OSP) 
  Pharmacies 
  Portable X-Ray Suppliers (PXRSs) 
  Radiation Therapy Centers  
  Rehabilitation Services 
  Religious Non-Medical Health Care Institutions (RNCHIs) 
  Rural Health Clinics (RHCs) 
  Skilled Nursing Facilities (SNFs)   
The CMS defines "institutional provider" in 42 CFR  424.502 to mean any provider/supplier 
that submits a paper Medicare enrollment application using the Form CMS-855A, Form CMS-
855B (except physician and non-physician practitioner organizations), or Form CMS-855S, or 
the associated Internet-based PECOS enrollment application.  (Note that MDPP suppliers no 
longer fall within this regulatory definition of institutional provider.  Per 42 CFR  
424.205(b)(5), the provider enrollment application fee is inapplicable to all MDPP suppliers that 
submit a Form CMS-20134 enrollment application.  Solely for purposes of appeal submissions, 
however, MDPP suppliers are included in the bulleted list above.) 
 
10.4.7.5  Additional Revocation Policies  
(Rev. 11020; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21) 
 
A.  Submission of Claims for Services Furnished Before Revocation 
 
Per 42 CFR  424.535(h), a revoked provider or supplier (other than a home health agency 
(HHA)) must, within 60 calendar days after the effective date of revocation, submit all claims for 
items and services furnished before the date of the revocation letter.  A revoked HHA must 
submit all claims for items and services within 60 days after the later of: (1) the effective date of 
the revocation, or (2) the date that the HHA's last payable episode ends.   
 
Nothing in  424.535(h) impacts the requirements of 42 CFR  424.44 regarding the timely 
filing of claims. 
 
B.  Reporting Revocations/Terminations to the State Medicaid Agencies and Childrens 
Health Program (CHIP) 
 
(If the instructions in this section 10.4.7.5(B) conflict with those in another CMS directive, the 
latter takes precedence.)   
 
Section 6401(b)(2) of the Patient Protection and Affordable Health Care Act (i.e., the Affordable 
Care Act) was enacted on March 23, 2010.  It requires that CMS establish a process for making 
available to each State Medicaid Plan or Child Health Plan the name, NPI, and other identifying 
information regarding any revoked or denied Medicare provider/supplier.  Accordingly, CMS 
provides a monthly revoked and denied provider list to all contractors via the Share Point 
Ensemble site.   
 
The contractor shall: 
 
  Access this list on the 5th day of each month via the Share Point Ensemble site   
 
  Review the monthly revoked and denied provider list for the names of Medicare providers 
revoked and denied in PECOS   
 
  Document any appeal actions a provider/supplier may have submitted after the 
provider/suppliers revocation or denial 
    Update the last three columns on the tab named Filtered Revocations of the spreadsheet for 
every provider/supplier revocation or denial  
 
The contractor shall not make any other modifications to the format of this form or its contents.  
 
The following are the only authorized entries to be made on the report:  
 
Appeal Submitted:  
Yes - (Definition: An appeal has been received.  (This includes either a CAP or Reconsideration 
request or notification of an ALJ or DAB action.))  
No - (Definition: No appeal of any type has been submitted)  
 
Appeal Type: 
CAP 
Reconsideration 
ALJ 
DAB 
 
Appeal Status: 
Under Review 
Revocation Upheld 
Revocation Overturned 
Denial Upheld 
Denial Overturned 
CAP accepted 
CAP denied 
Reconsideration Accepted 
Reconsideration Denied 
 
If a contractor is reporting that no appeal has been submitted, the appeal type and status columns 
will be noted as N/A. 
 
If an appeal action has been submitted to PEOG for certified providers/suppliers, the contractor 
shall access the PEOG appeals log via the Share Point Ensemble site to determine the appeal 
status to include on the spreadsheet. 
 
The contractor shall submit their completed reports by the 20th of each month to the CGI Share 
Point Ensemble site. 
 
C.  Opting-Out after Revocation   
 
Revoked suppliers cannot order, certify, or prescribe Part A or B services, items, or drugs to 
Medicare beneficiaries if they opt-out of Medicare after revocation.  For example, if Dr. 
Thompson is Medicare-revoked, he cannot opt-out and order back and knee orthoses for his 
patients. 
 
D.  Overpayments Based Upon Revocations   
The contractor shall commence procedures to collect overpayment after the timeframe for the 
appeal of the revocation has expired or within 10 days of the final appeal determination at the 
first level of appeal.  Overpayments are processed in accordance with 42 CFR Part 405, subpart 
C.   
 
If a revocation has a prospective effective date, the contractor shall assess an overpayment back 
to the date that is the more recent of the following: 
 
  The date when Medicare claims are determined to be ineligible for payment; or  
 
  The date that is within 4 years from the date of the initial claim determination or 
redetermination for good cause as defined in 42 CFR  405.986 (42 CFR  405.980).   
 
The date when Medicare claims are determined to be ineligible for payment may, but will not 
always, match the inactive date of the enrollment as reflected in PECOS and in MCS or FISS.  
Again, in determining an overpayment, the contractor shall use the starting date upon which 
claims are ineligible for reimbursement, not the date the enrollment is inactive according to 
PECOS and MCS or FISS.   
 
In accordance with 42 CFR  424.565, if a physician, non-physician practitioner, physician 
organization, or non-physician practitioner organization fails to comply with the reporting 
requirements specified in 42 CFR  424.516(d)(1)(ii), the contractor may assess an overpayment 
back to a date that is the more recent of the following: 
 
  The date of the final adverse action or change in practice location; or 
  
  The date that is within 4 years from the date of the initial claim determination or 
redetermination for good cause as defined in 42 CFR  405.986 (42 CFR  405.980).   
 
E.  Other Sources of Potential Bases for Revocations 
 
When CMS instructs the contractor to take revocation action, PEOG communicates such 
direction; neither the UPIC, the state agency, CMS Field Office, nor CMS Regional Office (RO) 
(including SOG Location) personnel can direct a contractor to revoke a provider/supplier.  
However, some of these entities may refer a potential revocation to PEOG.  This section 
10.4.7.5(E) discusses the operational aspects of these referrals. 
 
1.  UPICs 
 
a.  Background 
 
If, through its investigations, the UPIC believes that a particular provider/suppliers Medicare 
billing privileges should be revoked, it shall develop a case file - including the reason(s) for 
revocation and the data described in subsection (E)(1)(b) below - and submit the file and all 
supporting documentation to PEOG.   
  PEOG will review the case file and: 
 
  Return the case file to UPIC for additional development, or 
  Consider approving the UPICs recommendation for revocation. 
 
If PEOG approves the revocation recommendation, PEOG will: (1) instruct the applicable 
contractor to revoke the provider/supplier; and (2) notify the applicable contracting officers 
representative (COR). 
 
If the contractor receives a direct request from a UPIC to revoke a provider/supplier, it shall refer 
the matter to its PEOG BFL if it is unsure whether the UPIC received prior PEOG approval of 
the revocation. 
 
b.  Contents of Request 
 
The revocation request shall contain the following information:  
 
  Provider/supplier name; administrative location(s); community setting(s), if applicable type 
(e.g., DMEPOS supplier); Provider Transaction Access Number (PTAN); National Provider 
Identifier (NPI); applicable Medicare Administrative Contractor 
 
  Name(s), e-mail address(es), and phone number(s) of investigators  
 
  Tracking number  
 
  Provider/suppliers billing status (Active? Inactive? For how long?)  
 
  Whether the provider/supplier is a Fraud Prevention System provider/supplier  
 
  Source/Special Project  
 
  Whether the provider/supplier is under a current payment suspension  
 
  Legal basis for revocation  
 
  Relevant facts  
 
  Application of facts to revocation reason  
 
  Any other notable facts  
 
  Effective date (per 42 CFR  424.535(g))  
 
  Supporting documentation  
 
  Photos (which should be copied and pasted within the document)  
  2.  CMS Field Office or RO Revocations 
 
If a CMS Field Office (FO) or (RO) believes that Revocation Reason 8 (see 42 CFR  
424.535(a)(8) is appropriate in a certain case), the FO/RO will develop a case file - including the 
reason(s) for revocation - and submit the file and all supporting documentation to PEOG.  The 
case file must include the name, all known identification numbers (including the NPI and 
associated PTAN(s)), and locations of the provider/supplier, as well as detailed information to 
substantiate the revocation action. 
 
If PEOG concurs with the FO/ROs revocation recommendation, PEOG will: (1) instruct the 
contractor to revoke the provider/supplier; and (2) accordingly notify the FO/RO. 
 
(See section 10.4.3 of this chapter for information on the contractors responsibilities concerning 
involuntary terminations received from the SOG Location.)   
 
3.  OIG Identified Revocations 
 
PEOG is responsible for actions based on HHS OIG Identified revocations.  
 
F.   MDPP Supplier Revocation for Use of an Ineligible Coach  
 
1.  Background 
 
Section 424.205(h)(1)(v) established a new revocation reason for MDPP suppliers.  It permits 
revocation if the MDPP supplier knowingly permitted an ineligible coach to furnish MDPP 
services to beneficiaries, despite being previously removed from the MDPP suppliers roster 
through a CAP.  
 
If a contractor or UPIC suspects this scenario, it shall develop a case file - including the 
revocation reason(s) - and submit the file and all supporting documentation to PEOG. The 
contractor shall provide PEOG with the information described in section 10.4.7.5(E)(1)(b).  
 
PEOG will review the case file and:  
 
  Return the case file to the contractor for additional development, or  
 
  Consider approving the contractors recommendation for revocation.  
 
If PEOG approves the revocation recommendation, PEOG will: (1) instruct the contractor to 
revoke the provider/supplier; and (2) notify the applicable COR. 
 
If the contractor receives a direct request from a UPIC to revoke a provider/supplier, it shall refer 
the matter to its PEOG BFL if it is unsure whether the UPIC received prior PEOG approval of 
the revocation.  
 
2.  Effective Dates  
  An MDPP supplier revoked under  424.205(h)(1)(v) does not have CAP rights.  The revocation 
becomes effective 30 days after the contractor sends notice of the revocation.  
 
3.  Reenrollment Bar  
 
As stated in  424.205(h), if an MDPP supplier has its billing privileges revoked, it is barred 
from participating in Medicare from the effective date of the revocation until the end of the 
reenrollment bar. The reenrollment bar begins 30 days after CMS or its contractor mails notice of 
the revocation and lasts a minimum of 1 year, but not greater than 10 years, depending on the 
severity of the basis for revocation.  
 
10.4.8  Deactivations   
(Rev. 11859; Issued: 02-16-23; Effective: 03-17-23; Implementation: 03-17-23) 
 
A.  Bases for Contractor Action 
 
Unless indicated otherwise in this chapter or in another CMS instruction or directive, the 
contractor shall  without prior approval from its PEOG BFL - deactivate a provider/suppliers 
entire enrollment record and Medicare billing privileges when: 
 
(i)  The provider/supplier fails to respond to a revalidation request. 
 
(ii)  The provider/supplier fails to respond timely to a revalidation development request.  
 
(iii) The provider/supplier is enrolled in an approved status with neither an active reassignment 
nor practice location for 90 days or longer.  (The deactivation basis shall be 42 CFR  
424.540(a)(4), which permits deactivation if the provider/supplier is not in compliance with all 
enrollment requirements.  See sections 10.4.8(B) and (D) below for more information on this 
new deactivation ground.)  
 
(iv) The provider/supplier deactivates an EFT agreement and remains enrolled but does not 
submit a new EFT agreement within 90 days.  (The deactivation basis shall be 42 CFR  
424.540(a)(4).)  
 
(v) The provider/supplier is deceased, and a situation arises where: (1) a particular instruction in 
this chapter calls for deactivation due to the providers/suppliers death; and (2) said directive 
does not require obtaining PEOG approval prior to the deactivation.  (See reference to 42 CFR  
424.540(a)(6) below.)   
 
(vi) The provider or supplier is voluntarily withdrawing from Medicare, and a situation arises 
where: (1) a particular instruction in this chapter calls for deactivation due to the voluntary 
withdrawal; and (2) said directive does not require obtaining PEOG approval prior to the 
deactivation.  (See reference to 42 CFR  424.540(a)(7) below.)   
 
(vii) The providers or suppliers license has expired and the provider or supplier has not billed 
while the license was expired.  (The deactivation basis shall be 42 CFR  424.540(a)(4).)  
  The contractor shall not take deactivation action except as specified and permitted in this chapter 
or other CMS directives. 
 
B.  Regulatory Reasons for Deactivation in  424.540(a) 
 
1.  Grounds 
 
Section 424.540(a) lists eight deactivation grounds: 
 
Section 424.540(a)(1) - The provider/supplier does not submit any Medicare claims for 12 
consecutive calendar months. The 12-month period will begin the 1st day of the 1st month 
without a claim submission through the last day of the 12th month without a submitted claim. 
 
Section 424.540(a)(2) - The provider/supplier does not report a change to the information 
supplied on the enrollment application within the applicable time period required under Title 42.  
(For example, a provider/supplier type falling within the purview of  424.516(e)(1) and (2) 
failed to report a change in ownership or control within (i) 30 calendar days of when the change 
occurred, or (b) 90 calendar days of when the change occurred for all other information on the 
enrollment application.)   
 
If the provider/supplier submits a change of information and (a) it appears the change was not 
reported within 90 days of the change, (b) the contractor did not previously take administrative 
action against the provider/supplier, and (c) no revocation action is applicable, the contractor 
should process the change of information without deactivating the provider/supplier's enrollment. 
 
Section 424.540(a)(3) - The provider/supplier does not furnish complete and accurate 
information and all supporting documentation within 90 calendar days of receipt of notification 
from CMS to submit an enrollment application and supporting documentation, or resubmit and 
certify to the accuracy of its enrollment information. 
 
Section 424.540(a)(4) - The provider/supplier is not in compliance with all enrollment 
requirements.  (See section 10.4.8(D) below for more information.)   
 
Section 424.540(a)(5) - The providers/suppliers practice location is non-operational or 
otherwise invalid.  (See section 10.4.8(D) below for more information.)   
 
Section 424.540(a)(6) - The provider/supplier is deceased. 
 
Section 424.540(a)(7) - The provider/supplier is voluntarily withdrawing from Medicare. 
 
Section 424.540(a)(8) - The provider is the seller in an HHA change of ownership under  
424.550(b)(1). 
 
C.  Effective Dates 
 
(See  424.540(d) for regulations concerning deactivation effective dates.) 
  The effective dates of a deactivation are as follows: 
 
a.   Non-Billing ( 424.540(a)(1))  Unless stated otherwise in this chapter or in another CMS 
directive, the effective date is the date on which the deactivation is imposed.  
 
b.  Section 424.540(a)(2), (3), and (4) (see subsection (B) above)  Unless stated otherwise in 
this chapter or in another CMS directive, the effective date is the date on which the provider/ 
supplier became non-compliant (e.g., the day after the expiration of the 90-day period in which 
the provider was required to report a change of information).   
 
c.  Section 424.540(a)(5)  Unless stated otherwise in this chapter or in another CMS directive, 
the effective date is the date on which the providers/suppliers practice location became non-
operational or otherwise invalid. 
 
d.  Section 424.540(a)(6) - Unless stated otherwise in this chapter or in another CMS directive, 
the effective date is the date of death of the provider/supplier.   
 
e.  Section 424.540(a)(7) - Unless stated otherwise in this chapter or in another CMS directive, 
the effective date is the date on which the provider/supplier voluntarily withdrew from Medicare. 
 
f.  Section 424.540(a)(8) - Unless stated otherwise in this chapter or in another CMS directive, 
the effective date is the date of the sale.  (Note that PEOG will ultimately determine this effective 
date during its review of the case per subsection (F) below.) 
 
(See subsection 10.4.8(E) below for additional information on  424.540(a)(7).  See subsection 
10.4.8(F) below for additional information on  424.540(a)(8)). 
 
D.  Sections 424.540(a)(4) and (a)(5) 
(This section 10.4.8(D) is inapplicable to the situations described in section 10.4.8(A)(iii) and 
(iv).  These two scenarios do not require any referral to PEOG; the contractor can take 
deactivation action on its own volition.) 
The grounds for deactivation under  424.540(a)(4) and (a)(5) mirror the revocation reasons 
described in, respectively,  424.535(a)(1) and (a)(5).  When sending a potential  424.535(a)(1) 
and (a)(5) revocation case to PEOG for review per section 10.4.7.1(A) of this chapter, PEOG 
will determine whether a revocation or a deactivation (under  424.540(a)(4) or (a)(5)) is 
appropriate.  The contractor shall not deactivate a provider or supplier under  424.540(a)(4) or 
(a)(5) unless PEOG specifically directs the contractor to do so.   
 
E.  Section 424.540(a)(7) 
 
See section 10.6.1.3 of this chapter for information regarding certified provider/supplier 
voluntary terminations and section 10.4.3(B) for information on non-certified supplier voluntary 
terminations. 
 
F.  Section 424.540(a)(8)  
  See section 10.2.1.6.1 of this chapter for information regarding seller CHOWs.   
 
G.  Miscellaneous 
1.  Except for deactivations under  424.540(a)(8) (see  424.550(b)(1)) and  424.540(a)(7), the 
deactivation of Medicare billing privileges does not affect a provider/suppliers participation 
agreement. 
 
2.  Prior to deactivating an HHAs billing privileges for any reason (including under the 36-
month rule), the contractor shall refer the matter to its PEOG BFL for review and approval. The 
only exception for PEOG BFL review and approval is a deactivation due to failure to comply 
with a revalidation request. 
 
3.  Notwithstanding any other instruction to the contrary in this chapter, the provider/supplier 
may submit a rebuttal for deactivations imposed pursuant to  424.540(a)(7) or (8). For these two 
rebuttal reasons, the contractor shall abide by the rebuttal policies in section 10.4.8.1.  Note, 
however, that any such rebuttal only applies to the deactivation of billing privileges and not to 
the provider agreement termination.   
 
10.4.8.1  Deactivation Rebuttals  
(Rev. 11637; Issued: 10-07-22; Effective: 12-09-22; Implementation: 12-09-22) 
A. Background  
Pursuant to 42 CFR  424.546, a provider/supplier whose Medicare billing privileges have been 
deactivated under 42 CFR  424.540(a) may file a rebuttal. A rebuttal is an opportunity for the 
provider/supplier to demonstrate that it meets all applicable enrollment requirements and that its 
Medicare billing privileges should not have been deactivated.  Only one rebuttal request may be 
submitted per enrollment deactivation. Additional rebuttal requests submitted for the same 
deactivated enrollment for which a rebuttal has already been received shall be dismissed.  
If an application is received for a deactivated provider/supplier while a rebuttal submission is 
pending or during the rebuttal submission timeframe, the contractor shall process the application 
consistent with current processing instructions.  If the rebuttal determination is issued and 
overturns the deactivation prior to an application being approved, the contractor shall return the 
application received while the rebuttal determination was pending unless: (1) the submitted 
application is required to reactivate the provider/suppliers enrollment; or (2) if there are new 
changes being reported.  If an application (1) is received while a rebuttal submission is pending, 
(2) is approved prior to the issuance of a rebuttal determination, and (3) results in the providers 
or suppliers enrollment being reactivated without a gap in billing privileges, the contractor shall 
stop processing the rebuttal submission and issue an applicable moot letter. 
B.  Notification Letters for Deactivations   
If a basis is found to deactivate a providers or suppliers Medicare billing privileges under one 
of the regulatory authorities in 42 C.F.R.  424.540, the contractor shall deactivate the 
provider/supplier unless another CMS directive applies.  If a revocation authority is applicable, 
the contractor shall follow the instructions in sections 10.4.7 and 10.4.8 et seq. of this chapter in  lieu of deactivating the enrollment.  If no revocation authority applies, the contractor shall send 
notification of the deactivation using the applicable model deactivation notice. The contractor 
shall send a notification letter for every deactivated enrollment. The contractor shall ensure the 
deactivation notice contains sufficient details so it is clear why the providers or suppliers 
Medicare billing privileges are being deactivated.  The contractor shall send the deactivation 
notification letter via hard-copy mail and via e-mail (if a valid email address is available); the 
contractor should also send the notice via fax if a valid fax number is available. All notifications 
shall be saved in PDF format, and all notification letters shall be mailed on the same date listed 
on the letter. 
C.  Rebuttal Submissions  
1.  Requirements and Submission of Rebuttals 
 
Pursuant to 42 C.F.R.  424.546(b), to be accepted and processed, the rebuttal submission must:  
(1) Be in writing; 
(2) Specify the facts or issues concerning the rebuttal with which the provider or supplier 
disagrees, and the reasons for disagreement; 
(3) Include all documentation the provider or supplier wants CMS to consider in its review of 
the deactivation; 
(4) Be submitted in the form of a letter that is signed and dated by the individual supplier (if 
enrolled as an individual physician or nonphysician practitioner), the authorized official 
or delegated official (as those terms are defined in 42 CFR 424.502), or a legal 
representative (as defined in 42 C.F.R. 498.10); 
  If the legal representative is an attorney, the attorney must include a statement that 
he/she/they have the authority to represent the provider or supplier; this statement 
is sufficient to constitute notice of such authority.  
  If the legal representative is not an attorney, the provider or supplier must file 
with CMS written notice of the appointment of a representative; this notice of 
appointment must be signed and dated by, as applicable, the individual supplier, 
the authorized official or delegated official, or a legal representative. 
  Authorized or delegated officials for groups cannot sign and submit a rebuttal on 
behalf of a reassigned provider/supplier without the provider/supplier submitting 
a signed statement authorizing that individual from the group to act on 
his/her/their behalf. 
  Signatures may be original or electronic. Valid signatures include handwriting 
(wet) signatures in ink and digital/electronic signatures. Digital or electronic 
signatures such as those created by digital signature options, created in software, 
such as Adobe) and email signatures shall be accepted. Contractors shall contact 
ProviderEnrollmentAppeals@cms.hhs.gov for questions regarding electronic and 
digital signatures. 
  (5) Be received by the contractor within 15 calendar days from the date of the deactivation 
notice. The contractor shall accept a rebuttal submission via hard-copy mail, e-mail, 
and/or fax; 
If the rebuttal submission is not appropriately signed or if a statement from the attorney or 
written notice of representation is not included in the submission, the contractor shall send a 
development request for a proper signature or the missing statement/written notice (using the 
applicable model letter) before dismissing the rebuttal submission. The contractor shall allow 15 
calendar days from the date of the development request letter for the rebuttal submitter to 
respond to the development request.  
 
If a rebuttal submission: (1) is not appropriately signed and no response is received to the 
development request (if applicable); (2) is untimely (as described above); (3) does not specify the 
facts or issues with which the provider/supplier disagrees and the reasons for disagreement and 
no response is received to the development request; or (4) is a duplicative submission, the 
contractor shall dismiss the rebuttal submission using the applicable Rebuttal Dismissal Model 
Letter. For those rebuttal submissions that are improperly signed and/or do not specify the facts 
or issue with which the provider or supplier disagrees and the reasons for disagreement, the 
contractor shall send a development request via hard-copy mail, email, if available, to the 
provider/supplier requesting a proper signature and/or clarification on the facts or issues with 
which the provider or supplier disagrees and the reasons for disagreement using the applicable 
Rebuttal Development Model Letter. Sending the development letter via fax is optional. The 
contractor shall grant an additional 15-calendar days from the date of the development request 
letter for the provider or supplier to submit an acceptable rebuttal submission. If no response is 
received or the rebuttal submission is still deficient after the development request and the 15-
calendar day timeframe has expired, the contractor shall dismiss the rebuttal submission using 
the applicable Rebuttal Dismissal Model Letter. 
 
The contractor may make a good cause determination to accept any rebuttal that has been 
submitted beyond the 15 calendar-day filing timeframe. Good cause may be found where there 
are circumstances beyond the providers or suppliers control that prevented the timely 
submission of a rebuttal. These uncontrollable circumstances do not include the 
provider/suppliers failure to timely update its enrollment information, specifically its various 
addresses. If the contractor believes good cause exists to accept an untimely rebuttal submission, 
the contractor shall send a request approval email to ProviderEnrollmentAppeals@cms.hhs.gov 
within five calendar days of making the good cause determination. This email shall detail the 
contractors reasoning for finding good cause. Processing timeliness standards shall begin on the 
date the contractor receives a response from CMS.  
 
2. Time Calculations for Rebuttal Submissions 
 
If the 15th calendar day from the date on the deactivation notice falls on a weekend or federally-
recognized holiday, the rebuttal shall be accepted as timely if the contractor received it by the 
next business day.  
 
It is the providers or suppliers responsibility to timely update his/her/their/its enrollment record 
to reflect any changes to the providers or suppliers enrollment information including, but not 
limited to, its correspondence address. Failure to timely update a correspondence address or  other addresses included in its Medicare enrollment record does not constitute an in fact 
showing that the deactivation notice was received after the presumed receipt date (as described 
above). 
 
3.  Processing Rebuttal Submissions  
 
The contractor shall send an acknowledgement letter via hard-copy mail to the return address on 
the rebuttal submission within 10 calendar-days of receipt of the accepted rebuttal request using 
the Rebuttal Acknowledgment Model Letter, including a rebuttal tracking number and the 
providers or suppliers NPI. The acknowledgement letter shall also be sent via email if a valid 
email address is available (either in the enrollment record or rebuttal submission). It is optional 
for the contractor to send the acknowledgement letter via fax if a valid fax number is available. If 
a rebuttal determination is issued within 10 calendar-days of the date of receipt of the rebuttal 
submission then the contractor is not required to issue a receipt acknowledgement letter. 
 
The contractor shall process all accepted rebuttal submissions within 30 calendar-days of the 
date of receipt. If, while reviewing the rebuttal submission, the provider or supplier wishes to 
withdraw its rebuttal, the request to withdraw must be submitted to the contractor in writing 
before the rebuttal determination is issued. If a provider or supplier submits a written request to 
withdraw its rebuttal submission prior to the issuance of a rebuttal determination then the 
contractor shall issue a letter using the applicable Rebuttal Withdrawn Model Letter and no 
rebuttal determination shall be issued. 
 
The contractors review of the rebuttal submission shall only consist of whether the provider or 
supplier met the enrollment requirements and if billing privileges were deactivated appropriately.  
All materials received by the provider/supplier shall be considered by the contractor in its 
review. 
 
4.  Reason-Specific Instructions 
 
a.   424.540(a)(1) 
 
For deactivations under  424.540(a)(1), the contractor shall review submitted documentation 
and internal systems to confirm whether billing occurred during the 12-month period preceding 
the date of deactivation, starting with the first day of the first month 12 months prior to the date 
of deactivation. If it is confirmed that billing occurred within 12 months, the contractor shall 
issue a favorable rebuttal determination. If no billing occurred during the 12-month period prior 
to the date of deactivation, the contractor shall issue an unfavorable rebuttal determination.  
Consider the following illustration: 
 
EXAMPLE: Dr. Awesome has been enrolled in Medicare since 2010. A review of billing data 
reveals that Dr. Awesome has not submitted any Medicare claims since January 2019. Dr. 
Awesomes enrollment is deactivated, under 42 C.F.R.  424.540(a)(1), effective January 1, 
2020. Dr. Awesome timely submits a rebuttal in response to the deactivation. Upon review by 
the contractor, it is confirmed that Dr. Awesome had not submitted claims since January 2019.  
Therefore, an unfavorable rebuttal determination would therefore be appropriate in this scenario, 
for the deactivation was appropriate.   
  b.   424.540(a)(2) 
 
For deactivations under  424.540(a)(2), the contractor shall review the submitted documentation 
and internal records to determine whether the change of information was properly submitted 
within the required timeframe. The required timeframe to submit updated information is 
described at 42 C.F.R.  424.550, 410.33(g)(2), 424.57(c)(2), and 424.516(d). If information 
was submitted properly and timely, the contractor shall approve the rebuttal submission, issue a 
favorable rebuttal determination, and reinstate the provider s or suppliers Medicare billing 
privileges to an approved status. If it was not submitted properly and timely, the contractor shall 
deny the rebuttal request and issue an unfavorable rebuttal determination, as the deactivation was 
appropriate.  In making this determination, the contractor shall consider, at minimum, the 
following.  
 
  Whether the deactivation was implemented after the required timeframe to report a 
change of enrollment information elapsed; 
  Whether the letter notifying the provider/supplier of the deactivation was sent to the 
correct address as instructed in section 10.7 et seq. of this chapter; and 
  Whether the enrollment changes were received in an enrollment application that 
was processed to completion within the required timeframe.  
 
Consider the following illustration: 
 
EXAMPLE: Dr. Happy has reassigned his benefits to a physician group, Smile, LLC. Smile, 
LLC is Dr. Happys only reassignment and only practice location.  Smile, LLCs enrollment and 
corresponding billing privileges are revoked effective January 1, 2018. Dr. Happys enrollment 
is deactivated on February 1, 2018 for failing to update his enrollment record with respect to his 
practice location. Dr. Happy timely submits a rebuttal in response to the deactivation of his 
individual enrollment.  Upon review by the contractor of the submitted documentation and 
internal records, it is discovered that Dr. Happy submitted a change of information application 
received by the contractor on February 28, 2018 that sought to update his practice location.  
However, this application was ultimately rejected due to his failure to timely respond to a 
development request.  
 
In this scenario, the deactivation was correctly implemented after 30 days of the change of 
enrollment information  the change in practice location. However, an enrollment application 
updating Dr. Happys practice location that was processed to completion was not received within 
30 days of the change of enrollment information. Though the contractor received an application 
within 30 days of the change of enrollment information, that application was not processed to 
completion. Thus, an unfavorable rebuttal determination would be appropriate in this scenario, as 
the deactivation was appropriately implemented.  
 
c.   424.540(a)(3) 
 
For deactivations under  424.540(a)(3), the contractor shall review all submitted documentation 
and internal records to determine whether the provider or supplier furnished complete and 
accurate information and all supporting documentation within 90 calendar days of receipt of 
notification from CMS to submit an enrollment application and supporting documentation, or  resubmit and certify to the accuracy of its enrollment information.  In making this determination, 
the contractor shall consider, at minimum, the following: 
 
  Whether the deactivation was implemented after 90 days of the revalidation request. 
  Whether the letter notifying the provider or supplier of the requirement to revalidate 
was sent to the correct address as instructed in section 10.7 of this chapter.  
  Whether a revalidation application was timely received and was processed to 
completion.  
 
Consider the following scenario: 
 
EXAMPLE: On January 1, 2022, the contractor appropriately and timely informs Dr. Great that 
the contractor must receive a revalidation application from Dr. Great by April 15, 2022.  The 
contractor receives a revalidation application from Dr. Great on March 1, 2022.  The contractor 
requests that Dr. Great furnish further information needed to process the revalidation application. 
Dr. Great does not respond to the development request within 30 days as requested. The 
contractor rejects the March 1, 2022 revalidation application and subsequently deactivates Dr. 
Greats enrollment on April 16, 2022 under 42 C.F.R.  424.540(a)(3). Dr. Great timely files a 
rebuttal in response to the deactivation. Upon review of the submitted documentation and 
internal records, the contractor confirms that Dr. Great was appropriately and timely notified of 
the requirement to revalidate and that it did not receive a revalidation application within 90 days 
of the revalidation request that could be processed to completion.  Accordingly, an unfavorable 
rebuttal determination would be appropriate in this scenario, as the deactivation was 
appropriately implemented. 
 
d.   424.540(a)(4) and (5) 
 
For deactivations under  424.540(a)(4), the contractor shall review all submitted documentation 
and internal records to determine whether the provider or supplier was, in fact, compliant with all 
enrollment requirements at the time of the deactivation 
 
For deactivations under  424.540(a)(5), the contractor shall review all submitted documentation 
and internal records to determine whether the providers or suppliers practice location was 
operational or otherwise valid at the time of the deactivation.  
 
If the provider or supplier was indeed compliant or operational at the time of the deactivation, 
the contractor shall approve the rebuttal request and reinstate the providers or suppliers 
Medicare billing privileges to an approved status; prior PEOG review of the rebuttal or approval 
of the rebuttal request is not required.  
 
e.   424.540(a)(6)-(8) 
 
Although rebuttals under  424.540(a)(6)-(8) these three deactivation grounds are uncommon, 
the provider or supplier may submit one. Upon receipt of a rebuttal submission, the contractor 
shall review all submitted documentation and internal records to determine whether the 
deactivation pursuant to the regulatory basis in question was appropriate. If it was not, the 
contractor shall approve the rebuttal request and reinstate the provider/suppliers Medicare 
billing privileges to an approved status; prior PEOG review of the rebuttal or approval of the  rebuttal request is not required.  If the rebuttal was not submitted properly and timely, the 
contractor shall dismiss the rebuttal request.  
  
D.  Determination 
 
The contractor shall render a determination regarding a rebuttal submission using the appropriate 
Model Rebuttal Decision Letter. If the contractor is unable to render a determination, the 
contactor shall use the appropriate Model Letter for the specific situation. All determinations 
(including dismissals and withdrawals) related to rebuttal submissions shall be sent (1) via hard-
copy mail to the return address on the rebuttal submission; (2) via hard-copy mail to the 
correspondence mailing address on the enrollment records (if different from return address on 
rebuttal submission); and (3) by e-mail if a valid e-mail address is available (submitted as part of 
the rebuttal submission and/or listed in the enrollment record correspondence mailing address). 
The contractor may also send via fax if a valid fax number is available. All documentation shall 
be saved in PDF format. All notification letters shall be mailed on the same date listed on the 
letter. 
If the contractor issues a rebuttal determination favorable to the provider or supplier, it shall 
make the necessary modification(s) to the providers or suppliers Medicare billing privileges 
within 10 business days of the date on the favorable determination letter. This may include the 
elimination of the deactivation altogether so that there is no gap in billing privileges or a change 
in the deactivation effective date. If the contactor issues a rebuttal determination unfavorable to 
the provider or supplier, the providers or suppliers Medicare billing privileges shall remain 
deactivated until a reactivation application is received and processed to completion. 
If a rebuttal determination overturns the deactivation, the contractor shall return any 
application(s) received while the rebuttal submission was being reviewed or during the rebuttal 
submission timeframe that has not been processed to completion, unless the application is needed 
to reactivate the enrollment or if there are new changes being reported. If the contractor confirms 
that the application is not needed and that no new changes are being reported, the contractor shall 
use the following return reason in the Returned Application Model Letter found at 10.7.7.A of 
this chapter in response to the scenario described above: A rebuttal decision has been issued; 
therefore, the submitted Form CMS [855/588/20134] is not needed. 
If additional information/documentation is needed prior to reinstating the provider or supplier as 
part of a favorable rebuttal determination (e.g., deactivation due to non-response to revalidation 
and a complete application or missing information is needed to finalize the revalidation), the 
contractor shall document these next steps in its rebuttal determination letter. The contractor 
shall not reinstate the provider or supplier until the requested information is received and 
processed.  If the additional information/documentation is not received within 30 calendar days 
of the date of the rebuttal determination, the contractor shall contact the provider/supplier to 
again request the additional information/documentation within 10 calendar days of not receiving 
a response.  If no response is received within 30 calendar days of the second request for additional 
information/documentation, the contractor shall contact 
ProviderEnrollmentAppeals@cms.hhs.gov within 10 calendar days for further instruction. 
E.  No Further Review 
 
Pursuant to 42 C.F.R.  424.546(f), a determination made regarding a rebuttal request is not an 
initial determination and is not subject to further review.  Thus, no additional appeal rights shall 
be included on any rebuttal determination letter. 
 
F.  External Monthly Reporting for Rebuttals 
 
Using the provider enrollment rebuttals reporting template, the contractor shall complete all 
columns listed for all rebuttal submissions received and processed by the contractor. No column 
shall be left blank (except Column K, as described below). If the contractor is unable to complete 
all columns for a given rebuttal submission, the contractor shall contact 
ProviderEnrollmentAppeals@cms.hhs.gov within five business days of discovery to seek further 
guidance. 
 
The reports shall use only the formats identified below. All dates shall be formatted as 
mm/dd/yyyy (e.g. 01/13/2021). The reports shall be sent to CMS via email at 
ProviderEnrollmentAppeals@cms.hhs.gov no later than the 15th of each month. If this day falls 
on a weekend or a holiday, the report shall be submitted the following business day. The report 
shall include the prior months rebuttal submissions, as well as outcomes for all submissions 
previously received that were not yet completed and reported to CMS (e.g., the February report 
shall cover all January rebuttals). 
 
IMPORTANT: All submissions shall remain on the monthly report until a final 
outcome/decision has been reported to CMS. 
 
  Column A: The response in Column A labelled, Provider/Supplier Name (As it appears 
in PECOS) shall be the providers or suppliers Legal Business Name, exactly as it is 
spelled and formatted in the PECOS enrollment record (including capitalization, 
abbreviations, and punctuation). 
 
  Column B: The response in Column B labelled, NPI shall be the providers or 
suppliers NPI. If the provider/supplier has more than one NPI, the contract shall list each 
NPI, separated by a semi-colon. 
 
  Column C: The response in Column C labelled, EID (if applicable) shall be the 
providers or suppliers EID. If there is no EID associated with the provider/supplier, the 
response shall be N/A. 
 
  Column D: The response in Column D labelled, PTAN(s) (if applicable) shall include 
the providers or suppliers PTAN. If the provider/supplier has more than one PTAN, 
each PTAN shall be separated by a semicolon (e.g. L5988; 190002033). If the 
provider/supplier does not have a PTAN, the response shall be N/A. 
    Column E: The response in Column E labelled, Contractor (Including Jurisdiction), 
shall be in one of the following formats. No other formats are acceptable. 
 
  CGS J15 
o
  FCSO 
o
  NGS J6 
o
  NGS JK 
o
  Noridian JE 
o
  Noridian JF 
o
  Novitas JH 
o
  Novitas JL 
o
  NPE East 
o
  NPE West 
o
  NSC 
o
  Palmetto JJ 
o
  Palmetto JM 
o
  WPS J5 
o
  WPS J8 
o
 
  Column F: The response in Column F labelled, Regulatory Authority for Deactivation, 
shall be in the following format. If the response is Other (see Comments) the 
Contractors shall use Column K to provide explanatory notes (e.g. when a rebuttal is 
submitted in response to an enrollment action that does not afford rebuttal rights, describe 
the enrollment action in Column K). No other formats are acceptable: 
 
  424.540(a)(1) 
o
  424.540(a)(2)  
o
  424.540(a)(3) 
o
  424.540(a)(4) 
o
  424.540(a)(5) 
o
  424.540(a)(6) 
o
  424.540(a)(7) 
o
  424.540(a)(8) 
o
  Other (see Comments) 
o
 
  Column G: The response in Column G labelled, Date Rebuttal Received shall be the 
date on which the Contractor received the rebuttal. The date shall be formatted as 
mm/dd/yyyy (e.g. 10/25/2021). 
 
  Column H: The response in Column H labelled, Date Receipt Acknowledgement Sent 
to Provider/Supplier/Legal Representative, shall be Not yet sent if a receipt 
acknowledgement email/letter has not been sent to the provider/supplier/legal 
representative at the time the monthly report is sent to CMS. The response shall be N/A 
if a receipt acknowledgement email/letter is not required for that case (i.e., rebuttal 
determination is issued within 10-calendar days of the date of receipt of the rebuttal 
submission). Dates shall be formatted as mm/dd/yyyy (e.g. 06/15/2020). 
    Column I: The response in Column I labelled, Date Rebuttal Determination Issued 
shall be the date on which the Contractor issues the rebuttal determination. The date shall 
be formatted as mm/dd/yyyy (e.g. 09/19/2019). If a final rebuttal determination has not 
yet been issued, the contractors shall enter "In Process" as the response.  
 
  Column J: The response in Column J labelled, Final Decision Result, shall be one of 
the following. No other formats are acceptable. 
 
  Not Actionable: Rebuttal is no longer actionable (moot) because the basis for the 
o
deactivation has been resolved (e.g. deactivation was rescinded). 
  Favorable: (to provider/supplier) Contractor has determined that an error was 
o
made in the implementation of the deactivation. Therefore, the initial 
determination was overturned and the enrollment record has been placed in 
approved status. 
  Unfavorable: (to provider/supplier) Contractor upholds the initial determination 
o
resulting in the enrollment remaining deactivated. 
  Dismissed: The rebuttal submission does not meet the rebuttal submission 
o
requirements (e.g.  missing proper signature and did not timely respond to 
development request). 
  Withdrawn: Provider/supplier/representative has submitted written notice of its 
o
intent to withdraw its rebuttal before the contractor issued a determination and the 
contractor has acknowledge the withdrawal. 
  In Process: A final decision has not been issued. The Contractor is still 
o
processing the submission. 
 
  Column K: The response in Column K labelled, Comments, shall include any 
information related to the deactivation, rebuttal submission, or rebuttal determination that 
provides context for CMS in reporting the rebuttal and outcome. This column may be left 
blank if no additional information is necessary. 
 
10.5- Timeliness and Accuracy Standards 
(Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
Sections 10.5(A) through 10.5(B)(4) of this chapter address the timeliness and accuracy 
standards applicable to the processing of Form CMS-855, Form CMS-20134 applications (initial 
and change of information and revalidation), and opt-out affidavits. Even though the provisions 
of 42 CFR  405.818 contain processing timeframes that differ than those in sections 10.5(A) 
through 10.5(B)(4), the contractor shall adhere to the standards specified in sections 10.5(A) 
through 10.5(B)(4).  
 
The term PECOS applications means web-based applications.  For special instructions 
regarding the processing of applications submitted via PECOS 2.0, see section 10.3 of this 
chapter. The PECOS instructions in section 10.3 take precedence over those in this section 10.5.  
 
Note that the date of receipt of a PECOS application is the date the contractor received it, not the 
date on which the application required the contractors manual intervention per section 10.3. 
  The processing of an application or opt-out affidavit generally includes, but is not limited to, the 
following activities: 
 
  For paper applications - Receipt of the application or opt-out affidavit in the contractors 
mailroom and forwarding it to the appropriate office for review.  (This is the intake 
process.) 
 
  For PECOS applications - Electronic receipt of the application.  
 
  For paper applications  Completing the intake process. 
 
  Ensuring that the information on the application or opt-out affidavit is verified. 
 
  Requesting and receiving clarifying information. 
 
  Site visit (if necessary). 
 
  Requesting fingerprints (if necessary). 
 
  For certified providers/suppliers (and as applicable to the transaction and/or 
provider/supplier type), formal notification to the state and/or CMS Survey & Operations 
Group (SOG) Location of the contractors approval, denial, or recommendation for 
approval of the application. 
 
(Note: The timeliness metrics discussed in this section are a combination of Part A applications 
and Part B applications and opt-out affidavits.) 
 
For purposes of sections 10.5(A) and 10.5(B) below: 
 
  The term site visit means that the provider or supplier requires an on-site review to 
determine whether the provider or supplier is operational based on the provider/supplier 
type.  
 
  The term development means that the contractor needs to contact the provider or 
supplier for additional information.  (A development request (via letter, fax, email, the 
PCV, or telephone contact for development) to the provider or supplier is considered to 
be the first development request.) 
 
  The term fingerprinting means that 5 percent or greater owners (including partners who 
own at least 5 percent) of a provider or supplier is required to submit fingerprints for an 
additional level of screening. 
 
A. Standards for Initial and Change of Information Applications and Opt-Out Affidavits 
 
For purposes of sections 10.5(A)(1) through 10.5(A)(4) of this chapter, the term initial 
applications also includes: 
    Form CMS-855 or Form CMS-20134 change of ownership, acquisition/merger, and 
consolidation applications submitted by the new owner 
 
  Complete Form CMS-855 or Form CMS-20134 applications submitted by enrolled 
providers: (a) voluntarily, (b) as part of any change request if the provider does not have 
an established enrollment record in PECOS, or (c) as a Form CMS-855 or Form CMS-
20134 reactivation 
 
  Opt-out affidavits submitted for an eligible practitioners first opt-out period 
 
For purposes of sections 10.5(A)(1) through 10.5(A)(4) of this chapter, the term changes of 
information also includes: 
 
  Form CMS-855 and Form CMS-20134 change of ownership, acquisition/merger, and 
consolidation applications submitted by the old owner 
 
  Form CMS-588 changes submitted without a need for an accompanying complete Form 
CMS-855 or Form CMS-20134 application 
 
  Form CMS-855R applications submitted independently (i.e., without being part of a 
Form CMS-855I or Form CMS-855B package) 
 
  Form CMS-855 and Form CMS-20134 voluntary terminations 
 
  Opt-out early termination requests (of initial opt-out affidavits), changes of information 
and cancellation requests 
 
Initial and change of information application and opt-out timeliness standards shall be reported 
together. Likewise, initial, change of information, and opt-out affidavit accuracy shall be 
reported together. 
 
1.  Paper Initial and Change of Information Applications and Opt-Out Affidavits - 
Timeliness 
 
Please refer to section 10.5 above for definitions of site visits, development, and fingerprinting.  
 
a.  Form CMS-855 and Form CMS-20134 Initial and Change of Information Applications 
and Opt-Out Affidavits That Require a Site Visit, Development and/or Fingerprinting 
 
The contractor shall process 95 percent of all Form CMS-855 and Form CMS- 20134 initial and 
change of information applications and opt-out affidavits (initial, changes of information, 
termination requests and cancellation requests) that require a site visit, development and/or 
fingerprinting within 65 calendar days of receipt and process 100 percent of all Form CMS-855 
and Form CMS-20134 initial and change of information applications and opt-out affidavits 
(initial, changes of information, termination requests and cancellation requests) that require a site 
visit, development and/or fingerprinting within 100 calendar days of receipt. 
  b. Form CMS-855 and Form CMS-20134 Initial and Change of Information Applications 
and Opt-Out Affidavits That Do Not Require a Site Visit, Development and/or 
Fingerprinting  
 
The contractor shall process 95 percent of all Form CMS-855 and Form CMS- 20134 initial and 
change of information applications and opt-out affidavits (initials, changes of information, 
termination and cancellation requests) that do not require a site visit, development and/or 
fingerprinting within 30 calendar days of receipt. 
 
The contractor shall process 100 percent of all Form CMS-855 and Form CMS-20134 initial and 
change of information applications and opt-out affidavits (initials, changes of information, 
termination and cancellation requests) that do not require a site visit, development and/or 
fingerprinting within 65 calendar days of receipt. 
 
2. Paper Initial and Change of Information Applications and Opt-Out Affidavits  
Accuracy 
 
The contractor shall process 98 percent of paper Form CMS-855 and Form CMS-20134 initial 
and change of information applications and opt-out affidavits in full accordance with all of the 
instructions in this chapter (with the exception of the timeliness standards identified in sections 
10.5(A)(1) through 10.5(A)(2) of this chapter) and all other applicable CMS directives. 
   
3. PECOS Initial and Change of Information Applications - Timeliness 
 
This process generally includes, but is not limited to, verification of the application in accordance 
with existing instructions; requesting and receiving clarifying information in accordance with 
existing instructions; site visit (if required) and/or requesting fingerprints (if necessary). Please 
refer to Section 10.5 above for definitions of site visits, development, and fingerprinting. 
 
a. PECOS Initial and Change of Information Applications That Require a Site Visit, 
Development and/or Fingerprinting 
 
The contractor shall process 95 percent of all Form CMS-855 and Form CMS-20134 PECOS 
initial and change of information applications that require a site visit, development and/or 
fingerprinting within 50 calendar days of receipt and process 100 percent of all Form CMS-855 
and Form CMS-20134 PECOS initial and change of information applications that require a site 
visit, development and/or fingerprinting within 85 calendar days of receipt.  
 
b. PECOS Initial and Change of Information Applications That Do Not Require a Site 
Visit, Development and/or Fingerprinting 
 
The contractor shall process 95 percent of Form CMS-855 and Form CMS-20134 PECOS initial 
and change of information applications that do not require a site visit, development and/or 
fingerprinting within 15 calendar days of receipt and process 100 percent of Form CMS-855 and 
Form CMS-20134 PECOS initial and change of information applications that do not require a 
site visit, development and/or fingerprinting within 50 calendar days of receipt.  
 
4. PECOS Initial and Change of Information Applications - Accuracy   
The contractor shall process 98 percent of Form CMS-855 and Form CMS-20134 PECOS initial 
and change of information applications in full accordance with all of the instructions in this 
chapter (with the exception of the timeliness standards identified in section 10.5(A)(3) above) 
and all other applicable CMS directives. 
 
B. Standards for Revalidation Applications 
 
For purposes of sections 10.5(B)(1) through 10.5(B)(3)(b) of this chapter, the term revalidation 
applications includes complete Form CMS-855 or Form CMS-20134 revalidation applications 
submitted by enrolled providers. 
 
1. Paper Revalidation Applications that Require Site Visits, Development and/or 
Fingerprinting - Timeliness 
 
Please refer to section 10.5 above for definitions of site visits, development, and fingerprinting. 
 
a. Form CMS-855 and Form CMS-20134 Revalidation Applications That Require a Site 
Visit, Development and/or Fingerprinting  Timeliness 
 
The contractor shall process 80 percent of paper Form CMS-855 and Form CMS-20134 
revalidation applications that require site visits, development and/or fingerprinting within 65 
calendar days of receipt and process 100 percent of paper Form CMS-855 and Form CMS-20134 
revalidation applications within 100 calendar days of receipt. 
 
b. Paper Revalidation Applications that do not Require Site Visits, Development, and/or 
Fingerprinting - Timeliness 
 
The contractor shall process 80 percent of paper Form CMS-855 and Form CMS-20134 
revalidation applications that do not require site visits, development and/or fingerprinting within 
30 calendar days of receipt and process 100 percent of paper Form CMS-855 and Form CMS-
20134 revalidation applications within 65 calendar days of receipt. 
 
2. Paper Revalidation Applications - Accuracy 
 
The contractor shall process 98 percent of paper Form CMS-855 and Form CMS-20134 
revalidations in full accordance with all of the instructions in this chapter (with the exception of 
the timeliness standards identified in section 10.5(B)(1) above) and all other applicable CMS 
directives. 
 
3. PECOS Revalidation Applications - Timeliness 
 
This process generally includes, but is not limited to, verification of the application in accordance 
with existing instructions; requesting and receiving clarifying information in accordance with 
existing instructions; site visit (if required) and/or requesting fingerprints (if necessary). Please 
refer to section 10.5 above for definitions of site visits, development, and fingerprinting. 
 
a. PECOS Revalidation Applications That Require a Site Visit, Development and/or  Fingerprinting - Timeliness 
 
The contractor shall process 80 percent of all Form CMS-855 and Form CMS- 20134 PECOS 
revalidation applications that require a site visit, development and/or fingerprinting within 50 
calendar days of receipt and process 100 percent of all Form CMS-855 and Form CMS-20134 
PECOS revalidation applications that require a site visit, development and/or fingerprinting 
within 85 calendar days of receipt.  
 
b. PECOS Revalidation Applications That Do Not Require a Site Visit, Development 
and/or Fingerprinting - Timeliness 
 
The contractor shall process 80 percent of Form CMS-855 and Form CMS-20134 PECOS 
revalidation applications that do not require a site visit, development and/or fingerprinting within 
15 calendar days of receipt and process 100 percent of Form CMS-855 and Form CMS-20134 
PECOS revalidation applications that do not require a site visit, development and/or 
fingerprinting within 50 calendar days of receipt.  
 
4. PECOS Revalidation Applications - Accuracy 
 
The contractor shall process 98 percent of Form CMS-855 and Form CMS-20134 PECOS 
revalidation applications in full accordance with all of the instructions in this chapter (with the 
exception of the timeliness standards identified in sections 10.5(B)(1) and 10.5(B)(3)(b) above) 
and all other applicable CMS directives. 
 
C. General Timeliness Principles 
 
Unless stated otherwise in this chapter or in another CMS directive, the principles discussed 
below apply to all applications discussed in sections 10.5(A)(1) through 10.5(B)(3) of this 
chapter (e.g., change of ownership (CHOW) applications submitted by old and new owners, 
CMS-588 forms).  
 
1. Clock Stoppages  
 
The processing timeliness clock temporarily stops when the situations identified in section 
10.5(C)(1) occur:  
 
  Referring an application to the Office of Inspector General (OIG) or the Unified Program 
Integrity Contractor (UPIC).  
 
  Waiting for a final sales agreement (e.g., CHOW, acquisition/merger).  
 
  Contacting: (i) the SOG Location, and/or state agency regarding a provider-based or 
CHOW determination; (ii) the SOG Location or state agency with a question regarding the 
application of a CMS policy; (iii) contacting the SOG Location or state agency. 
 
  Referring a provider or supplier to update their information in the National Plan & 
Provider Enumeration System.   
  Contacting CMS Provider Enrollment & Oversight Group (PEOG) for the following 
reasons: questions regarding the application or CMS policy; an adverse legal action 
review; affiliations/overpayments found on the monthly report or PECOS; Advanced 
Provider Screening criminal alerts; delayed site visits; referrals to PEOG (if required 
under this chapter) for final review of certain certified provider/supplier applications.  
 
  Referring a provider to the Social Security Administration to resolve a discrepancy 
involving a social security number or to the Internal Revenue Service to resolve a tax 
identification number or individual tax identification number issue.  
 
  Contacting another contractor for any type of PECOS update (i.e.: locked associates). 
 
  Contacting the PECOS Maintainer for resolutions to system issues (i.e.: RightNow 
tickets). 
 
  Practice location and special payment address changes as well as specialty changes with 
future dates. 
 
  If fingerprints are required, the timeliness clock stops when the fingerprint request is 
issued and resumes when the contractor receives the results.  (If additional information is 
developed at the same time as the fingerprint request is issued, no action shall be taken on 
the developed information until after the fingerprint results are received.)  
 
  Any other clock stoppage expressly permitted in this chapter or by CMS 
 
Should a dependent application be needed to continue processing (e.g., a Form CMS-855R is 
needed to complete a reassignment when only a Form CMS-855I is received), the processing 
clock stops when the development is issued and resumes once the development is received. 
 
Consistent with section 10.6.19(I), the contractor shall document in PECOS any delays by 
identifying when the referral to CMS, the OIG, etc., was made, the reason for the referral, and 
when a response was received.  The contractor will thus be able to furnish explanatory 
documentation to CMS should applicable time limits be exceeded. To illustrate, assume that a 
contractor received an initial Form CMS-855I application on March 1. On March 30, the 
contractor sent a question to CMS and received a response on April 7. The processing time clock 
stops from March 31 to April 7. The contractor should document PECOS to explain that it 
forwarded the question to CMS, the dates involved, and the reason for the referral.  
 
2. Calendar Days  
 
Unless otherwise stated in this chapter, all days in the processing time clock are calendar days, 
not business days. If the final day of a metric falls on a weekend or holiday, this remains the 
day by which the application must be processed.  If the contractor cannot finish processing the 
application until the next business day, it should document in PECOS that the final day of the 
metric fell on a Saturday/Sunday/holiday and furnish any additional explanation as needed.  
  3. Date-Stamping  Paper Applications Only 
 
As a general rule, all incoming correspondence must be date-stamped on the day it was received 
in the contractors mailroom. This includes, but is not limited to:  
 
  Any Form CMS-855 or Form CMS-20134 application, including initials, changes, 
CHOWs, etc. (The first page of the application must be date-stamped.)  
 
  Letters from providers. (The first page of the letter must be date-stamped.) 
 
  Supporting documentation, such as licenses, certifications, articles of incorporation, and 
billing agreements. (The first page of the document or the envelope must be date-
stamped.)  
 
  Data that the provider furnishes (via mail or fax) per the contractors request for 
additional information. (All submitted pages must be date-stamped. This is because some 
contractors interleaf the new/changed pages within the original application. Thus, it is 
necessary to determine the sequence in which the application and the additional pages 
were received.)  
 
(Note: PECOS applications are considered date stamped on the date the application was 
received.) 
 
The timeliness clock begins on the date on which the application/envelope is date-stamped in the 
contractors mailroom, not the date on which the application is date-stamped or received by the 
provider enrollment unit. As such, the date-stamping activities described in the above bullets 
must be performed in the contractors mailroom. In cases where the mailroom staff fails to date-
stamp a particular document, the provider enrollment unit may date-stamp the page in question. 
However, there shall not be long lapses between the time it was received in the mailroom and the 
time the provider enrollment unit date-stamped the pages.  
 
In addition, and unless stated otherwise in this chapter or in another CMS directive, all incoming 
enrollment applications (including change requests) must be submitted via mail (unless 
circumstances require submission via fax or email).  
 
4. When the Processing Cycle Ends  
 
For (1) Form CMS-855A applications, and (2) Form CMS-855B applications submitted by 
ambulatory surgical centers (ASCs) or portable x-ray suppliers, the processing cycle ends on the 
date that the contractor enters a final status in PECOS (e.g., denied, returned, rejected, approval 
recommended) rather than the date on which the contractor sends formal notification of approval 
recommended, etc., to the state or SOG Location. (Note that accompanying applications (e.g., 
Form CMS-855R applications submitted with a Form CMS-855B for an ASC) would also end 
their processing cycle). 
  In situations involving a change request that does not require a recommendation (i.e., it need not 
be forwarded to and approved by the state), the cycle ends on the date that the contractor enters a 
final status (approved, denied, rejected, returned, etc.) in PECOS.  
 
For (1) Form CMS-855I applications, (2) Form CMS-855R applications, (3) Form CMS-855B 
applications from suppliers other than ASCs and portable x-ray suppliers, (4) Form CMS-20134 
and (5) Form CMS-855S applications the processing cycle ends on the date that the contractor 
enters a final status (approved, denied, rejected, returned, etc.) in PECOS.  
 
5. PECOS Applications 
 
See section 10.3 of this chapter for additional information on the processing of PECOS 
applications.    
 
10.6 -Additional Topics Pertaining to Medicare Enrollment  
(Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 
In reviewing the instructions in this section 10.6 et seq., the contractor shall be mindful of the 
PECOS 2.0 guidance in section 10.3 of this chapter.  Note that the latter instructions take 
precedence over the former with respect to PECOS matters. 
10.6.1  Certified Providers/ Certified Suppliers  
(Rev. 11125; Issued 11-18-21; Effective: 12-03-21; Implementation: 01-03-22) 
 
All references to the SOG Location (formerly the RO) in this section 10.6.1 et seq. refer to the 
applicable CMS Regional Offices Survey & Operations Group (SOG) Location.  Also, and 
except as otherwise indicated, all references to provider include certified suppliers (e.g., 
ambulatory surgical centers, portable x-ray suppliers). 
 
 
10.6.1.1  Changes of Ownership (CHOWs)  Transitioned Certified 
Providers and Suppliers  
 (Rev. 11432; Issued: 05-26-22; Effective: 05-27-22; Implementation: 05-27-22) 
 
 (Until further notice from CMS, the instructions in sections 10.6.1.1 through 10.6.1.1.4 
apply only to certified provider and certified supplier types that have officially 
transitioned as part of the transition of various certification activities from the SOG 
Location to the states, the contractors, and PEOG.  These provider/supplier types include 
SNFs, HHAs, CMHCs, CORFs, Part A OPT/OSP, ASCs, and PXRSs.  The contractor shall 
continue to use the existing CHOW instructions--now in section 10.6.22 of this chapter--for 
all non-transitioned certified provider/supplier types. 
 
When executing the instructions in sections 10.6.1.1 through 10.6.1.1.4, the contractor can 
disregard directives that obviously do not apply to the provider/supplier type in question 
(e.g., references to home health agencies do not apply to SNFs). 
   Except as otherwise noted, the term CHOW as used in section 10.6.1.1 et seq. includes 
CHOWs, acquisitions/mergers, and consolidations.  Though the Change of Ownership (CHOW) 
Information section of the Form CMS-855A separates the applicable transactions into CHOWs, 
acquisition/mergers, and consolidations for ease of disclosure and reporting, they fall within the 
general CHOW category under 42 CFR  489.18 (e.g., an acquisition/merger is a type of CHOW 
under  489.18). 
 
Note that the CHOW instructions in 10.6.1.1 through 10.6.1.1.4 apply to HHA CHOWs taking 
place under 42 CFR  489.18.  For changes in majority ownership under 42 CFR  424.550(b), 
see section 10.2.1.6.1 of this chapter. 
 
10.6.1.1.1  General Background on CHOWs  
(Rev. 11125; Issued 11-18-21; Effective: 12-03-21; Implementation: 01-03-22) 
 
A.   Overall Process 
 
CHOWs are officially defined in and governed by 42 CFR  489.18 and CMS Publication (Pub.) 
100-07, chapter 3, sections 3210 through 3210.5(C).  In the past, the SOG Location had made the 
determination as to whether a CHOW had occurred (unless this function was delegated).  The 
process now involves, in general (and with exceptions), the following: 
 
  The contractor sends the application (and all supporting documentation) and its 
recommendation for approval (if applicable) to the state agency (hereafter simply state) for 
review 
  The state notifies the contractor of its recommendation  
  The contractor notifies the CMS Provider Enrollment & Oversight Group (PEOG) of the 
recommendation.  PEOG signs the provider agreement and performs other administrative 
functions pertaining to the CHOW application 
  Once PEOG completes the required administrative actions, PEOG will notify the contractor 
thereof  
  The contractor completes processing and notifies the provider of the approval of the 
transaction using the appropriate model letter (sending a copy thereof to the state and SOG 
Location (and, if applicable, accrediting organization) 
 
(Thus, and except as otherwise stated in section 10.6.1.1 et seq., SOG Locations are no longer 
directly involved in the CHOW process for applications received on or after MMDDYY.  SOG 
locations will, however, continue to provide policy-related assistance regarding CHOWs.) 
 
Specific details on these steps are outlined in section 10.6.1.1 et seq.  
 
Note that although certified suppliers are not explicitly referenced in  489.18, the principles of 
this regulatory provision are generally applied to these suppliers. 
 
B.  Governing Regulations 
 
Pursuant to  489.18(a)(1) through (a)(4) (and as outlined in more detail below), the following 
situations generally constitute a CHOW:   
(1) Partnership  The removal, addition, or substitution of a partner (unless the partners 
expressly agree otherwise), as permitted by applicable state law.  
 
(2) Unincorporated sole proprietorship - Transfer of title and property to another party 
constitutes a CHOW.   
(3) Corporation  (i) The merger of the provider corporation into another corporation; or (ii) the 
consolidation of two or more corporations that results in the creation of a new corporation.  
(4) Leasing - The lease of all or part of a provider facility constitutes a change of ownership of 
the leased portion. 
 
(See section 10.6.1.1.2 below for more detailed information on the types of transactions that can 
constitute a CHOW.) 
 
Under  489.18(c) and Pub. 100-07, chapter 3, section 3210, when there is a CHOW, the existing 
provider agreement is automatically assigned to the new owner unless the new owner rejects 
assignment of the provider agreement.  If the new owner rejects this assignment, the provider 
cannot participate in Medicare without going through the same process as any new provider 
(e.g., initial enrollment, undergoing a state survey).  Automatic assignment of the existing 
provider agreement to the new owner means the new owner is subject to all the terms and 
conditions under which the existing agreement was issued.   
 
10.6.1.1.2  Examples of CHOW and Non-CHOW Situations 
(Rev. 11125; Issued 11-18-21; Effective: 12-03-21; Implementation: 01-03-22) 
 
A.  Introduction 
 
Pub. 100-07, chapter 2, section 3210.1D outlines in detail certain types of transactions (based on 
business type) that involve (or do not involve) a CHOW.  This list is not exhaustive, however, 
and CMS recognizes that scenarios may arise that do not fall within the normal/typical categories 
of CHOW transactions.  Indeed, it is not possible for CMS to address in these instructions every 
conceivable case.  Hence, if the contractor is uncertain as to how to handle a situation that could 
involve a CHOW under 42 CFR  489.18, it may contact its PEOG BFL for assistance or the 
SOG location representative.  
 
In reviewing this section 10.6.1.1.2, the contractor should keep in mind the following: 
 
1. Other Business Types - Although  489.18 addresses only sole proprietorships, partnerships, 
corporations, and lease arrangements, other types of business entities (such as limited liability 
companies (LLCs)) can have CHOWs.  These entities will be identified within the category in 
section 10.6.1.1.2(B) to which they are most applicable. 
 
2.  Assignment  Any statement in section 10.6.1.1.2(B) that a particular business transaction 
constitutes a CHOW assumes that the new owner accepted assignment of the provider 
agreement.  In cases where a  489.18-type business transaction occurred but assignment was not 
accepted (as discussed in detail in section 10.6.1.1.3.2 below): (a) no CHOW has taken place; (b)  the provider agreement does not transfer; and (c) the entity must enroll as a brand new provider. 
Moreover, the existing owner must voluntarily terminate the providers enrollment and 
agreement consistent with existing regulations and the policies in this chapter.  
 
3.  CHOW Categories on the Form CMS-855A - For purposes of provider enrollment only, there 
are three main categories of CHOWs captured on the Form CMS-855A application:  
 
a. Standard CHOW - This occurs when a providers CMS Certification Number (CCN) and 
provider agreement are transferred to another entity as a result of the latters purchase of the 
provider.  To illustrate, suppose Entity A is enrolled in Medicare, but Entity B is not.  B acquires 
A.  Assuming all regulatory requirements are met, As provider agreement and CCN will transfer 
to B. 
 
This is the most frequently encountered change of ownership scenario.  As explained in section 
10.6.1.1 et seq., even though it is technically an acquisition (i.e., B bought/acquired A) under  
489.18, this situation falls under the CHOW category  as opposed to the 
Acquisition/Merger category  on the Form CMS-855A. 
 
b.   Acquisition/Merger - In general, this occurs when two or more Medicare-enrolled entities 
combine, leaving only one remaining CCN and provider agreement.  For instance, suppose 
Entity A and Entity B are both enrolled in Medicare, each with its own CCN and provider 
agreement.  The two entities decide to merge.  Entity Bs CCN and provider agreement will be 
eliminated (leaving only Entity As CCN and provider agreement). 
 
If the acquisition results in an existing provider having new owners but keeping its existing 
provider number, the applicant should check the CHOW box in the Basic Information section of 
the Form CMS-855A. 
 
Unlike the new owner in a CHOW or consolidation, the new owner in an acquisition/merger 
need not complete the entire Form CMS-855A.  This is because the new owner is already 
enrolled in Medicare.  As such, the provider being acquired should be reported as a practice 
location in the Practice Location Information section of the new owners Form CMS-855A. 
 
c.   Consolidations - This occurs when the merger of two or more Medicare-enrolled entities 
results in the creation of a brand new entity. To illustrate, if Entities A and B decide to combine 
and, in the process, create a new entity (Entity C), the CCNs and provider agreements of both A 
and B will be eliminated.  Entity C will have its own CCN and provider agreement. 
 
Note the difference between acquisitions/mergers and consolidations.  In an acquisition/merger, 
when A and B combine there is one surviving entity.  In a consolidation, when A and B combine 
there are no surviving entities.  Rather, a new entity is created  Entity C. 
 
Regardless of which of these three categories the particular transaction falls under on the Form 
CMS-855A, the central issue for the contractor is whether a CHOW has occurred pursuant to  
489.18.  In other words, the question of how the transaction is reported on the application is less 
important than the determination as to whether the CHOW requirements have been met.  Indeed, 
merely because the provider reports a transaction as a  489.18 CHOW on the Form CMS-855 
does not mean that one has legally occurred.  The contractor will therefore (as discussed below)  have to carefully analyze the scenario and legal documentation to ascertain whether a CHOW is 
involved. 
 
4.  Continued Responsibility  In ascertaining whether a CHOW has occurred, another important 
consideration for the contractor is whether the owning entity/individual is (or is no longer) 
responsible for the provider and its operations.  If some form of ownership change has occurred 
but the same individual/entity (e.g., the same corporation) generally remains as the principal 
owner of the provider, no CHOW has occurred; except as otherwise stated in this chapter, 
therefore, the transaction should be treated as a change of information. 
 
5.  Change in Process  Notwithstanding the expanded CHOW instructions in this section 
10.6.1.1 et seq., the contractor should remember that the only changes to the CHOW process are 
generally as follows: 
 
  The SOG location no longer makes the formal determination as to whether a CHOW has 
occurred.   
  If the contractor recommends approval of the CHOW, it forwards the application to the state 
only (not to the SOG Location) 
  If the state recommends approval to the contractor, the contractor coordinates with PEOG (as 
described below) 
  After PEOG responds to the contractor, the contractor finalizes the application  
 
Except as otherwise stated in these instructions, therefore, the contractor shall continue to follow 
the procedures it has in the past. 
 
B.  CHOWs by Business Type 
 
(See section 10.6.4 of this chapter for basic information on the forms of business structures 
frequently encountered in provider enrollment.) 
 
The scenarios below are not an exhaustive list of all the types of CHOWs that may or may not 
occur.  Furthermore, the following situations may have different, unique facts that could raise 
questions as to whether a CHOW has indeed taken place.  The contractor will thus encounter 
CHOW cases not precisely addressed in these instructions and, if uncertain regarding how they 
should be handled, may contact its PEOG BFL for guidance.  
 
1.   Sole Proprietorship 
 
If the provider is an entity owned by a single individual, a transfer of title to the enterprise to 
another person or firm (whether or not this includes transfer of title to the real estate) constitutes 
a CHOW.  It is also a CHOW if the former owner becomes one of the members of a partnership 
or corporation succeeding him/her as the new owner (e.g., Mr. Jones is the sole proprietor of 
Provider X, and he sells the business to a corporation of which he will become a shareholder).   
 
As discussed in section 10.6.4 of this chapter, a sole proprietorship is neither a solely-owned 
corporation nor a solely-owned LLC (e.g., an LLC with only one owner/member remains an 
LLC and is not a sole proprietorship simply because there is only a single owner/member).   
2.  Partnership 
General partnership (i.e., a partnership with no limited partners) - In a general partnership, the 
removal, addition, or substitution of an individual/entity as a partner in the entity dissolves the 
partnership unless: (1) state law holds otherwise; or (2) the partnership agreement expressly 
states otherwise.  If the partnership is indeed dissolved based on a partners 
removal/addition/substitution, a new partnership is created and a CHOW has occurred.  
 
Limited partnership  The departure/replacement of a general partner in a limited partnership 
will often result in the dissolution of the limited partnership, the creation of a new one, and the 
occurrence of a CHOW; these results typically do not stem from the departure or replacement of 
a limited partner.  In either case, the contractor shall carefully examine the relevant documents 
(e.g., the Form CMS-855, limited partnership agreement) to see if the limited partnership has 
undergone a CHOW.      
 
3 - Corporation 
(For purposes of this section 10.6.1.1.2 only, and unless stated otherwise: (1) the term 
corporation includes LLCs; and (2) the term stock includes LLC ownership interests.  Thus, 
a reference to the merger of two corporations could include, for instance, the merger of an LLC 
with a corporation to create a brand new LLC or corporation.) 
 
A merger of one or more corporations into the surviving Medicare-participating provider 
corporation (i.e., a merger into the participating corporation) is not recognized as a CHOW of 
the surviving corporation.  However: 
 
  If the corporation that survives is not the former owner of the provider entity, there is a 
CHOW; and 
 
  Consolidation or merger of two or more corporations that results in the creation of a new 
corporate entity having ownership/control over a provider organization constitutes a CHOW.  
 
4 - Leasing 
 
When all or part of a provider facility is leased, it constitutes a CHOW.  If only part of the 
provider is leased, the original provider agreement remains in effect only with respect to the 
unleased portion.  The lease of part of the facility constitutes a CHOW.   
 
10.6.1.1.3  Ascertaining Whether a CHOW Has Occurred  
(Rev. 11125; Issued 11-18-21; Effective: 12-03-21; Implementation: 01-03-22) 
 
Sections 10.6.1.1.3.1, 10.6.1.1.3.2, and 10.6.1.1.3.3 outline the general steps the contractor must 
undertake in a potential CHOW situation.  The contractor should also review sections 
10.6.1.1.3.1.1 and 10.6.1.1.4 below regarding special circumstances that might occur when 
performing these steps.  In addition, nothing in this section 10.6.1.1.3 et seq. prohibits the  contractor from returning or rejecting the application if grounds for doing so under this chapter 
10 exist.   
 
Except as otherwise stated, the instructions in this section 10.6.1.1.3 et seq. apply to both Form 
CMS-855A and Form CMS-855B applications from certified providers. 
 
10.6.1.1.3.1  Step 1 - Initial Review of the CHOW Application 
(Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Process 
 
Upon receipt of a Form CMS-855 CHOW application, the contractor shall undertake the 
following (in whichever order the contractor prefers): 
 
(i)  Ensure that all data validations otherwise required per this chapter have been 
performed.    
 
(ii)  Ensure that the submitted application(s) is complete consistent with the instructions in 
this chapter. 
 
(iii)  Ensure that the provider has submitted all documentation otherwise required per this 
chapter.  For CHOW purposes, this also includes the following: 
 
(a) Legal Documentation of CHOW - The legal documents that governed the transaction, such as 
a sales agreement, bill of sale, or transfer agreement.  (See section 10.6.1.1.3.1.1 below for more 
information on such documents.)  
  
(b) Form CMS-1561 (Health Insurance Benefit Agreement).  (In lieu of the Form CMS-1561, 
rural health clinics (RHCs) must submit the Form CMS-1561A and ambulatory surgical centers 
(ASCs) must submit the Form CMS-370.)  (See https://www.cms.gov/Medicare/CMS-
Forms/CMS-Forms/CMS-Forms-List for more information.)  These forms are generally known 
as provider agreements and supplier agreements, as applicable. 
 
(c) Evidence of state licensure, if applicable.  (This can be furnished consistent with existing 
instructions in this chapter concerning submission of evidence of state licensure.) 
 
(d) Evidence of successful electronic submission of the Form HHS-690 through the Office of 
Civil Rights (OCR) portal, as applicable.  (Evidence should be either written or electronic 
documentation.) (See https://www.hhs.gov/sites/default/files/forms/hhs-690.pdf for more 
information.)   
 
(e) Applicable CMS Form that requests certification in Medicare.  (These include, for example, 
CMS-377 for ASCs, CMS-3427 for end-stage renal disease (ESRD) facilities, etc.) (See 
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List for more 
information.)   
  (f) Form CMS-1539 - Medicare/Medicaid Certification and Transmittal 
(https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS011722). 
 
(g) Form CMS-2567  Statement of Deficiencies and Plan of Correction 
(https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS008860).   
 
(h) For skilled nursing facilities (SNFs), a signed patient transfer agreement.  (See 
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertEmergPrep/Downloads/Facility-Transfer-Agreement-Example.pdf for 
an example.)   
 
(The provider must complete, sign, date, and include the applicable CMS forms described in this 
subsection (A)(iii); the provider need not, of course, complete those sections of the forms that are 
reserved for CMS.  For organizational providers, an authorized official (as defined in  424.502) 
must sign the forms; for sole proprietorships, the sole proprietor must sign.)   
 
Notwithstanding the foregoing, if any document in subsection (A)(iii)(b), (d), (e), (f), (g), or (h) 
above is missing, unsigned, undated, or otherwise incomplete, the contractor need not develop 
for the form(s) or the information thereon; the contractor shall instead notify the state in its 
recommendation letter which document(s) was/were missing or otherwise incomplete.  For all 
other missing or incomplete required documentation, the contractor shall follow the normal 
development instructions in this chapter.   
 
Note that if the application is rejected and this results in the expiration of the applicable time 
period for reporting the change (e.g., 30 days), the contractor shall e-mail its PEOG BFL 
notifying him/her of the rejection.  PEOG will determine whether the providers/suppliers 
billing privileges should be deactivated under  424.540(a)(2) or  424.550(b)(2) or revoked 
under  424.535(a)(1) or (a)(9).  PEOG will notify the contractor of its decision. 
 
(iv) Ascertaining whether a formal  489.18 CHOW has occurred  This involves performing 
all necessary background research, which can include:   
 
  Reviewing the sales or lease agreement  
  Reviewing the ownership information in Sections 2, 5, and 6 of the Form CMS-855A (or 
Sections 5 and 6 of the Form CMS-855B) 
  Reviewing whether the provider checked Yes or No to the question in Section 2 of the 
Form CMS-855A concerning the acceptance of assignment of the provider agreement.   
  Contacting the provider(s) to request clarification of the sales agreement, etc.  (Unless 
otherwise stated in this chapter, the provider must furnish any such clarification in writing; e-
mail (including the PCV) is acceptable.) 
 
(v) As applicable, take into account the supplemental instructions in sections 
10.6.1.1.3.1(B), 10.6.1.1.3.1.1 and 10.6.1.1.4 of this chapter. 
 
B. Additional Instructions 
  1.  TIN Change - While a CHOW is typically accompanied by a TIN change, this is not always 
the case.  On occasion, the TIN remains the same; conversely, sometimes the provider is 
changing its TIN but not its ownership.  In short, while a change of TIN (or lack thereof) is 
evidence that a CHOW may or may not have occurred, it is not the most important factor; rather, 
the change in the providers ownership arrangement is the central issue.  Hence, the contractor 
shall review the sales/lease agreement closely, for this will help indicate whether a CHOW has 
occurred.  Again, CMS stresses that the terms and conditions of the sales agreement are the 
primary indicator of the existence or non-existence of a CHOW. 
 
2.  Request for Information and/or Clarification  If, after its initial review under subsection (A), 
the contractor remains uncertain as to whether a CHOW has taken place, the contractor: (i) 
reserves the right to request any clarifying information from the provider (e.g., additional 
documentation concerning the sale); and/or (ii) may contact its PEOG BFL or the SOG Location 
for assistance.  (This may include situations where, for instance, (i) the provider believes that the 
transaction is merely a stock transfer but the contractor disagrees, and (ii) the contractor is 
uncertain whether the provider is accepting assignment.)   
 
3.  Acceptance of Assignment  Regardless of the providers response to the Form CMS-855 
question concerning whether the provider accepts assignment, the contractor shall review the 
sales/transfer agreement and any other documentation to confirm whether the providers 
response is consistent with the agreement.  (For example, if the provider responds no to the 
question, the contractor shall review the sales agreement to ensure consistency.)  If an 
inconsistency is discovered, the contractor shall contact the provider for clarification. 
 
4.  Situations Requiring Referral to PEOG  The contractor shall refer the case and all supporting 
documentation (e.g., sales agreement) to its PEOG BFL in either of the following situations:  
 
  The provider reports a CHOW based strictly on a relinquishment by the owner of all 
authority and responsibility for the provider organization without a  489.18-level change of 
ownership.  (For instance, the sales agreement indicates that the provider is selling only 10% 
of its ownership stake but the provider claims the transaction is a CHOW because it is 
relinquishing all control of the provider to the party to which its 10% ownership share is 
being sold.) 
  It appears the owner of a provider is entering into a franchise agreement with a corporate 
chain (and thus uses the chains name). 
 
10.6.1.1.3.1.1  Special Processing Instructions and Considerations for the 
Initial Review Process 
(Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A. Form CMS-855A  Old and New Owner Applications 
 
Unless stated otherwise in this chapter: 
 
  The contractor shall ensure that all applicable sections of the Form CMS-855A for both the 
old and new owner are completed in accordance with the instructions on the Form CMS-855A.  
     The instructions in this section 10.6.1.1.3.1.1(A) apply only to the Form CMS-855A. 
 
1.  Previous Owner(s) 
 
The previous owners Form CMS-855A CHOW application does not require a recommendation 
for approval.  Any recommendations will be based on the CHOW application received from the 
new owner. 
 
If the previous owner's Form CMS-855A is available at the time of review, the contractor shall 
examine the information therein against the new owners Form CMS-855A to ensure consistency 
(e.g., same names).  If the previous owner's Form CMS-855A has not been received, the 
contractor shall contact the previous owner and request it.  However, the contractor may begin 
processing the new owners application without waiting for the arrival of the previous owners 
application.  It may also make its CHOW recommendation to the state without having received 
the previous owners Form CMS-855A.   
 
If a certification statement is not on file for the individual signing the previous owners 
application, the contractor shall request that the Individual Ownership and/or Managing Control 
section of the Form CMS-855A be completed for said person.   
 
Note that the previous owners Form CMS-855A CHOW application is essentially the equivalent 
of a Form CMS-855A voluntary termination submission; this is because the old owner is 
voluntarily leaving the Medicare program.  As such, the contractor shall not require the old 
owner to submit a separate Form CMS-855A voluntary termination along with its Form CMS-
855A CHOW application. 
 
2.  New Owner 
 
If a Form CMS-855A is not received from the new owner within 14 calendar days of receipt of 
the old owners Form CMS-855A, the contractor shall contact the new owner.  If, within 30 
calendar days after the contractor contacted it, the new owner fails to (1) submit a Form CMS-
855A and (2) indicate that it accepts assignment of the provider agreement, the contractor shall 
send an e-mail to its PEOG BFL notifying him/her of the situation. PEOG will determine 
whether the providers billing privileges should be deactivated under  424.540(a)(2) or  
424.550(b) or revoked under  424.535(a)(1) or (a)(9).  PEOG will notify the contractor of its 
decision. 
 
In the situations described in the previous paragraph where the contractor is awaiting the new 
owners application after received the old owners, the contractor shall: (1) begin processing the 
old owners application; and (2) if possible, ascertain whether a CHOW has taken place.   
 
3.  Order of Processing of Old/New Owner Applications 
 
To the maximum extent practicable, Form CMS-855A applications from the previous and new 
owners in a CHOW should be processed as they arrive.  However, unless the instructions in this 
chapter indicate otherwise, the contractor should attempt to send the previous and new owners 
applications to the state simultaneously, rather than as soon as they are processed.  For instance,  suppose the previous owner submits an application on March 1.  The contractor should begin 
processing the application immediately without waiting for the arrival of the new owners 
application.  Yet the contractor should avoid sending the previous owners application to the 
state until the new owners application is processed.  (For acquisition/mergers and consolidations 
(as those terms are described on the Form CMS-855A), the contractor may send the applications 
to the state separately.)  
 
4.  Form CMS-855A: CHOWs Involving Subtypes 
 
a.  Separate Reporting 
 
Any subunit that has a separate provider agreement must report its CHOW on a separate Form 
CMS-855A.  It cannot report the CHOW via the main providers Form CMS-855A.  If the 
subunit does not have a separate provider agreement (e.g., hospital psychiatric unit), the CHOW 
can be disclosed on the main providers Form CMS-855A; this is because the subunit is a 
practice location of the main provider and not a separately enrolled entity.  
 
b.  Change in Subtype 
 
A CHOW may occur in union with a change in the facilitys provider subtype.  This can happen, 
for instance, when a hospital undergoes a CHOW and changes from a general hospital to another 
type of hospital, such as a psychiatric hospital.  Although a change in hospital type is considered 
a change of information (COI), the provider need not submit separate applications  one for the 
COI and one for the CHOW.  Instead, all information (including the change in hospital type) 
should be reported on the CHOW application; the entire application should then be processed as 
a CHOW (assuming it indeed qualifies as such).  However, if the facility is changing from one 
main provider type to another (e.g., hospital converting to a skilled nursing facility) and also 
undergoing a CHOW, the provider must submit its application as an initial enrollment.  The 
contractor shall notify the provider of this and return the application.     
 
(NOTE:  For Medicare purposes, a critical access hospital (CAH) is a separately-recognized 
provider type.  Thus, a general hospital undergoing a CHOW while converting to a CAH must 
submit its Form CMS-855A as an initial enrollment, not as a CHOW.)   
 
5.  Transitioning to Provider-Based Status (Form CMS-855A Submissions Only) 
 
Consistent with existing CMS policy, a provider undergoing a CHOW pursuant to 42 CFR 
 489.18 may be assigned to a new contractor jurisdiction only if the provider is 
transitioning from freestanding to provider-based status.  In such cases, the contractor for 
the new jurisdiction (the new contractor) shall process both the old and new owners 
Form CMS-855A applications.  Should the old/previous (or current) contractor receive 
the old and/or new owners Form CMS-855A applications, it shall (a) forward the 
application to the new contractor within 5 business days of receipt and (b) notify the new 
contractor within that same timeframe that the application was sent. 
 
B.  Sales and Lease Agreements 
  Except as indicated otherwise, this subsection (B) applies to Form CMS-855A and Form CMS-
855B applications. 
 
1.  Verification of Terms  
 
The contractor shall ascertain whether: (1) the sales/lease agreement includes the signatures of 
the old and new owners, for the agreement must contain the signatures of both parties to the 
transaction (if it does not, the contractor shall develop for an agreement containing both 
signatures); (2) the information contained in the sales agreement is consistent with that reported 
on the new owner's Form CMS-855A or the submitted Form CMS-855B (e.g., same names, 
effective date); (3) the terms of the contract indicate that the new owner will accept assignment 
of the provider agreement; and (4) the transaction falls within the scope of organizational 
transactions covered under  489.18 and this section 10.6.1.1 et seq.   
 
(Note that a bill of sale/lease agreement/sales transfer agreement is a sales/lease business 
document and should not be confused with a patient transfer agreement.) 
 
A sales/lease agreement often will not specifically refer to the Medicare provider agreement, 
assets, and liabilities.  However, if (1) the box in the Change of Ownership (CHOW) Information 
section of the Form CMS-855A is checked "Yes" and (2) the sales/lease agreement either 
confirms that the new owner will accept assignment or is relatively silent on the matter, the 
contractor can proceed as normal.  If the agreement indicates that assignment will not be 
accepted, however, the contractor shall follow the instructions in section 10.6.1.1.3.2(A) below.   
 
As previously mentioned, any clarifying data must be furnished in writing (e.g., additional legal 
documentation, letter, e-mail).  If the clarification  for whatever reason - requires an update to 
the suppliers Form CMS-855 application, the contractor shall request the submission of said 
update.  In addition, if the contractor discovers discrepancies between the data in the sales 
agreement and that on the Form CMS-855, the contractor shall seek clarifying information and, 
if necessary, obtain an updated Form CMS-855. 
 
2.  Form of Sales/Lease Agreement  
 
There are instances where the parties in a CHOW did not sign a sales or lease agreement in 
the conventional sense of the term; the parties, for example, might have documented their 
agreement via a bill of sale.  The contractor can accept such documentation in lieu of a 
sales/lease agreement so long as (1) the document addresses the transactions terms and (2) the 
information in the agreement is consistent with that on the Form CMS-855 (as discussed above). 
 
3.  Submission of Sales/Lease Agreement  
 
a.  General Requirements  Unless specified otherwise in this chapter: (i) both the previous and 
new owners in a Form CMS-855A CHOW situation must submit copies of the interim and final 
sales/lease agreements; and (ii) copies of the interim and final sales/lease agreement must be 
submitted in Form CMS-855B CHOW situations. 
 
b.  Forwarding to State - The contractor shall not forward a copy of the application to the state 
until it has received and reviewed the final sales/lease agreement.  However, the contractor need  not reverify the information on the Form CMS-855 while waiting for the final agreement, even if 
the data therein may be somewhat outdated by the time the final agreement is received. 
 
c.  Failure to Submit - If a final sales/lease agreement is not submitted within 30 days after the 
contractors receipt of the new owners application, the contractor shall reject the application.  
Though the contractor must wait until the 30th day to reject the application, the contractor may 
proceed with rejection regardless of how many times it contacted the new owner or what types of 
responses (short of the actual receipt of the agreement) were received. 
 
C.  Relocation of Entity 
 
A new owner may intend to relocate the provider concurrent with a CHOW.  If the relocation is 
to a site in a different geographic area serving different clients than previously served and 
employing different personnel to serve those clients, the contractor shall notify the state via e-
mail immediately.  If the state believes that this situation has resulted in the effective creation of 
a new provider, the contractor shall return the application and notify the new owner that a new, 
initial enrollment application must be submitted.  The provider must also notify the state or, if 
applicable, accreditation agency.  
 
D.  Intervening Change of Ownership  
 
In situations where the provider (1) submits a Form CMS-855 initial application or CHOW 
application and (2) subsequently submits a Form CMS-855 CHOW application before the 
contractor has finalized the first application, the contractor shall adhere to the following: 
 
Situation 1  The provider submitted an initial application followed by a CHOW application, and 
a recommendation for approval to the state has not yet been made for the initial application: The 
contractor shall return both applications and require the provider to re-submit an initial 
application with the new owners information. 
 
Situation 2 - The provider submitted a CHOW application followed by another CHOW 
application, and a recommendation for approval to the state has not yet been made for the first 
CHOW application: The contractor shall process both applications  preferably in the order they 
were received  and shall, if recommendations for approval are warranted, refer both 
applications to the state in the same package.  The accompanying notice/letter to the state shall 
explain the situation. 
 
Situation 3 - The provider submitted an initial application followed by a CHOW application, and 
a recommendation for approval of the initial application has been made to the state  The 
contractor shall: 
 
  Return the CHOW application. 
 
  Notify the state via e-mail that a change of ownership has occurred (the new owner should be 
identified) and that the contractor will require the new provider to resubmit a new initial 
application containing the new owners information. 
     Request via letter that the provider submit a new initial Form CMS-855 application 
containing the new owners information within 30 days of the date of the letter.  If the provider 
fails to do so, the contractor shall return the originally submitted initial application and notify the 
provider and the state of this via letter.  If the provider submits the requested application, the 
contractor shall process it as normal and, if a recommendation for approval is made, send the 
revised application package to the state with an explanation of the situation; the originally 
submitted initial application becomes moot. If the newly submitted/second initial application is 
denied, however, the first submitted application is denied as well; the contractor shall notify the 
provider and the state accordingly. 
 
Situation 4 - The provider submitted a CHOW application followed by another CHOW 
application, and a recommendation for approval has been made for the first application - The 
contractor shall: 
 
  Notify the state via e-mail that (1) a subsequent change of ownership has occurred (the new 
owner should be identified) and (2) the contractor will require the provider to resubmit a new 
CHOW application containing the subsequent/second new owners information. 
 
   Process the new/second CHOW application as normal. If a recommendation for approval is 
made, the contractor shall send the revised CHOW package to the state with an explanation of 
the situation; the first CHOW application becomes moot.  If the newly submitted/second CHOW 
application is returned per section 10.6.1.1.3.2 below, the first application should, too, be 
returned.  The contractor shall notify the provider and the state accordingly. 
 
E.  Potential CHOW  
 
On occasion, a provider or supplier submits a Form CMS-855 change of information to report a 
large-scale stock transfer or other significant ownership change that the provider does not believe 
is (or report as) a CHOW.  If the contractor suspects that the transaction in question might indeed 
be a CHOW, it shall request clarifying information (e.g., copy of the stock transfer agreement). 
 
F.  Entry into PECOS - Paper Applications Only 
 
If it appears that the new owner will be accepting assignment and that the transaction falls within 
the scope of  489.18, the contractor shall enter the CHOW information into the new enrollment 
record that shall be created for the new owner.  (If the state recommends approval of the CHOW 
(see section 10.6.1.1.3.3 below), the Part A providers CCN will be maintained in the new 
owners enrollment record once the record is switched to an approved status.) 
 
A new enrollment record must be created if a new TIN is established pursuant to the CHOW.  
 
(For PECOS applications, PECOS will automatically perform the enrollment record activities 
described in this subsection (F).)   
 
10.6.1.1.3.2  Step 2  Post-Initial Review Actions and Scenarios 
(Rev. 11125; Issued 11-18-21; Effective: 12-03-21; Implementation: 01-03-22) 
  After the contractor completes the tasks in section 10.6.1.1.3.1, several results are possible.  
These are discussed below.  Should the contractor encounter a scenario not addressed herein, it 
may contact its PEOG BFL for guidance.  As a reminder, nothing in section 10.6.1.1.3.2 
prohibits the contractor from returning or rejecting the application if otherwise permitted to do so 
per this chapter.    
 
A.   Scenarios 
 
1.   The contractor ascertains that the transaction falls within the scope of  489.18 and that the 
new owner has accepted assignment  If there are no apparent grounds for denying the 
application (e.g., the new owner has a felony conviction, false information was submitted, a 
newly reported chief executive officer is excluded), the contractor shall make a recommendation 
for approval to the state consistent with existing practice and via existing means.  (This includes 
sending recommendations via hard copy mail if the state only accepts this method of 
transmission.)  If a denial ground exists, however, the contractor shall refer the matter to its 
PEOG BFL for guidance before submission to the state, notwithstanding any other instruction in 
this chapter to the contrary. The contractor should include an explanation of the ground(s) it 
believes exists for the denial (including the regulatory citation). 
 
(For Form CMS-855B CHOW applications: Note that an approval recommendation can be made 
(and must be treated as a CHOW) notwithstanding the general rule that a TIN change constitutes 
an initial enrollment; in other words, the reporting rules regarding CHOWs/assignments in this 
particular situation take precedence over the change of TIN principle.) 
 
2.  The contractor ascertains that the transaction falls within the scope of  489.18 but the new 
owner has not accepted assignment  The contractor shall:  
(a) return the application; and (b) notify the new owner in the return letter that it must submit the 
following within 30 days from the date of the return letter: (i) an initial Form CMS-855 
application to enroll as a new provider; and (ii) a voluntary termination application for the 
existing provider.  If the new owner fails to do so within 30 days of the request, the contractor 
shall contact its PEOG BFL via e-mail with this information notwithstanding any other 
instruction to the contrary in this chapter.  PEOG will review the matter and respond to the 
contractor. 
 
3.  The contractor ascertains that the transaction does not fall within the scope of  489.18 (e.g., 
stock transfer), regardless of whether the new owner accepted assignment - This qualifies as an 
ownership change under 42 CFR  424.516 rather than a CHOW under  489.18.  The contractor 
shall: (a) return the application; and (b) notify the provider in the return letter that it must submit 
a Form CMS-855 application to report the ownership change within 30 days of the return letter.  
If the provider fails to do so, the contractor shall contact its PEOG BFL via e-mail with this 
information notwithstanding any other instruction to the contrary in this chapter. 
 
(The only exception to the policies in the previous paragraph is if (1) the submission is a Form 
CMS-855B and (2) the  424.516 ownership change also involves a change of TIN.  In this 
scenario, the contractor shall: (a) return the application; and (b) notify the supplier in the return 
letter that it must submit the following within 30 days from the date of the return letter: (i) an 
initial Form CMS-855B application to enroll as a new supplier; and (ii) a voluntary termination 
application.  If the supplier fails to do so, the contractor shall contact its PEOG BFL the  contractor shall contact its PEOG BFL via e-mail with this information notwithstanding any 
other instruction to the contrary in this chapter. 
 
B.  Referral to State   
 
If the contractor believes that a recommendation for approval per section 10.6.1.1.3.2(A)(1) is 
warranted, it shall send a recommendation letter to the state (with a copy to the accreditation 
organization (AO), if applicable). The letter shall follow the format of existing model CHOW 
recommendation letters in section 10.7 et seq. of this chapter.  (Neither the SOG Location nor 
PEOG need be copied on the letter.)  The CHOW package shall: (1) be sent to the state in a 
manner consistent with existing and past practice; and (2) contain all the applicable documents 
described in section 10.6.1.1.3.1(A)(iii) above.  (For instance, the package must include, among 
other things, the CMS-377 for ASC and the CMS-3427 for ESRD facilities.)   
 
The state will: (1) review the package for completeness; (2) review the contractors 
recommendation for approval; (3) perform any state-specific functions; and (4) contact the 
contractor with any questions.  The contractor shall respond to any state inquiry in Item (4) 
within 5 business days.  If the inquiry involves the need for the contractor to obtain additional 
data, documentation, or clarification from the provider, however, the timeframe is 15 business 
days; if the provider fails to respond to the contractor within this timeframe, it shall notify the 
state thereof.  The contractor may always contact its PEOG BFL should it need the latters 
assistance with a particular state inquiry. 
 
10.6.1.1.3.3  Step 3  Post-State Review Actions and Scenarios 
(Rev. 11432; Issued: 05-26-22; Effective: 05-27-22; Implementation: 05-27-22) 
 
The state will notify the contractor once it has completed the tasks identified in section 
10.6.1.1.3.2(B) above (normally within 90 days of receiving the package from the contractor).  In 
general, there are two potential outcomes: 
 
A.  Approval Not Recommended 
 
If the state does not recommend approval, it will notify the contractor thereof.  The contractor 
may accept the notification so long as it is in writing (e-mail is fine).  No later than 5 business 
days after receiving this notification, the contractor shall send an e-mail to 
MedicareProviderEnrollment@cms.hhs.gov with the following information and documents: (1) 
the Form CMS-855 application or PECOS Application Data Report; (2) a copy of the final 
sales/transfer agreement; and (3) a copy of the Form CMS-1539 or similar documentation 
received from the state.  PEOG will review the matter, perform any administrative functions, and 
respond to the contractor with applicable direction. 
 
B.  Approval Recommended 
 
If the state recommends approval, it will typically (though not always) do so via a Form CMS-
1539; the contractor may accept any documentation from the state signifying that the latter 
recommends approval.  (Note that the contractor will not receive a tie-in or tie-out notice, neither 
of which are issued any longer for CHOWs.)   
No later than 5 business days after receipt of the recommendation, the contractor shall send an e-
mail to MedicareProviderEnrollment@cms.hhs.gov with the following information and 
documents: (1) the Form CMS-855 application (or PECOS Application Data Report) and all 
application attachments; (2) a copy of the final sales/transfer agreement; (3) a copy of the Form 
CMS-1539 or similar documentation received from the state; (4) a copy of the provider-signed 
Form CMS-1561/1561A/370 (as applicable); (5) a copy of the Form HHS-690; and (6) a copy of 
the draft approval letter, with the effective date shown on the Form CMS-1539 (or similar 
documentation) included in the draft letter.  PEOG will countersign the provider agreement, 
assign an effective date of the CHOW based on the information received from the contractor, and 
approve the draft letter (with possible edits).   
 
Within 5 business days of receiving from PEOG the signed provider agreement and effective 
date, the contractor shall: (1) send the CHOW approval letter and a copy of the CMS-
countersigned provider agreement to the provider (with a copy to the AO, if applicable); and (2) 
switch the PECOS record from approval recommended to approved consistent with existing 
instructions. 
 
10.6.1.1.4  Additional CHOW Processing Policies  
(Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
Except as otherwise stated, the instructions in this section 10.6.1.1.4 apply to the Form CMS-
855A and Form CMS-855B. 
 
A.  Payment Changes - In a CHOW, the contractor shall continue to pay the old owner until it 
receives from PEOG the e-mail, effective date, and signed provider agreement referenced 
in Section 10.6.1.1.3.3(B).  Hence, any application from the old owner or new owner to change 
the EFT account or special payment address to that of the new owner shall be returned.  It is 
ultimately the responsibility of the old and new owners to coordinate any payment arrangements 
between themselves while the contractor and the state are reviewing the CHOW.  It is 
recommended that the contractor notify the new owner of this while processing the application. 
 
B.  National Provider Identifiers (NPI) - Depending on the sales terms, the new owner may 
obtain a new NPI or maintain the existing NPI.  Once CHOW processing is complete, the old 
owner is prohibited from billing for services (i.e., services furnished after CHOW processing is 
complete); only the new owner may submit claims using the existing CCN.  As already stated, 
the old owner and new owner must arrange between themselves any payment matters regarding 
claims for services furnished during the CHOW processing period. 
 
C.  CHOW Pre-Approval Changes of Information   
 
1.  Old Owner 
 
If  prior to receiving an approval recommendation from the state - the contractor receives from 
the old owner a Form CMS-855 request to change any of the providers enrollment data, the 
contractor shall return the change request if the information involves changing the providers: 
  i.  EFT or special payment address information to that of the new owner (as described in section 
10.6.1.1.4(A) above);   
 
ii.  Practice location or base of operations to that of the new owner; 
 
iii.  Ownership or managing control to that of the new owner;  
 
iv.  Legal business name, TIN, or doing business as name to that of the new owner. 
 
All other pre-state recommendation Form CMS-855 change requests from the old owner can 
be processed normally. 
 
2.  New Owner 
 
If  prior to receiving an approval recommendation from the state - the contractor receives from 
the new owner a Form CMS-855 request to change any of the provider/suppliers existing 
enrollment information, the contractor shall return the change request.  This is because the old 
owner remains the owner of record at this time; the new owner therefore has no standing to 
submit Form CMS-855 changes on behalf of the provider. 
 
D.  Change of Transaction Type in PECOS - There may be instances where the contractor 
enters a transaction into PECOS as a CHOW, but it turns out that the transaction was not a 
CHOW (e.g., was a stock transfer; was an initial enrollment because the new owner refused to 
accept assignment).  If the contractor cannot change the transaction type in PECOS, it can leave 
the record in a CHOW status; however, it should note in PECOS that the transaction was not a 
CHOW. 
 
E.  Unreported CHOW - If the contractor learns via any means (including from the state or 
SOG Location) that an enrolled provider has been purchased by another entity or has purchased 
another Medicare-enrolled provider, the contractor shall immediately request Form CMS-855A 
CHOW applications from both the previous and new owners (or request a Form CMS-855B 
CHOW application from the ASC or PXRS).  If the new owner fails to submit a Form CMS-855 
within the latter of (1) the date of acquisition or (2) 30 days after the request, the contractor shall 
send an e-mail to its PEOG BFL notifying him/her of the situation. PEOG will determine 
whether the providers billing privileges should be deactivated under  424.540(a)(2) or  
424.550(b) or revoked under  424.535(a)(1) or (a)(9).  PEOG will notify the contractor of its 
decision. 
 
F.  Precise Time of CHOW - In general, a Medicare CHOW is considered to have taken place 
at 12:01 a.m. on the date specified (i.e., in the first minute of the 24-hour day).  Legal 
responsibility and the right to payment changes when the clock moves past midnight into the 
CHOW effective date. 
 
G.  Termination of CCN - If the new owner rejects assignment, the CCN associated with that 
agreement (the old owners) also terminates on the date of the ownership transfer.  
 
H.  Clock Stoppages and Processing Alternatives - While awaiting PEOGs reply on any 
matter in this section 10.6.1.1 et seq. in which the contractor is required to refer a matter to  PEOG - and beginning on the date following the sending of the e-mail referenced therein - the 
application processing time clock is stopped.  It resumes on the date on which the contractor 
receives PEOGs final response.  Communication between the contractor and PEOG during this 
waiting period (e.g., PEOG request for additional information from the contractor) does not 
restart the clock.   
 
In addition, nothing in this section 10.6.1.1 et seq. negates other permissible clock stoppages and 
processing alternatives outlined in this chapter that can apply to the applications addressed in this 
section 10.6.1.1 et seq.  
 
10.6.1.2  Changes of Information  Transitioned Certified Providers and 
Suppliers 
(Rev. 11682; Issued: 11-04-2022; Effective: 12-05-2022; Implementation: 12-05-2022) 
 
 (Until further notice from CMS, the instructions in this section 10.6.1.2 apply only to 
certified provider and certified supplier types that have officially transitioned as part of 
the transition of various certification activities from the SOG Location to the states, the 
contractors, and PEOG.  These provider/supplier types include SNFs, HHAs, CMHCs, 
CORFs, FQHCs, Part A OPT/OSP providers, ASCs, PXRSs, hospitals, hospices, and 
ESRD facilities.  The contractor shall continue to use the existing change of information 
instructions--now in section 10.6.22.1 of this chapter--for all non-transitioned certified 
provider/supplier types. 
 
When executing the instructions in this section 10.6.1.2, the contractor can disregard 
directives that obviously do not apply to the transitioned provider/supplier type in question 
(e.g., references to hospitals).  
 
All references to the SOG Location (formerly the RO) in this section 10.6.1.2 refer to the 
applicable CMS Regional Offices Survey & Operations Group (SOG) Location.  Also, and 
except as otherwise indicated, all references to provider include certified suppliers (e.g., 
ambulatory surgical centers, portable x-ray suppliers). 
 
The instructions in this section 10.6.1.2 address the handling of changes of information involving 
certified providers and certified suppliers.  With the transition of certain functions from the SOG 
Locations to the contractors and the Provider Enrollment & Oversight Group (PEOG), the 
processing instructions for these changes of information are slightly different from previous 
guidance.  In particular: (1) the SOG Locations will be much less involved in the process; (2) tie-
in and tie-out notices will no longer be issued; (3) the contractor will be responsible for finalizing 
changes previously requiring SOG Location approval; and (4) recommendations of approval will 
be made to (and reviewed by) the state agency (hereafter occasionally referenced simply as 
state) only and not the SOG Location.    
 
Except as stated otherwise: 
 
(1) Any provider-specific instructions in section 10.2.1 et seq. of this chapter pertaining to 
changes of information (e.g., relocation of a federally qualified health clinic site) take precedence 
over those in this section 10.6.1.2.   
(2) Any instructions pertaining to ownership changes in section 10.6.1.1 et seq. of this chapter 
take precedence over those in this section 10.6.1.2.  
 
(3) Any instructions pertaining to voluntary terminations of entire enrollments and/or provider 
agreements in section 10.6.1.3 of this chapter take precedence over those in this section 10.6.1.2.   
 
(4) Any instructions in this section 10.6.1.2 concerning the voluntary termination of a branch, 
sub-unit, or other practice location that does not involve the termination of the entire enrollment 
and/or provider agreement take precedence over those in section 10.6.1.3.  For instance, suppose 
a certified providers Form CMS-855A enrollment has three practice locations and/or sub-units.  
The provider is voluntarily terminating one of them.  Here, the contractor shall use the 
instructions in section 10.6.1.2 when processing this transaction.  Now assume that a provider is 
of a type that must individually and separately enroll each location.  The provider has three 
separately enrolled locations with three separate provider agreements.  The provider seeks to 
terminate one of these locations.  Since this will involve the termination of an individual/entire 
enrollment and corresponding provider agreement, the instructions in section 10.6.1.3 apply. 
 
A.  Changes of Information Requiring Recommendation to the State  
 
1.  Types 
 
The following Form CMS-855 transactions require an approval recommendation to (and review 
by) the state prior to approval:  
 
  Addition of outpatient physical therapy/outpatient speech pathology extension site  
 
  Addition of HHA branch 
 
  Addition or deletion of a prospective payment system (PPS)-excluded psychiatric unit, 
rehabilitation unit, or transplant program 
 
  Addition or deletion of swing-bed approval (see Section 2A2 of the Form CMS-855A) 
 
  Conversion of a hospital from one type to another (e.g., acute care to psychiatric) 
 
  Addition, deletion, or relocation of a hospice practice location 
 
  Addition, change, and/or relocation of a hospital practice location when a survey of the 
new site may be required.  (If the contractor is uncertain as to whether the state will 
perform a survey, it may (1) contact the state for guidance or (2) make the referral 
based on the contractors experience with these types of changes and with the practices 
of the state in question.  Note that a survey often may be required if the location is 
shifting outside of the existing geographic area.) 
 
  Addition of PXRS practice location  
  2.  Initial Contractor Review and Recommendation 
The contractor shall process the change request consistent with the instructions in this chapter 
(e.g., verification of data, developing for missing or conflicting data).    If the contractor 
determines that the change/addition should be approved, it shall send the appropriate 
recommendation letter (see section 10.7 et seq.) to the state with all applicable documentation 
that the contractor currently sends in such situations.  The SOG Location need not be copied on 
the letter. 
 
Nothing in this section 10.6.1.2(A)(2): 
 
  Prohibits the contractor from returning or rejecting the application if grounds for doing so 
exist.   
  Supersedes any applicable requirement for performing a site visit (including the timing of 
such visits). 
 
3.  State Review and Contractor Receipt of Recommendation 
 
The state will review the recommendation of approval, the application, and any other pertinent 
information.  If the state decides to perform a survey, it will do so and notify the contractor 
thereof.   
 
a.  State Recommends Approval  
 
If the state concludes that the change/addition should be approved, it will make a 
recommendation to this effect to the contractor, typically via a Form CMS-1539 and/or similar 
confirming documentation.  No later than 5 business days after receipt of the recommendation, 
the contractor shall send an e-mail to MedicareProviderEnrollment@cms.hhs.gov containing 
general identifying data about the provider (including LBN, NPI, CCN, specialty, facility name 
and address), a copy of the Form CMS-1539 (or other similar documentation evidencing the 
states approval recommendation, if available), the draft provider approval letter, and a 
description of the change to be made.  If, to the contractors knowledge, a new CCN is required, 
the name and address of the new entity requiring the CCN should be furnished along with the 
effective date.  If a termination is involved (e.g., HHA branch), the contractor shall include the 
old CCN and the termination date in the e-mail. 
 
Once PEOG responds to the contractor, the latter may finalize its processing of the application 
(e.g., sending copies of the provider notification of approval to the state and, if applicable, 
accrediting organization; switching the PECOS record from approval recommended to 
approved).  
 
b.  State Does Not Recommend Approval 
 
If the state does not recommend approval, the contractor shall refer the matter to 
MedicareProviderEnrollment@cms.hhs.gov for guidance.  The e-mail to him/her shall contain 
(1) the identifying data described in (3)(a) above; (2) a copy of the notification from the state 
declining to recommend approval; and (3) any other information the contractor deems pertinent.   PEOG will review the matter and furnish the contractor additional instructions, which the 
contractor shall follow. 
 
4.  Additional Policies 
 
a.  Post-Recommendation Inquiries - Once the contractor has made its recommendation for 
approval to the state, any inquiry the contractor receives from the provider regarding the status of 
its change request shall be referred to the state.  
 
b.  Pending State Recommendation - So as not to keep the PECOS record in approval 
recommended status interminably, if the contractor does not receive the states recommendation 
after 120 days, it may contact the state to see if its recommendation is forthcoming. The 
contractor may contact the state every 30 days thereafter to ascertain the recommendations 
status.  
 
c.  State Practice - The PECOS record should not be switched to Approved until the 
contractor receives the states approval recommendation.  However, if the contractor knows that 
the state in question generally does not review this type of transaction, the contractor need not 
send the transaction to the state and shall instead follow the instructions in section 10.6.1.2(B) 
below. 
 
B.  Post-Approval State Notification Required 
 
Form CMS-855 changes that do not mandate a recommendation to the state but do require post-
approval correspondence with PEOG and the state (and, if applicable, the accrediting 
organization) include: 
 
  Except as described in section 10.6.1.2(A), deletions/voluntary terminations of practice 
locations or hospital subunits.  (Note that this scenario is different from cases where the provider 
is voluntary terminating its enrollment as a whole (per section 10.6.1.3 of this chapter) rather 
than simply terminating a single location or subunit within its enrollment.)    
 
  LBN, TIN, or doing business as name changes that do not involve a CHOW 
 
  Except as described in section 10.6.1.2(A), address changes that generally do not require a 
survey of the new location 
 
  Addition, change, and/or relocation of a hospital practice location (including 
physician/practitioner group practice locations) for which a survey is not required. 
 
  Ownership changes that involve neither a 42 CFR  489.18 CHOW nor a  424.550(b) 
exempt or non-exempt change in HHA majority ownership (e.g., a 15 percent owner of a hospice 
sells her ownership stake).   
 
The contractor shall: 
  (1)  Inform PEOG, the state, and the AO (if appropriate) of the changed information (via any 
mechanism it chooses, including copying PEOG/state/AO on the notification letter or e-mail to 
the provider) no later than 10 calendar days after it has completed processing the transaction.  
Such notice to the PEOG/state/AO shall specify the type of information that is changing.  (Prior 
PEOG approval of the change is not required, though PEOG will update applicable national 
database as needed.) 
 
(2)  Switch the PECOS record to Approved.   
 
C.  All Other Changes of Information 
 
1.  General Principle 
 
For all Form CMS-855 change requests not identified in section 10.6.1.2(A)(1) and (B) above 
(and except as stated in subsection (C)(2) below), the contractor shall: (1) notify the provider via 
letter, fax, e-mail, or telephone that the change has been made; and (2) switch the PECOS record 
to Approved.  The contractor need not notify the state, SOG Location, or PEOG of the change. 
 
2.  FQHCs 
 
If an FQHC is adding, deleting, or changing a Section 13 contact person , the contractor shall 
send an approval letter via e-mail and copy the MedicareProviderEnrollment@cms.hhs.gov 
mailbox (with FQHC COI in the subject line) thereon.  (Aside from this exception, all other 
instructions in subsection (C)(1) apply to this scenario.)  See section 10.2.1.4(D) of this chapter 
for more information on FQHC changes of information. 
 
D.  Revalidations, Reactivations, and Complete Form CMS-855 Applications 
 
1.   When Referral Required - In situations where the provider submits a (1) Form CMS-855 
reactivation, (2) Form CMS-855 revalidation, or (3) full Form CMS-855 as part of a change of 
information (i.e., the provider has no enrollment record in PECOS), the contractor shall make a 
recommendation to the state and switch the PECOS record to approval recommended only if 
the application contains new/changed data falling within one of the categories in section 
10.6.1.2(A)(1).  For instance, if a revalidation application reveals a new hospital psychiatric unit 
that was never reported to CMS via the Form CMS-855, the contractor shall make a 
recommendation to the state and await the states approval recommendation before switching the 
record to Approved.   In this situation, the contractor should forward the application to the 
state with a note explaining that the only matter the state needs to consider is the new hospital 
unit. 
 
2.  No Referral Required - If the application contains new/changed data falling within one of 
the categories in section 10.6.1.2(B), the contractor can switch the PECOS record to 
Approved.  It shall also inform the state of the changed information (via any mechanism it 
chooses, including copying the state on the notification letter or e-mail to the provider) no later 
than 10 calendar days after it has completed processing the transaction.  
 
E.  Unsolicited Notifications from State 
  If the contractor receives notice of a providers change of information from the state but the 
provider never submitted the required Form CMS-855 change request to the contractor, the 
contractor shall: (1) alert the state of the situation; and (2) contact the provider and have it 
complete and submit the change request.  However, if the data in question is not collected on the 
Form CMS-855, the contractor need not make this request.   
 
F.  Special ESRD Instructions 
 
Notwithstanding any other contrary instruction in this chapter, if an ESRD change of information 
application results in the issuance of a new or additional CCN, the contractor shall copy the 
ESRD Network on the approval letter it sends to the provider.  The contact information for the 
ESRD Network can be found at https://esrdnetworks.org/membership/esrd-networks-contact-
information/.  
 
G.  Clock Stoppages and Processing Alternatives - While awaiting PEOGs reply on any 
matter in this section 10.6.1.2 in which the contractor is required to refer a matter to PEOG - and 
beginning on the date following the sending of the e-mail referenced therein - the application 
processing time clock is stopped.  It resumes on the date on which the contractor receives 
PEOGs final response.  Communication between the contractor and PEOG during this waiting 
period (e.g., PEOG request for additional information from the contractor) does not restart the 
clock.   
 
In addition, nothing in this section 10.6.1.2 negates other permissible clock stoppages and 
processing alternatives outlined in this chapter that can apply to the applications addressed in this 
section 10.6.1.2.  
 
10.6.1.3  Voluntary Terminations     
(Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
The CMS Provider Enrollment & Oversight Group (PEOG) and Medicare Administrative 
Contractors have assumed a number of enrollment-related functions previously handled by state 
agencies (hereafter occasionally referenced as state) and CMS Survey & Operations Group 
Locations (SOG Locations) concerning certified provider and certified supplier voluntary 
terminations.  This section 10.6.1.3 instructs the contractor on how to process such transactions.  
Unless stated otherwise, these instructions take precedence over those in section 10.4.3 of this 
chapter.  
 
Except as stated otherwise in this chapter, this section does not apply to voluntary terminations 
pursuant to an HHA change in majority ownership under  424.550(b)(1).  Instructions 
concerning the handling of these transactions are in section 10.2.1.6.1 of this chapter.  
 
A.  Background 
 
Consistent with the principles of 42 CFR  489.52(a) (and except as otherwise required), a 
certified provider/supplier that wishes to terminate its agreement with Medicare must send 
written notice of its intention to the SOG Location, the state agency, or the contractor within the  timeframes addressed in  489.52.  Under CMS Publication (Pub.) 100-07, chapter 2, section 
2005F, the notice is a letter on letterhead with an authorized signature.   
 
Submission of a Form CMS-855 voluntary termination application is not mandatory but is highly 
preferred.  Providers and suppliers are encouraged to continue to submit this form.   
 
Section 10.6.1.3(B) below discusses various scenarios that the contractor may encounter in 
processing certified provider/supplier voluntary terminations.  These should be reviewed and 
considered in conjunction with the policies in section 10.6.1.3(C) below, particularly those in 
subsections (C)(2), (C)(3), (C)(6), and (C)(7).    
 
B.  Situations and Scenarios 
 
1.  Termination Reported to Contractor Via Form CMS-855 or Letter with No Prior Notice 
from State Agency or SOG Location 
 
If the contractor receives a Form CMS-855 voluntary termination application or a voluntary 
termination letter (but not both) directly from a certified provider/supplier without having 
received any termination notification from the state/SOG Location, the following apply:  
 
(i) The contractor shall: (a) process the application/letter consistent with the timeframes for 
voluntary terminations in section 10.4.3 of this chapter; and (b) as applicable, follow the 
instructions in section 10.6.1.3(C) below.   
 
(NOTE: If the application/letter is from a skilled nursing facility (SNF), the contractor shall 
contact the state agency to determine whether the SNF complies with the requirements of 42 
CFR  483.15(c)(8) and 483.70(l). These two provisions address the SNFs required notice to 
the state of an impending closure and patient safety. If the state indicates that the SNF is not 
compliant, the contractor shall contact its PEOG Business Function Lead (BFL) for guidance; if 
compliance is confirmed, the contractor can proceed as normal.)   
 
(ii) Prior to finalizing its processing of the Form CMS-855 or letter submission, the contractor 
shall e-mail a copy of the draft approval letter (see the applicable model letter in section 
10.7.5.1) containing the appropriate termination effective date, reason for termination, and 
source of the termination notice (i.e., Form CMS-855 or letter) to PEOG at 
MedicareProviderEnrollment@cms.hhs.gov, with S&C Voluntary Termination in the e-mails 
subject line.   
 
(iii) PEOG will update the Automated Survey Process Environment (ASPEN) system, notify the 
contractor thereof, and, if the provider/supplier is deemed, provide the contractor the name and 
e-mail address of the applicable accreditation organization (AO).   
 
(iv) Within 3 business days of receiving of the aforementioned notice from PEOG, the contractor 
shall: (1) e-mail a copy of the final signed approval letter to the provider/supplier, SOG 
Location, state agency, and AO (if the provider/supplier is deemed); and (2) deactivate the 
provider/supplier in the Provider Enrollment, Chain and Ownership System (PECOS) pursuant to 
the instructions/guidance in section 10.6.1.3(C)(9) below.       
  2.  Termination Reported to Contractor Via Form CMS-855 and Letter with No Prior 
Notice from State Agency or SOG Location 
 
If the contractor receives a Form CMS-855 voluntary termination application and a voluntary 
termination letter directly from a certified provider/supplier without having received any 
termination notification from the state/SOG Location, the following apply:  
 
(i) If the Form CMS-855 and letter arrive either simultaneously or before the contractor begins 
processing one of them, the contractor has the discretion to determine which submission to 
process unless a Form CMS-855 was submitted via PECOS; in this latter case, the contractor 
shall process the Form CMS-855 rather than the letter.    It need not process both of them; the 
submission that the contractor does not process may be returned (consistent with the instructions 
in this chapter) or placed in the provider/supplier file, and the contractor need take no further 
action thereon.     
 
(ii) If the contractor receives both submissions and it has begun processing one of them, the 
contractor shall continue processing that document.  The contractor can return the other 
submission (consistent with the instructions in this chapter) or place it in the provider/supplier 
file; no further action thereon is required. 
 
(iii) Regardless of whether (2)(i) or (ii) applies, the contractor shall process the submission  
consistent with the instructions in section 10.6.1.3(B)(1) above. 
 
3.  Notice of Voluntary Termination Received from State Agency and/or SOG Location 
without the Contractor Having Received a Form CMS-855 or Letter Directly From the 
Provider/Supplier 
 
Although many voluntary termination submissions from certified providers/suppliers are via the 
Form CMS-855, there are occasions where the provider/supplier will only notify the state agency 
and/or SOG Location.  The contractor will typically learn of this when it receives a Form CMS-
1539 (Medicare/Medicaid Certification and Transmittal) and/or other written notification from 
the state/SOG Location. (The state uses the Form CMS-1539 to communicate findings to the 
SOG Location with respect to a facilitys compliance with health and safety requirements.)  In 
such situations, the following apply: 
 
(i) The contractor may accept from the state/SOG Location written documentation other than the 
Form CMS-1539.  This includes, for example, a Form CMS-2007 or even a voluntary 
termination letter of the type described in sections 10.6.1.3(B)(1) and (B)(2) above; indeed, the 
provider/supplier sometimes sends its termination letter directly to the state/SOG Location and 
the latter simply forwards it to the contractor.     
 
If the contractor has questions concerning said documentation, it shall contact the state/SOG 
Location for clarification. (This could include situations when it is unclear: (1) whether a 
termination is involved; (2) which provider/supplier is to be terminated; or (3) if the state 
forwards to the contractor a termination request that the state received from the provider, 
whether the state considers it to be a valid termination request.).  
  (ii) Upon receipt of the Form CMS-1539 (or other/additional state/SOG Location document), the 
contractor need not develop with the provider/supplier for a Form CMS-855A/B voluntary 
termination application or a letter. Instead:   
 
(A) The contractor shall abide by the applicable instructions in section 10.6.1.3(C) below (e.g., 
section (C)(6) regarding effective dates; section (C)(7) concerning cessations of business).  If the 
notice from the state was a voluntary termination letter from the provider/supplier (as described 
in section 10.6.1.3(B)(3)(i) above), the contractor shall pay particular attention to the instructions 
in section 10.6.1.3(C)(3) below. 
 
(B) The contractor shall e-mail a copy of the draft approval letter (see section 10.7.5.1 of this 
chapter) containing the appropriate termination effective date, reason for termination, and source 
of the termination notice to MedicareProviderEnrollment@cms.hhs.gov, with S&C Voluntary 
Termination in the subject line.   
 
(C) PEOG will update ASPEN, notify the contractor thereof, and, if the provider/supplier is 
deemed, provide the contractor the name and e-mail address of the applicable AO.   
 
(D) Within 3 business days of receiving of the aforementioned notice from PEOG, the contractor 
shall: (1) e-mail a copy of the final signed letter to the provider/supplier, SOG Location, state 
agency, and AO (if the provider/supplier is deemed); and (2) deactivate the provider/supplier in 
PECOS pursuant to the instructions/guidance in section 10.6.1.3(C)(9)) below. 
 
4.  Notification of Termination Received from the State Agency and/or SOG Location and 
Directly from the Provider/Supplier Via the Form CMS-855 and/or Letter  
 
The contractor shall adhere to the instructions in this section (B)(4) in the following situations: 
 
(i)  The contractor receives notification of termination (i.e., via Form CMS-1539 or other 
documentation) from the state/SOG Location after the provider/supplier has been 
deactivated in PECOS pursuant to the latters Form CMS-855/letter voluntary termination 
submission - Within 10 calendar days of receiving the state/SOG Location notification, the 
contractor shall inform the state/SOG Location via e-mail that the provider/supplier has already 
been deactivated in PECOS and terminated in ASPEN.  No further action by the contractor is 
necessary. 
 
(ii) The contractor receives notification of termination from the state/SOG Location while 
the contractor is processing a Form CMS-855/letter voluntary termination submission but 
before the provider/supplier has been deactivated in PECOS  The contractor shall: (i) 
continue processing the application/letter normally and to completion, consistent with the 
instructions in this section 10.6.1.3; and (ii) e-mail a copy of the final signed letter to the 
provider/supplier, SOG Location, state agency, and AO (if the provider/supplier is deemed) after 
the provider/supplier has been deactivated in PECOS. 
 
(iii) The contractor receives notification of termination (i.e., via Form CMS-1539 or other 
documentation) from the state/SOG Location before the contractor received or began 
processing the providers/suppliers Form CMS-855/letter voluntary termination 
submission  The contractor:   
(A)  Shall follow the instructions in section 10.6.1.3(B)(3) above 
 
(B)  Need not contact the provider/supplier about its Form CMS-855/letter submission prior to 
the completion of all of the steps in section 10.6.1.3(B)(3)(ii) above   
 
(C)  Either in the termination approval letter (which the contractor may modify for the purpose) 
sent to the provider/supplier or via a simultaneous or separate e-mail to the provider/supplier, the 
contractor shall notify the provider/supplier that its submission to the contractor was not 
processed due to the provider/suppliers prior notification to the state/SOG Location. (If this 
communication is sent separately from the approval letter or the e-mail containing the letter, the 
contractor shall send the separate e-mail no later than 10 calendar days after sending the letter.)    
 
(iv) The contractor receives notification of termination from the state/SOG Location and a 
separate voluntary termination Form CMS-855/letter from the provider/supplier without 
having begun the processing of either  The contractor has the discretion to determine which 
submission to process unless a Form CMS-855 was submitted via PECOS; in this latter case, the 
contractor shall process the Form CMS-855.   It need not process both of them; the submission 
that the contractor does not process may be returned (consistent with the instructions in this 
chapter) or placed in the provider/supplier file, and the contractor need take no further action 
thereon.     
 
C.  Additional Certified Provider/Supplier Voluntary Termination Policies 
 
1.  Completion of Form CMS-1539  The state completes the Form CMS-1539.  In Part II 
thereof, the following fields contain: (i) 26-Termination Action 00; Code for a voluntary 
termination; and (ii) 28 Termination Date; this is the effective date of the voluntary termination. 
 
2.  Required Contents of Voluntary Termination Letter Received Directly from Provider/Supplier 
 If the contractor is processing a voluntary termination letter it received directly from the 
provider/supplier (as opposed to receiving it from the state/SOG Location), the contractor shall 
ensure that the letter: 
 
  Is on the provider/suppliers letterhead 
  Contains the provider/suppliers legal business name, NPI, and CMS Certification Number 
(CCN) 
  States with sufficient clarity (in the contractors judgment) that the provider/supplier wishes 
to terminate its Medicare provider/supplier agreement and/or enrollment.  (No exact, 
uniform, standard language from the provider/supplier is necessary; the letter must merely 
furnish adequate notice of the provider/suppliers intentions).    
  Is signed and dated by an authorized representative of the provider/supplier.  This person 
need not be on file as an authorized or delegated official of the provider/supplier.  The 
contractor shall accept the persons signature if it has no reason to suspect that he/she lacks 
the authority to act on the provider/suppliers behalf.  If it has doubts, however, it may 
contact its PEOG for guidance. 
  (The applicable regulations do not require that the letter contain the termination effective date or 
the reason for the termination.  For purposes of ascertaining the effective date and reason, the 
contractor shall follow the instructions in section 10.1.3(C)(6).) 
 
If the letter does not meet all of the above requirements, the contractor shall develop with the 
provider/supplier for the missing or deficient information.  Development shall be consistent with 
the general developmental instructions in this chapter (e.g., 30 days for provider/supplier to 
respond) except as follows: 
 
  The contractor may develop for the missing or clarifying information via any means, even by 
telephone.  No application development letter is required. 
  Except as stated in sections 10.6.1.3(C)(3) and (C)(6) below, all missing or clarifying data 
must be furnished via a new letter signed by an authorized representative (who need not be 
the same person who signed the original letter).  
 
If the provider/supplier fails to respond fully and completely to the aforementioned request 
within the required timeframe, the contractor shall contact its PEOG BFL for guidance and 
include a copy of the initial provider/supplier letter in the e-mail to PEOG. 
 
(See section 10.6.1.3(C)(3) below for instances where the guidance in this section 10.6.1.3(C)(2) 
may apply to voluntary termination letters submitted to the state/SOG Location rather than to the 
contractor.)    
 
1.  Provider/Suppliers Voluntary Termination Letter Received Directly from the state/SOG 
Location Without the Contractor Having Received a Termination Notification from the 
Provider/Supplier  As explained in section 10.6.1.3(B)(3) above, the contractor may receive a 
provider/suppliers voluntary termination letter directly from the state/SOG Location without 
having received any termination notification (i.e., letter or Form CMS-855) from the 
provider/supplier.  If the contractor encounters this situation, the contractor shall adhere to the 
following: 
 
(i)  Provider/Supplier Voluntary Termination Letter Received from State/SOG Location Without 
Other Confirming Documentation - If the letter is unaccompanied by a Form CMS-1539 or other 
documentation signifying that the state/SOG Location (1) considers the termination letter as 
valid or (2) otherwise accepts the termination request, the contractor shall contact the state via e-
mail for clarification on these issues.  If the state indicates that it considers the provider/supplier 
as having terminated its provider/supplier agreement, the contractor shall process the termination 
consistent with the instructions in section 10.6.1.3(B)(3); any missing or unclear information 
(e.g., reason for the termination, effective date, CCN) shall be obtained from the state and/or 
SOG Location.  If the state is merely forwarding the provider/supplier letter to the contractor for 
processing without making any determination as to whether the termination is valid, the 
contractor shall process the letter consistent with the instructions in section 10.6.1.3(B)(1) and 
(C)(2).    
 
(ii) Provider/Supplier Voluntary Termination Letter Received from State/SOG Location With 
Additional Documentation Confirming that the State Considers the Provider/Supplier As Having  Terminated Its Agreement - The contractor shall process the termination consistent with the 
instructions in section 10.6.1.3(B)(3). 
 
4.  Tie-Out Notices  SOG Locations no longer issue tie-out notices (Form CMS-2007) for 
voluntary terminations. 
 
5.  Special Payments - Upon receipt of a Form CMS-855 voluntary termination application or a 
voluntary termination letter directly from the provider/supplier per the instructions in this section 
10.6.1.3, the contractor may (but is not required to) ask the provider/supplier to complete or 
update the Special Payments portion of Section 4 of the Form CMS-855 so that future 
payments can be sent thereto.  If the provider/supplier is adding a special payment address, it 
should be included in the same transaction as the voluntary termination action (i.e., one 
transaction incorporating both items).  If the provider/supplier is changing its existing special 
payments address, the transaction constitutes a separate change request (i.e., one termination and 
one change request).  The provider/supplier is not required to submit a Form CMS-588 in 
conjunction with a termination. 
  
6.  Termination Effective Dates and Termination Reasons  As noted previously,  489.52(b) 
outlines the applicable effective dates for voluntary terminations.  The contractor shall adhere to 
the following instructions regarding these dates as well as certain situations pertaining to 
termination reasons: 
 
(i)  The contractor receives a Form CMS-855 or voluntary termination letter per section 
10.6.1.3(B)(1) or (B)(2) (i.e., the contractor receives a termination submission from the 
provider/supplier before receiving notification from the state/SOG Location):  
 
(A)  If the provider/suppliers submission is missing either the effective date of termination or the 
reason for the termination (or if either data element is not sufficiently clear to the contractor), the 
contractor shall develop with the provider/supplier for the missing/unclear data.  The contractor 
may develop for the information via any means, even by telephone; no development letter is 
required.  The provider/supplier must furnish the data via e-mail or other written format, but a 
new letter is not required.  If the provider/supplier fails to submit the requested data within 30 
days, the contractor shall contact its PEOG BFL for guidance.  If the provider/supplier submits 
the data, the following effective dates apply: 
 
(1) The termination reason is that the provider/supplier has ceased business (which includes non-
operational status)  The termination effective date in ASPEN is that on which the 
provider/supplier stopped providing services to the community. (See section 10.6.1.3(C)(6)(i)(C) 
below for additional instructions concerning cessations of business.) 
 
(2) The termination reason does not involve a cessation of business or non-operational status 
(e.g., the provider simply wishes to depart Medicare without closing its business; the provider 
elects not to renew its state license)  The contractor shall include on the draft approval letter the 
termination effective date the provider/supplier furnished.  However, the contractor shall include 
in its e-mail to PEOG (see section 10.6.1.3(B)(1)(ii) above) notification as to whether this 
effective date is less than 6 months from the date on which the contractor first received the 
provider/suppliers Form CMS-855/letter.  If it is less than 6 months, PEOG will determine 
whether this termination effective date is acceptable.     
(B)  If the provider/suppliers initial submission contains the termination effective date and 
reason, and no development on these issues is needed, the contractor shall proceed as instructed 
per, as applicable, sections 10.6.1.3(B)(1), (B)(2), and (C)(6)(i)(A) above.   
 
(C)  In cases where a cessation of business (including non-operational status) is involved, a 
retroactive termination effective date is permissible if there were no Medicare beneficiaries 
receiving services from the facility on or after the requested termination date.  The contractor 
shall confirm this via a claims review prior to forwarding the e-mail and approval letter to PEOG 
per section 10.6.1.3(B)(1)(ii).  If claims were submitted, the contractor shall contact the 
provider/supplier via e-mail to confirm that services were indeed rendered and adjust the 
termination date with the provider/supplier; if no adjustment is made or contact cannot be made, 
an overpayment request must be issued. 
 
(ii)  The contractor is processing a Form CMS-1539 or other documentation received from the 
state/SOG Location other than the provider/suppliers voluntary termination letter  The 
contractor shall use the termination date listed on the Form CMS-1539 or other documentation as 
the termination effective date, even if a subsequent submission from the provider/supplier (e.g., 
Form CMS-855) uses a different date.  If no termination date is listed on the submission from the 
state/SOG Location, the contractor shall contact the state agency for guidance.  
 
Except as otherwise stated in this section 10.6.1.3 or unless directed otherwise by PEOG, the 
contractor: (1) shall use/apply the termination effective date listed on whichever submission it is 
processing (e.g., the contractor is processing the providers Form CMS-855 voluntary 
termination application before receiving any documentation from the state); and (2) need not 
alter this termination effective date based on a subsequent submission from provider/supplier or 
the state/SOG Location.  
 
7.  State Agency Performs Survey Based on Cessation of Business 
 
(i)  Solicitation of Information 
 
Situations may arise where the state (i) performs a survey of a certified provider/supplier based 
on a compliant or a cessation of business and (ii) finds that the provider/supplier is no longer 
operational and/or has vacated the practice location.  The state will notify the contractor of its 
findings via the Form CMS-1539 or other documentation.  Upon receipt of this documentation, 
the contractor shall send to the provider/supplier the applicable notice in section 10.7.2 of this 
chapter requesting that the provider/supplier: (1) provide evidence to the contractor (with a copy 
to the state) that it is still operational; (2) submit a request to the contractor (either via letter or a 
Form CMS-855) to voluntarily terminate its enrollment; or (3) submit a Form CMS-855 change 
of information application to report a changed practice location address (and any other changed 
data).  The contractor shall copy the state and SOG Location on the notice and give the 
provider/supplier 10 calendar days from the date the notice is sent to respond to the request. 
 
(ii)  Potential Outcomes 
 
(A)  The provider/supplier timely furnishes evidence to the contractor and the state that it is still 
operational at the same location  The contractor need take no additional action on the matter  until it receives confirmation from the state concerning the latters review. (If the contractor 
receives evidence from the provider/supplier more than 10 days after the request was made, it 
shall contact the state for guidance.) 
 
While the contractor may forward the provider/suppliers evidence to the state to ensure that the 
latter received it, the contractor is not required to do so.  It is ultimately (1) the 
provider/suppliers responsibility to copy the state on its submission to the contractor and (2) up 
to the state to determine whether the evidence of operational status the provider/supplier 
submitted is sufficient. 
 
Upon receiving notice from the state as to the reviews results, the contractor shall follow the 
applicable instructions in this section 10.6.1.3 if the provider/supplier is to be terminated (e.g., 
the state sends a Form CMS-1539 to the contractor).  If the provider/supplier was indeed found 
operational, the contractor need take no further action.   
 
(B)  The provider/supplier submits a Form CMS-855 voluntary termination and/or a voluntary 
termination letter in response to the contractors aforementioned solicitation - The contractor 
shall process the submission consistent with the instructions in section 10.6.1.3(B)(1) and/or 
(B)(2), as applicable.  Notwithstanding any instruction to the contrary in this section 10.6.1.3, the 
contractor shall use the termination effective date listed on the Form CMS-1539 or other 
documentation from the state (rather than the date on the Form CMS-855/letter) as the 
termination effective date.   
 
(C)  The provider/supplier timely submits a Form CMS-855 to change its address  The 
contractor shall process the change request to completion, notify the provider/supplier thereof via 
the applicable instructions in this chapter 10, and forward a copy of the change request via e-mail 
to the state and SOG Location via e-mail.  In this e-mail, the contractor shall: (1) notify the 
state/SOG Location of the new address; (2) reference the Form CMS-1539 (or other 
documentation) that the state had sent to the contractor; and (3) notify the state if PECOS 
indicated any addresses other than the old or new address at which the provider/supplier 
might be located.   
 
(D)  The provider/supplier fails to respond to the contractors solicitation - The contractor shall 
process the voluntary termination consistent with the instructions in section 10.6.1.3(B)(3) 
above.  
 
8.  Clock Stoppages  In any circumstance where the contractor is required under section 
10.6.1.3 to contact PEOG (including sending a termination to PEOG for approval) or the 
state/SOG Location for a determination, approval, or guidance of some type, the application 
processing time clock is stopped.  It resumes on the date on which the contractor receives 
PEOG/state/SOG Locations decision, resolution, determination, or final guidance, as applicable.  
Interim communication between the contractor and PEOG/state/SOG Location during such 
waiting periods (e.g., PEOG request for additional information from the contractor) does not 
restart the clock.  Optional communications---that is, communications with PEOG/state/SOG 
Location that are not specifically directed under this section 10.6.1.3---do not stop the processing 
clock.  
 
9.  PECOS Deactivation Date    
a.  Matching Dates - As indicated previously, the termination effective date will be entered into 
ASPEN.  The date of deactivation in PECOS (and except if PEOG instructs otherwise) should 
match the termination effective date with the exception of certified suppliers paid via MCS, in 
which case the PECOS deactivation date shall be the day after the termination date.    
 
b.  Already Deactivated  If the provider/supplier is already deactivated in PECOS pursuant to 
42 CFR  424.540(a)(1) through (a)(6) (i.e., the provider/suppliers billing privileges are merely 
stopped) and the provider/supplier is now voluntarily terminating their enrollment, no change in 
the deactivation effective date in PECOS is needed (notwithstanding any contrary instruction in 
this chapter).  
 
c.  Seller CHOW - Notwithstanding paragraph (9)(b) above, the deactivation effective date in 
PECOS---as well as the voluntary termination date---is the day before the date of the sale.  For 
certified suppliers paid via MCS, however, the deactivation effective date shall be the date of the 
sale.  (Note that this paragraph (9)(c) does not apply to HHA changes in majority ownership for 
which no exception applies; see section 10.2.1.6.1(B) of this chapter for more information.) 
 
10.6.2  Establishing Effective Dates  
(Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
In reviewing this section 10.6.2, it is important that the contractor keep in mind the 
distinctions between: (1) the date of enrollment/approval; (2) the effective date of billing 
privileges under 42 CFR  424.520(d); and (3) the date from which the supplier may 
retrospectively bill for services under  424.521(a). 
 
(Note that the date of receipt of a PECOS application is the date on which the contractor received 
it, not the date on which the application required the contractors manual intervention per section 
10.3.) 
 
A.  Date of Enrollment/Approval 
 
For suppliers other than ambulatory surgical centers and portable x-ray suppliers, the date of 
enrollment is the date the contractor approved the application.  The enrollment date cannot be 
made retroactive.  To illustrate, suppose a practitioner met all the requirements needed to enroll 
in Medicare (other than the submission of a Form CMS-855I) on January 1.  He submits his 
Form CMS-855I to the contractor on May 1, and the contractor approves the application on June 
1.  The date of enrollment is June 1, not January 1.   
 
B. Establishing Effective Dates of Billing Privileges for Certain Suppliers Under 42 CFR  
424.520(d) 
 
1. Applicability 
 
This section 10.6.2(B) applies to the following individuals and organizations:  
  a.  Physicians; physician assistants; nurse practitioners; audiologists; clinical nurse specialists; 
certified registered nurse anesthetists; anesthesiology assistants; certified nurse- midwives; 
clinical social workers; clinical psychologists; independently billing psychologists, registered 
dietitians or nutrition professionals; physical therapists; occupational therapists; speech-
language pathologists; and physician and non-physician practitioner organizations (e.g., 
group practices) consisting of any of the categories of individuals identified above. 
 
b.  Ambulance suppliers  
 
c.  Part B hospital departments 
 
d.  CLIA labs   
 
e.  Opioid treatment programs. 
 
f.  Mammography centers 
 
g.  Mass immunizers/pharmacies 
h.  Radiation therapy centers 
i.  Home infusion therapy suppliers 
(See 42 CFR  424.520(d)(2) and 424.521(a)(2) for the regulatory listing of these 
providers/suppliers.) 
 
2. Background 
 
In accordance with 42 CFR  424.520(d)(1), the effective date of billing privileges for the 
individuals and organizations identified in  424.520(d)(2) (and section 10.6.2(B)(1) above) is 
the later of: 
 
(i)  The date the supplier filed an enrollment application that was subsequently approved, or 
 
(ii)  The date the supplier first began furnishing services at a new practice location. 
 
NOTE:  The date of filing for Form CMS-855 applications is the date on which the contractor 
received the application, regardless of whether the application was submitted via paper or 
Internet-based PECOS. 
 
3.  Retrospective Billing Under 42 CFR  424.521(a) 
 
Consistent with 42 CFR  424.521(a)(1), the individuals and organizations identified in  
424.521(a)(2) (and section 10.6.2(B)(1) above) may retrospectively bill for services when:  
 
(i)  The supplier has met all program requirements, including state licensure requirements; and 
 
(ii) The services were provided at the enrolled practice location for up to   
(A) 30 days prior to their effective date if circumstances precluded enrollment in advance of 
providing services to Medicare beneficiaries, or  
 
(B) 90 days prior to their effective date if a Presidentially-declared disaster under the Robert T. 
Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. 5121-5206 (Stafford Act) 
precluded enrollment in advance of providing services to Medicare beneficiaries. 
 
The contractor shall interpret the aforementioned phase circumstances precluded enrollment to 
mean that the supplier meets all program requirements (including state licensure) during the 30-
day period before an application was submitted and no final adverse action (as that term is 
defined in  424.502) precluded enrollment.  If a final adverse action precluded enrollment 
during this 30-day period, the contractor shall only establish an effective billing date the day 
after the date that the final adverse action was resolved--so long as it is not more than 30 days 
prior to the date on which the application was submitted. 
 
If the contractor believes that the aforementioned Presidentially-declared disaster exception may 
apply in a particular case, it shall contact its CMS Provider Enrollment & Oversight Group 
Business Function Lead for a determination on this issue. 
 
4.  Summarizing the Distinction Between Effective Date of Billing Privileges and 
Retrospective Billing Date 
 
As already discussed, the effective date of billing privileges is the later of the date of filing or 
the date (the supplier) first began furnishing services at a new practice location. The 
retrospective billing date, however, is up to...30 days prior to (the suppliers) effective date (of 
enrollment).  To illustrate, suppose that a non-Medicare enrolled physician begins furnishing 
services at an office on March 1.  She submits a Form CMS-855I initial enrollment application 
on May 1.  The application is approved on June 1 (which, as discussed in section 10.6.2(A) 
above, is the date of enrollment).  The physicians effective date of billing privileges is May 1, 
which is the later of: (1) the date of filing, and (2) the date she began furnishing services.  The 
retrospective billing date is April 1 (or 30 days prior to the effective date of billing privileges), 
assuming that the requirements of 42 CFR  424.521(a) are met.  The effective date entered into 
PECOS and the Multi-Carrier System will be April 1; claims submitted for services provided 
before April 1 will not be paid. 
 
C.  Effective Date of Reassignment 
 
Per 42 CFR  424.522(a), the effective date of the reassignment is 30 days before the Form 
CMS-855R is submitted if all applicable requirements during that period were otherwise met.   
The contractor shall apply this policy in the following manner: 
 
1.  Form CMS-855R submitted as stand-alone without Form CMS-855I  The effective date in 
 424.522(a) applies to the reassignment unless the effective date that the supplier listed on the 
Form CMS-855R is later than what the  424.522(a) date is, in which case the Form CMS-855R-
listed effective date controls.   
  2.  Form CMS-855R submitted with Form CMS-855I either simultaneously or as part of 
development (e.g., physician only submits Form CMS-855I and contractor develops for Form 
CMS-855R)  The contractor shall apply the Form CMS-855I effective date (per 42 CFR  
424.520(d) and 424.521(a)) to the Form CMS-855R.  When one or both of these forms requires 
the contractor to develop for information  and for purposes of establishing the  
424.520(d)/424.521(d) effective date -- the contractor may apply the receipt date of the first 
application that is submitted as complete (i.e. no further development is necessary). 
 
3.  Form CMS-855R submitted with Form CMS-855B either simultaneously or as part of 
development  The contractor shall apply the Form CMS-855B effective date (per 42 CFR  
424.520(d) and 424.521(a)) to the Form CMS-855R.  When one or both of these forms requires 
the contractor to develop for information  and for purposes of establishing the  
424.520(d)/424.521(d) effective date -- the contractor may apply the receipt date of the first 
application that is submitted as complete (i.e. no further development is necessary). 
 
Notwithstanding the foregoing, the contractor shall apply the 90-day retroactive billing period 
referenced in subsection 10.6.2(B)(3)(ii)(B) above to the Form CMS-855R submissions 
described in this subsection (C) in the event of a Presidentially-declared disaster under the 
Stafford Act). 
 
D.  Effective Date for Certified Providers and Certified Suppliers 
 
Note that 42 CFR  489.13 governs the determination of the effective date of a Medicare 
provider agreement or supplier approval for health care facilities that are subject to survey and 
certification.  Section 489.13 has been revised to state that: (1) the date of a Medicare provider 
agreement or supplier approval may not be earlier than the latest date on which all applicable 
federal requirements have been met; and (2) such requirements include the contractors review 
and verification of an application to enroll in Medicare.   
 
E.  Effective Date for Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and 
Supplies (DMEPOS) 
Per  424.57(b), DMEPOS suppliers must meet, among other requirements, the following 
conditions in order to be eligible to receive payment for a Medicare-covered item:  
(1) The supplier has submitted a completed application to CMS to furnish Medicare-covered 
items including required enrollment forms. (The supplier must enroll separate physical locations 
it uses to furnish Medicare-covered DMEPOS, with the exception of locations that it uses solely 
as warehouses or repair facilities.)  
(2) The item was furnished on or after the date CMS issued to the supplier a DMEPOS supplier 
number conveying billing privileges. (CMS issues only one supplier number for each location.) 
This requirement does not apply to items furnished incident to a physician's service. 
 
The contractor shall indicate the suppliers status as approved in PECOS upon the contractor 
making the determination the supplier meets all of the supplier standards found at  424.57(c). 
The date the supplier was approved in PECOS shall be the suppliers effective date.   
F.  Form CMS-855O Effective Dates 
 
Notwithstanding any other instruction in the chapter to the contrary, the effective date of a Form 
CMS-855O enrollment per 42 CFR  424.522 is the date on which the Medicare contractor 
received the Form CMS-855O application if all other requirements are met --- meaning the Form 
CMS-855O was processed to approval. 
 
G.  Effective Date for Medicare Diabetes Prevention Program (MDPP) Suppliers 
 
In accordance with 42 CFR  424.205(f), the effective date of billing privileges for MDPP 
suppliers is the later of:  
 
  The date the supplier filed an enrollment application that was subsequently approved,  
 
  The date the supplier filed a corrective action plan that was subsequently approved by a 
Medicare contractor, or  
 
  The date the supplier first began furnishing services at a new administrative location that 
resulted in a new enrollment record or Provider Transaction Access Number.  (For PECOS 
applications, see section 10.3 of this chapter for information about what constitutes an 
enrollment record in PECOS.) 
 
Under no circumstances should an effective date for billing privileges be prior to April 1, 2018. 
For any Form CMS-20134 submitted prior to April 1, 2018 and subsequently approved, the 
contractor shall note April 1, 2018 as the MDPP suppliers effective date, even if this date is in 
the future.  
 
NOTE: The date of filing for paper Form CMS-20134 applications is the date on which the 
contractor received the application. For Internet-based PECOS applications, the date of filing is 
the date that the contractor received an electronic version of the enrollment application and a 
signed certification statement submitted via paper or electronically. 
 
 
H.  Future Effective Dates 
 
If the contractor cannot enter an effective date into PECOS because the provider/supplier, its 
practice location, etc., is not yet established, the contractor may use the authorized officials date 
of signature as the temporary effective date.  Once the provider/supplier and the effective date 
are established (e.g., notification from the state is received), the contractor shall change the 
effective date in PECOS. 
 
10.6.3  Legal Business Name 
(Rev. 10524; Issued: 12-17-20; Effective: 11-13-20; Implementation: 11-13-20) 
 
A.  Legal Business Name Punctuation and Special Characters 
  PECOS and NPPES allow for the entry of punctuation and certain special characters in the 
providers Legal Business Name (LBN).  Examples of acceptable punctuation and special 
characters are ampersands, apostrophes, commas, hyphens, left and right parentheses, periods, 
pound signs, and quotation marks. 
 
When punctuation or special characters are part of a providers LBN as shown on the IRS CP-
575, the punctuation or special characters should also appear in the LBN in NPPES and the LBN 
in PECOS.  However, the contractor may use its discretion with respect to accepting a match 
between NPPES and PECOS if a comma or a period is the only discrepancy between the LBN in 
NPPES and the LBN in PECOS.  The contractor should not delay processing a providers 
Medicare enrollment application by requiring the provider to change its LBN in NPPES in order 
to conform to a discrepancy related to punctuation and/or special character. 
 
Examples of LBN Matches and Non-Matches and Actions to Be Taken 
 
NPPES LBN   PECOS LBN  Exact Match 
Health Systems, Inc.  HEALTH SYSTEMS,  Yes, this is an exact match. 
INC. 
Quality Care,  Quality Care, Inc.  No, this is not an exact match (because of the 
Incorporated  abbreviation Inc. in the PECOS LBN). 
 
In this case, the contractor may accept the match since 
both versions are an accurate match (e.g., 
Incorporated or Inc; Limited Liability Company or 
LLC; etc.) 
Health &  Health and Rehabilitation  No, this is not an exact match (because the ampersand 
Rehabilitation, Inc.  Inc.  and and do not match). 
 
In this case, the contractor shall refer to the IRS CP-
575. If the ampersand is displayed on the IRS CP-575, 
the Medicare contractor may accept the match.  If the 
ampersand is not present and the word and is 
present, the Medicare contractor shall ask the provider 
to correct its NPPES information.  The provider must 
change its LBN in NPPES to read in accordance with 
the IRS CP-575. 
 
Allergy & Asthma,  Allergy & Asthma, INC.  Yes, this is an exact match.  Upper and lower cases do 
Inc.  not affect a match. 
Foot-Ankle, LLC  Foot Ankle LLC  No, this is not an exact match (because the hyphen is 
in one LBN but not in the other). 
 
In this case, the contractor shall refer to the IRS CP-
575. If the hyphen is displayed on the IRS CP-575, 
the contractor may accept the match.  If the hyphen is 
not present, the contractor shall ask the provider to 
correct its NPPES information. The provider must  NPPES LBN   PECOS LBN  Exact Match 
Health Systems, Inc.  HEALTH SYSTEMS,  Yes, this is an exact match. 
INC. 
change its LBN in NPPES to read in accordance with 
the IRS CP-575.  
 
Rehab and Health,  Rehabilitation and Health,  No, this is not an exact match (because Rehab and 
Inc.  Inc.  Rehabilitation are different words). 
 
In this case, the contractor should refer to the IRS CP-
575. If the LBN Rehab and Health, Inc. is displayed 
on the IRS CP-575, the contractor may accept the 
match.  If Rehabilitation and Health, Inc. is present, 
the contractor should ask the provider to correct its 
NPPES information. The provider must change its 
LBN in NPPES to read in accordance with the IRS 
CP-575. 
 
Many enrolled providers may actually be subparts of other enrolled providers, and some of those 
subparts entered their doing business as name as their LBN when applying for their NPIs.  
Once a contractor determines for certain that this situation exists, the contractor shall ask the 
provider to correct its NPPES information.  The provider can (1) change its LBN in NPPES to 
read in accordance with the IRS CP-575, and (2) report its doing business as name in NPPES 
as an Other Name and indicate the type of other name as a doing business as name. 
 
10.6.4  Provider and Supplier Business Structures 
(Rev. 10868; Issued: 07-14-21; Effective: 08-13-21; Implementation: 08-13-21) 
 
This section explains the legalities of various types of business organizations that may enroll, 
including sole proprietorships.  Note that the providers or suppliers (hereafter occasionally 
referred to collectively as provider) organizational structure can have a significant impact 
on the type of information it must furnish on the Form CMS-855 or CMS-20134. 
 
Business organizations are generally governed by state law.  Thus, State X may have slightly 
different rules than State Y regarding certain entities.  (In fact, X may permit the creation of 
certain types of legal entities that Y does not.)  The discussion below gives only a broad 
overview of the principal types of business entities and does not take into account different 
state nuances. 
 
Since CMS issues a 1099 based on an enrolled entitys business structure, providers should 
consult their accountant or legal advisor to ensure that they are establishing the correct 
business structure. 
 
A.  Sole Proprietorships 
 
A business is a sole proprietorship if it meets all of the following criteria: 
    It files a Schedule C (1040) with the Internal Revenue Service (this form reports the 
businesss profits/losses); 
 
  One person owns all of the businesss assets; and 
 
  It is not incorporated. 
 
A sole proprietorship is not a corporation.  Suppose a physician operates his/her business as a 
home health agency.  If he/she incorporates his/her business, the business becomes a 
corporation (even though the physician is the only stockholder).  The frequently used term 
unincorporated sole proprietorship is therefore a misnomer because sole proprietorships by 
definition are unincorporated.  In addition, merely because the sole proprietor hires 
employees does not mean the business is no longer a sole proprietorship.  Assume that W is a 
sole proprietor and he hires X, Y, and Z as employees.  Ws business is still a sole 
proprietorship because he remains the 100% owner of the business.  If, however, W had sold 
parts of his sole proprietorship to X, Y, and Z, the business would no longer be a sole 
proprietorship because there is now more than one owner. 
 
Note that professional associations (PAs) are generally not considered to be sole 
proprietorships; the PA designation is typically used in states that do not allow individuals to 
incorporate and form professional corporations.  The PA will have its own employer 
identification number and is considered (like a professional corporation) to be a legal entity 
that is separate and distinct from the individual. 
 
B.  Processing Enrollments for Sole Proprietorships 
 
1.  Application Form Sections 
 
If the provider indicates in the Identifying Information/Business Information section of the 
Form CMS-855A, CMS-855B, CMS-855I, CMS-855S or CMS-20134 that he/she is a sole 
proprietor, the contractor shall adhere to the following: 
 
  The legal business name (LBN) in the Business Information section should list the 
persons (the sole proprietors) legal name. 
 
  The tax identification number (TIN) in the Business Information section should list 
the persons social security number. 
 
  The Final Adverse Legal Actions/Convictions section of the Form CMS-855A, CMS-
855B, CMS-855I, CMS-855S or CMS-20134 must be completed with information 
about the individuals final adverse action history. 
 
  The Organizational Ownership and/or Managing Control section of the Form CMS-
855A, CMS-855B, CMS-855I, CMS-855S or CMS-20134 will not apply unless the 
person has hired an entity to exercise operational or managerial control over the 
business (i.e., no owners will be listed in the section, for the sole owner has already  reported his/her personal information in the Identifying Information and Adverse 
Legal Actions sections).   
 
  No owners, partners, or directors/officers need to be reported in the Individual 
Ownership and/or Managing Control section.  However, all managing employees 
(whether W-2 or not) must be listed.   
 
  If the sole proprietor is not enrolling as a physician or non-physician practitioner via 
the Form CMS-855I, he/she may have authorized and delegated officials. 
 
Since most sole proprietorships that complete the Form CMS-855A, CMS-855B, CMS-855I, 
CMS-855S or CMS-20134 will also have an EIN, the contractor shall request from the 
provider a copy of its CP-575, any federal tax department tickets, or any other preprinted 
information from the IRS containing the providers EIN. 
 
2. Reassignments of Benefits 
 
If a physician or non-physician practitioner who is currently reassigning all of his/her 
benefits attempts to enroll as a sole proprietorship or the sole owner of his/her professional 
corporation, professional association, or limited liability company, the contractor shall call or 
e-mail the old practice location to determine if the physician or non-physician practitioner is 
still employed there; if he or she is not, the contractor shall contact the practitioner to verify 
that he or she is indeed attempting to enroll as a sole proprietorship or sole owner. 
 
C.  Partnerships 
 
A partnership is an association of two or more persons/entities who carry on a business for 
profit.  Each partner in a partnership is an owner.  If A and B form the Y Partnership and 
each contributes $50,000 to start the business, each partner owns one-half of Y. 
 
In several respects, a partnership is the opposite of a corporation: 
 
  Each partner is liable for all the debts of the partnership.  Using the example above, 
suppose the Y Partnership breached a contract it had with X, who now sues for 
$10,000.  Since each partner is liable for all debts, X can collect the entire $10,000 
from A, or from B, or $5,000 from each, etc.   This is because, unlike a corporation, a 
partnership is not really a separate and distinct entity from its partners/owners; the 
partners are the partnership.  If Y had been a corporation, the owners (A and B) 
would likely have been shielded from liability. 
 
  There is no double taxation with partnerships.  The partnership itself does not pay 
taxes, although each partner pays taxes on any income he/she earns from the business. 
 
  Unlike a corporation, a partnership generally does not file with the state upon its 
creation documents similar to articles of incorporation.  Instead, a partnership has a 
partnership agreement, which amounts to a contract between the partners outlining 
duties, responsibilities, powers, etc.   
  Each partner has the right to participate in running the businesss day-to-day 
operations, unless the partnership agreement dictates otherwise. 
 
An alternative type of partnership is a limited partnership (as opposed to a general 
partnership, described above).  While possessing many of the characteristics of a 
general partnership, there are some key differences.  First, a limited partnership (LP) 
must file formal documents with the state.  Second, a LP has two types of partners 
general and limited.  The general partner(s) runs the business yet is personally 
responsible for all of the LPs debts; the limited partner(s) has limited liability yet 
cannot participate in the management of the business. 
 
 
D.  Limited Liability Companies  
 
A limited liability company (LLC) is a legal entity that is neither a partnership nor a 
corporation but has characteristics of both.  Its owners have limited liability (as with 
stockholders in a corporation).  Also, the LLC does not pay federal taxes (similar to a 
partnership), although its owners  usually labeled members - must pay taxes on any 
dividends they earn.   
 
An LLC should not be confused with a limited liability corporation, which is a type of 
corporation in some states.  A limited liability company is not a corporation or partnership 
but a distinct legal entity created and regulated by special state statutes. 
 
Note that certain Form CMS-855 or Form CMS-20134 information is required of different 
entities.  The primary example of this is in the Individual Ownership and/or Managing 
Control section.  If the provider is a corporation, it must list its officers and directors on the 
form.  Partnerships and LLCs, on the other hand, do not have officers or directors and 
therefore need not list them. 
 
E.  Joint Ventures 
 
A joint venture is when two or more persons/entities combine efforts in a business enterprise 
and agree to share profits and losses.  It is similar to a partnership and is treated as a 
partnership for tax purposes.  The core difference is that while a partnership is an ongoing 
business, a joint venture is a temporary, one-time business undertaking.  A joint venture, 
therefore, is to some extent a temporary partnership. 
 
F.  Corporations 
 
A corporation is an entity that is separate and distinct from its owners (called stockholders, or 
shareholders).  To form a corporation, various documents  such as articles of incorporation 
 must be filed with the state in which the business will incorporate.  The principal elements 
of a corporation are: 
    Limited Liability  This is the main reason for a businesss decision to operate as a 
corporation.  Suppose Corporation X has ten stockholders, each owning 10% of the 
business.  X breached a contract it had with Company Y, which now wants to sue Xs 
owners.  Unfortunately for Y, it can generally only sue X itself; it cannot sue Xs 
shareholders.  The corporations owners are essentially shielded from liability for the 
corporation actions because, as stated above, a corporation is separate and distinct 
from its owners. 
 
  Despite the concept of limited liability, there may be isolated instances where a 
corporations owners/stockholders can be held personally liable for the corporations 
debts.  This is known as piercing the corporate veil.  
 
  Double Taxation  This is the principal reason for a businesss decision not to be a 
corporation.  Double taxation means that: (1) the corporation itself must pay taxes; 
and (2) each shareholder must pay taxes on any dividends he/she receives from the 
business. 
 
  Board of Directors  Most corporations are run by a governing body, typically called 
a board of directors. 
 
(As discussed in section 10.6.7.2 of this chapter, there is an important difference 
between the term director in the context of board members and someone who has 
director in his/her job title (e.g., Director of Finance).  Simply because an 
individual works for a corporation as a director of a department, unit, etc., does not 
automatically mean he/she is a member of the board of directors.  If the entity is a 
corporation, and for purposes for the Individual Ownership and/or Managing Control 
section of the Form CMS-855 and Form CMS-855, the term director means board 
members.    
 
Two special types of corporations that contractors may encounter are: 
 
  Professional Corporation (PC) - In general, a PC (1) is organized for the sole 
purpose of rendering professional services (such as medical or legal), and (2) all 
stockholders in a PC must be licensed to render such services.  Thus, if A, B, and C 
want to form a physician practice (each is a 1/3 stockholder) and only A is a medical 
professional, a PC probably cannot be formed (depending, though, on what the 
applicable state PC statute says).  A PCs title will usually end in PC, PA 
(Professional Association), or Chartered. 
 
  Close Corporation (CC) (or closely-held corporation)  This type of corporation 
has a very limited number of stockholders.  Unlike most corporations, a CCs board 
of directors generally does not run the business; rather, the shareholders do.  The 
stock is typically not sold to outsiders. 
 
Although PCs and CCs are considered corporations for enrollment purposes, state laws 
governing these entities are often different from those that govern regular corporations 
(i.e., states have separate statutes for regular corporations and for PCs/CCs.)   In many  cases, an entity must specifically elect to be a PC or CC when filing its paperwork with the 
state. 
 
G.  Non-Profit Organizations 
 
The term non-profit organization (NPO) can be misleading.  It does not signify an 
organization that is prohibited from making a profit.   Rather, it means that all of the 
organizations profits are put back into the entity to promote its goals, which are usually 
political, social, religious, or charitable in nature; an NPO is not organized primarily for 
profit but instead to further some other goal.  An entity can acquire NPO status by obtaining 
an IRS 501(c)(3) certification from the IRS (meaning it is tax-exempt) or by acquiring such 
status from the state in which it is located. 
 
NPOs are typically operated and/or managed by a board of trustees or other governing body.
NPO status is important for enrollment purposes because NPOs generally do not have 
  
owners.  (See section 10.6.4(D)(3) of this chapter for more information on NPO reporting 
requirements.) 
 
H.  Government-Owned Entities 
 
For purposes of enrollment, a government-owned entity (GOE) exists when a particular 
government body (e.g., federal, state, city or county agency) will be legally and financially 
responsible for Medicare payments received.  For example, suppose Smith County operates 
Hospital X.  Medicare overpaid X $100,000 last year.  If Smith County is the party 
responsible for reimbursing Medicare this amount, X is considered a government-owned 
entity. 
 
Note that-- 
 
  GOEs do not have owners.  Thus, the Organizational Ownership and/or Managing 
Control sections of the Form CMS-855 or CMS-20134 need only contain the name of the 
government body in question.  Using our example above, this would be Smith County. 
 
  For the Individual Ownership and/or Managing Control section of the Form CMS-855 or 
CMS-20134, the only people that must be listed are managing employees.  This is 
because GOEs do not have corporate officers or directors. 
 
The provider must submit a letter from the government body certifying that the government 
entity will be responsible for any Medicare payments. 
 
10.6.5  National Provider Identifier (NPI) 
(Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Submission of NPI 
 
Every provider or supplier that submits an enrollment application must furnish its NPI(s) in the 
applicable section(s) of the Form CMS-855 or CMS-20134.  The provider need not submit a  copy of the NPI notification it received from the National Plan and Provider Enumeration 
System (NPPES) because PECOS will verify the NPIs of the provider/supplier and all other NPIs 
listed on the application.   
 
B.  Additional NPI Information 
 
The contractor shall only enter NPI data into PECOS that is submitted in conjunction with a 
Form CMS-855 or CMS-20134 (e.g., initial, change request).  Thus, if a provider submits a Form 
CMS-855 or CMS-20134 change of information that only reports the providers newly assigned 
NPI, or reports multiple NPIs that need to be associated with a single Medicare identification 
number, the contractor may treat this as a change request and enter the data into PECOS. 
 
C.  Subparts - General 
 
The contractor shall review and become familiar with the principles outlined in the Medicare 
Expectations Subpart Paper, the text of which follows below.  It was originally issued in 
January 2006 and has since been slightly updated to reflect certain changes in Medicare 
terminology. 
 
CMS encourages all providers to obtain NPIs in a manner similar to how they receive CMS 
Certification Numbers (CCNs) (i.e., a one-to-one relationship).  For instance, suppose a home 
health agency is enrolling in Medicare.  It has a branch as a practice location.  The main provider 
and the branch will typically receive separate (albeit very similar) CCNs.   It would be advisable 
for the provider to obtain an NPI for the main provider and another one for the branch  that is, 
one NPI for each CCN. 
 
D.  Medicare Subparts Paper - Text 
 
MEDICARE EXPECTATIONS ON DETERMINATION OF SUBPARTS  
BY MEDICARE ORGANIZATION HEALTH CARE PROVIDERS WHO ARE 
COVERED ENTITIES UNDER HIPAA 
 
 
Purpose of this Paper 
 
Medicare assigns unique identification numbers to its enrolled health care providers.  They are 
used to identify the enrolled health care providers in the HIPAA standard transactions that they 
conduct with Medicare (such as electronic claims, remittance advices, eligibility 
inquiries/responses, claim status inquiries/responses, and coordination of benefits) and in cost 
reports and other non-standard transactions. 
 
This paper is a reference for Medicare contractors.  It reflects the Medicare programs 
expectations on how its enrolled organization health care providers that are covered entities 
under HIPAA1 will determine subparts and obtain NPIs for themselves and any subparts.   These 
 
1 Covered entities under HIPAA are health plans, health care clearinghouses, and those health care 
providers who transmit any health information in electronic form in connection with a health transaction 
for which the Secretary of HHS has adopted a standard (referred to in this paper as HIPAA standard  expectations may change over time to correspond with any changes in Medicare statutes, 
regulations, or policies that affect Medicare provider enrollment. 
 
These expectations are based on the NPI Final Rule, on statutory and regulatory requirements 
with which Medicare must comply, and on policies that are documented in Medicare operating 
manuals and other directives.  These Medicare statutes, regulations and policies pertain to 
conditions for provider participation in Medicare, enrollment of health care providers in 
Medicare and assignment of identification numbers for billing and other purposes, submission of 
cost reports, calculation of payment amounts, and the reimbursement of enrolled providers for 
services furnished to Medicare beneficiaries. 
   
This paper categorizes Medicares enrolled organization health care providers as follows: 
 
  Certified providers and certified suppliers 
  Supplier groups and supplier organizations 
  Suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) 
 
This paper is not intended to serve as official HHS guidance to the industry in determining 
subparts for any covered health care providers other than those that are organizations and are 
enrolled in the Medicare program.  This paper does not address health care providers who are 
enrolled in Medicare as individual practitioners.  These practitioners are Individuals (such as 
physicians, physician assistants, nurse practitioners, and others, including health care providers 
who are sole proprietors).  In terms of NPI assignment, an Individual is an Entity Type 1 
(Individual) and is eligible for a single NPI.   As Individuals, these health care providers cannot 
be subparts and cannot designate subparts.  A sole proprietorship is a form of business in which 
one person owns all of the assets of the business and the sole proprietor is solely liable for all of 
the debts of the business.  There is no difference between a sole proprietor and a sole 
proprietorship.  In terms of NPI assignment, a sole proprietor/sole proprietorship is an Entity 
Type 1 (Individual) and is eligible for a single NPI.  As an Individual, a sole proprietor/sole 
proprietorship cannot have subparts and cannot designate subparts. 
 
Discussion of Subparts in the NPI Final Rule and its  
Applicability to Enrolled Medicare Organization Health Care Providers 
 
The NPI Final Rule adopted the National Provider Identifier (NPI) as the standard unique health 
identifier for health care providers for use in HIPAA standard transactions.  On or before May 
23, 2007, all HIPAA covered entities (except small health plans), to include enrolled Medicare 
providers and suppliers that are covered entities, were required to obtain NPIs and to use their 
NPIs to identify themselves as health care providers in the HIPAA standard transactions that 
they conduct with Medicare and other covered entities.  Covered organization health care 
providers are responsible for determining if they have subparts that need to have NPIs.  If such 
subparts exist, the covered organization health care provider must ensure that the subparts obtain 
their own unique NPIs, or they must obtain them for them. 
 
 
transactions).  Most Medicare Organization health care providers send electronic claims to Medicare (they 
are HIPAA standard transactions), making them covered health care providers (covered entities).  The NPI Final Rule contains guidance for covered organization health care providers in 
determining subparts.  Subpart determination is necessary to ensure that entities within a covered 
organization health care provider that need to be uniquely identified in HIPAA standard 
transactions obtain NPIs for that purpose. 
 
The following statements apply to all entities that could be considered subparts: 
 
  A subpart is not itself a separate legal entity, but is a part of a covered organization health 
care provider that is a legal entity.  (All covered entities under HIPAA are legal entities.) 
 
  A subpart furnishes health care as defined at 45 CFR  160.103. 
 
The following statements may relate to some or all of the entities that a Medicare covered 
organization health care provider could consider as subparts: 
 
  A subpart may or may not be located at the same location as the covered organization 
health care provider of which it is a part. 
 
  A subpart may or may not have a Taxonomy (Medicare specialty) that is the same as the 
covered organization health care provider of which it is a part. 
 
  Federal statutes or regulations pertaining to requirements for the unique identification of 
enrolled Medicare providers may relate to entities that could be considered subparts 
according to the discussion in the NPI Final Rule.  Medicare covered organization health 
care providers must take any such statutes or regulations into account to ensure that, if 
Medicare providers are uniquely identified now by using Medicare identifiers in HIPAA 
standard transactions, they obtain NPIs in order to ensure they can continue to be 
uniquely identified.  Medicare is transitioning from the provider identifiers it currently 
uses in HIPAA standard transactions (for organizations, these could be CCNs, Provider 
Transaction Access Numbers (PTANs)known as legacy identifiers or legacy numbers) 
to NPIs.  This makes it necessary that Medicare organization health care providers obtain 
NPIs because the NPIs have replaced the identifiers currently in use in standard 
transactions with Medicare and with all other health plans.  In addition, Medicare 
organization health care providers must determine if they have subparts that need to be 
uniquely identified for Medicare purposes (for example, in HIPAA standard transactions 
conducted with Medicare).  If that is the case, the subparts will need to have their own 
unique NPIs so that they can continue to be uniquely identified in those transactions. 
 
  A subpart that conducts any of the HIPAA standard transactions separately from the 
covered organization health care provider of which it is a part must have its own unique 
NPI. 
 
Enrolled Medicare organization health care providers that are covered entities under HIPAA 
must apply for NPIs as Organizations (Entity Type 2).  Organization health care providers as 
discussed in this paper are corporations or partnerships or other types of businesses that are 
considered separate from an individual by the State in which they exist.  Subparts of such 
organization health care providers who apply for NPIs are also Organizations (Entity Type 2).   
Medicare Statutes, Regulations, Manuals 
 
The Social Security Act (sections 1814, 1815, 1819, 1834, 1861, 1865, 1866, and 1891) and 
Federal regulations (including those at 42 CFR 400.202, 400.203, 403.720, 405.2100, 409.100, 
410.2, 412.20, 416.1, 418.1, 424, 482.1, 482.60, 482.66, 483, 484, 485, 486, 489, 491, and 
493.12) establish, among other things, the Conditions for Participation for Medicare providers 
and set requirements by which Medicare enrolls providers, requires cost reports, calculates 
reimbursement, and makes payments to its providers.  These Medicare statutory and regulatory 
requirements are further clarified in various Medicare operating manuals, such as the State 
Operations Manual and the Program Integrity Manual, in which requirements and policies 
concerning the assignment of unique identification numbers, for billing and other purposes, are 
stated. 
 
Medicare Organization Providers and Subparts: 
Certified Providers and Certified Suppliers 
 
Existing Medicare laws and regulations do not establish requirements concerning the assignment 
of unique identification numbers to Medicare certified providers and certified suppliers for 
billing purposes. 
 
Certified Providers that bill Medicare Part A (hereinafter referred to as providers): 
 
  Providers apply for Medicare enrollment by completing a Form CMS-855A. 
 
  Most providers are surveyed and certified by the States3 prior to being approved as Medicare 
providers.2 
 
  Providers have in effect an agreement to participate in Medicare. 
 
  Providers include, but are not limited to:  skilled nursing facilities, hospitals4, critical access 
hospitals, home health agencies, rehabilitation agencies (outpatient physical therapy, speech 
therapy), comprehensive outpatient rehabilitation facilities, hospices, community mental 
health centers, religious non-medical health care institutions. 
 
  Providers are assigned CCNs to identify themselves in Medicare claims and other 
transactions, including cost reports for those providers that are required to file Medicare cost 
reports. 
 
  In general, each entity that is surveyed and certified by a State is separately enrolled in 
Medicare and is considered a Medicare provider.  (One exception involves home health 
agency branches.  The branches are not separately enrolled Medicare providers.)  In many 
cases, the enrolled provider is not itself a separate legal entity; i.e., it is an entity that is a part 
 
 
2 Religious non-medical health care institutions are handled differently. 
3 Hospitals bill Medicare Part B for certain types of services. 4 The check-digit algorithm will determine the validity of an NPI.  
This is not the same as knowing the health care provider being identified by a particular NPI.  of an enrolled provider that is a legal entity and is, for purposes of the NPI Final Rule, 
considered to be a subpart. 
 
Certified Suppliers, which bill Medicare Part B: 
 
  Certified suppliers apply for Medicare enrollment by completing a Form CMS-855A or 
CMS-855B, depending on the supplier type.3 
 
  Certified suppliers include ambulatory surgical centers, portable x-ray suppliers, independent 
clinical labs (CLIA labs), rural health centers, and federally qualified health centers. 
 
  Certified suppliers are typically surveyed and certified by the States prior to being approved 
for enrollment as Medicare certified suppliers.  (For CLIA labs, each practice location at 
which lab tests are performed must obtain a separate CLIA Certificate for that location, 
though there are a few exceptions to this.) 
 
  Certified suppliers may have in effect an agreement to participate in Medicare. 
 
  Certified suppliers are assigned CCNs for purposes of identification within Medicare 
processes.  However, the contractors assign unique identification numbers to certain certified 
suppliers for billing purposes.  (For CLIA labs, a CLIA number is typically assigned to each 
practice location for which a CLIA certificate is issued.  A CLIA number may not be used to 
identify a clinical laboratory as a health care provider in HIPAA standard transactions.  
The CLIA number has no relation to the Medicare PTAN.) 
 
  In many cases, the enrolled certified supplier is not itself a separate legal entity; i.e., it is an 
entity that is a part of an enrolled provider or certified supplier that is a legal entity and is, for 
purposes of the NPI Final Rule, considered to be a subpart. 
 
In general, Medicare bases its enrollment of providers and certified suppliers on two main 
factors:  (1) whether a separate State certification or survey is required, and (2) whether a 
separate provider or certified supplier agreement is needed.  (The Taxpayer Identification 
Number, or TIN, is a consideration as well, though not to the degree of the two main factors.)  
The CMS Survey & Operations Group (SOG) Location generally make the final determinations 
on both of these factors; hence, Medicare provider and certified supplier enrollment policy is 
dictated to a significant degree by the CMS regional offices decisions in particular cases. 
 
Medicare Expectations for NPI Assignments for Providers and Certified Suppliers:  To 
help ensure that Medicare providers and certified suppliers do not experience denials of claims or 
delays in Medicare claims processing or reimbursement, Medicare encourages each of its 
enrolled providers and certified suppliers to obtain its own unique NPI.  These NPIs have 
replaced the legacy numbers that are used today in HIPAA standard transactions and in other 
transactions, such as cost reports.  In order for subpart determinations to mirror Medicare 
enrollment, each enrolled provider and certified supplier that is a covered organization health 
care provider should:  
 
  Obtain its own unique NPI.   
  Determine if it has any subparts that are themselves enrolled Medicare providers.  If there are 
subparts, ensure that they obtain their own unique NPIs, or obtain the NPIs for them.  
Example:  An enrolled provider (a hospital) owns 10 home health agencies, all operating 
under the TIN of the hospital.  Because the hospital and each of the 10 home health agencies 
is separately surveyed and enters into its own provider agreement with Medicare, a total of 
11 unique NPIs should be obtained:  one for the hospital, and one for each of the 10 home 
health agencies. 
 
Regardless of how an enrolled provider or certified supplier that is a covered organization health 
care provider determines subparts (if any) and obtains NPIs (for itself or for any of its subparts, if 
they exist), Medicare payments, by law, may be made only to an enrolled provider or certified 
supplier. 
 
Medicare Organization Providers and Subparts: 
Supplier Groups and Supplier Organizations 
 
Existing Medicare laws and regulations do not establish requirements concerning the assignment 
of unique identification numbers to supplier groups and supplier organizations for billing 
purposes. 
 
  Supplier groups and supplier organizations apply for Medicare enrollment by completing a 
Form CMS-855B or CMS-20134. 
 
  Supplier groups and supplier organizations bill Medicare Part B. 
 
  Certain supplier organizations are certified by the States, certified by the Food and Drug 
Administration (FDA), or must undergo an on-site inspection by the contractor.  These 
requirements vary by type of supplier organization. 
 
  Supplier groups are primarily group practices, such as a group of physicians or other 
practitioners. 
 
  Supplier organizations include ambulance companies, mammography facilities, 
independent diagnostic testing facilities (IDTFs) and MDPP Suppliers. 
 
Medicare enrolls supplier groups/supplier organizations based on TINs.  A supplier group or 
supplier organization may have multiple locations; however, if each location operates under the 
same single TIN, Medicare does not separately enroll each location. There are exceptions: 
 
1. When there is more than one Medicare specialty code associated with a single TIN. For 
instance, if a physician group practice is also an IDTF, it has two different Medicare specialties.  
The supplier group (the physician group practice) must enroll as a group and the supplier 
organization (the IDTF) must enroll as a supplier organization.  The group practice would 
complete a Form CMS-855B and the IDTF would complete a Form CMS-855B.  Each one 
would receive its own unique Medicare identification number. 
  2. If a separate site visit, state certification, or on-site inspection by the contractor or if FDA 
certification is required for each practice location of that supplier group/supplier organization. 
 
In these above exceptions, Medicare separately enrolls each different Medicare specialty and 
each separately visited, certified or contractor-inspected practice location. 
 
Medicare Expectations for NPI Assignments for Supplier Groups and Supplier 
Organizations:  To help ensure that Medicare supplier groups and supplier organizations do not 
experience delays in Medicare claims processing or reimbursement, Medicare encourages each 
of its enrolled supplier groups and supplier organizations to obtain its own unique NPI.  These 
NPIs have replaced the legacy numbers that are used today in HIPAA standard transactions and 
in other transactions, such as cost reports.  In order for subpart determinations to mirror 
Medicare enrollment, each enrolled supplier group and supplier organization that is a covered 
organization health care provider should ensure the following: 
 
  Obtain its own unique NPI. 
 
  Determine if it has any subparts that are themselves enrolled Medicare providers.            If 
there are subparts, ensure that they obtain their own unique NPIs, or obtain the NPIs for 
them. 
 
EXAMPLE:  An enrolled IDTF has four different locations, and each one must be separately 
inspected by the contractor.  All four locations operate under a single TIN.  Because each 
location is separately inspected in order to enroll in Medicare, a total of four unique NPIs should 
be obtained:  one for each location. 
 
Regardless of how an enrolled supplier group or supplier organization that is a covered 
organization health care provider determines subparts (if any) and obtains NPIs (for itself or for 
any of its subparts, if they exist), Medicare payments, by law, may be made only to an enrolled 
supplier group or supplier organization. 
 
Medicare Organization Providers and Subparts: DMEPOS Suppliers  
 
Medicare regulations require that each practice location of a supplier of DMEPOS (if it has more 
than one) must, by law, be separately enrolled in Medicare and have its own unique Medicare 
identification number. 
 
  A supplier of DMEPOS enrolls in Medicare by completing a Form CMS-855S. 
 
  Suppliers of DMEPOS bill Durable Medical Equipment Medicare Administrative 
Contractors (DME MACs). 
 
  Suppliers of DMEPOS include but are not limited to pharmacies, oxygen 
suppliers, and outpatient physical therapy agencies.  (Any organization that sells 
equipment or supplies that are billed to Medicare through the DME MAC must be 
enrolled as a supplier of DMEPOS via the appropriate NPE contractor.  
Sometimes, these are organizations that also furnish services that are covered by  Medicare, such as ambulatory surgical centers.  In order to be reimbursed for the 
DME supplies that they sell, they must separately enroll in Medicare as a supplier 
of DME.) 
 
Medicare Expectations for NPI Assignments for Suppliers of DMEPOS:  Each enrolled 
supplier of DMEPOS that is a covered entity under HIPAA must designate each practice location 
(if it has more than one) as a subpart and ensure that each subpart obtains its own unique NPI. 
 
Final Notes About NPIs 
 
Enrolled organization health care providers or subparts that bill more than one Medicare 
contractor:  An enrolled organization health care provider or subpart is expected to use a single 
(the same) NPI when billing more than one Medicare contractor.  For example, a physician 
group practice billing Contractor X and also billing Contractor Y would use a single (the same) 
NPI to bill both contractors. 
 
Enrolled organization health care providers or subparts that bill more than one type of 
Medicare contractor:  Generally, the type of service being reported on a Medicare claim 
determines the type of Medicare contractor that processes the claim.  Medicare will expect an 
enrolled organization health care provider or subpart to use a single (the same) NPI when billing 
more than one type of Medicare contractor.  However, in certain situations, Medicare requires 
that the organization health care provider (or possibly even a subpart) enroll in Medicare as more 
than one type of provider.  For example, an ambulatory surgical center enrolls in Medicare as a 
certified supplier and bills a Part A/B MAC.  If the ambulatory surgical center also sells durable 
medical equipment, it must also enroll in Medicare as a supplier of DME and bill a DME MAC.  
This ambulatory surgical center would obtain a single NPI and use it to bill the A/B MAC and 
the DME MAC.  Medicare expects that this ambulatory surgical center would report two 
different Taxonomies when it applies for its NPI:  (1) that of ambulatory health care facility
clinic/center--ambulatory surgical (261QA1903X) and (2) that of suppliersdurable medical 
equipment & medical supplies (332B00000X) or the appropriate sub-specialization under the 
332B00000X specialization. 
 
Enrolled organization health care providers that determine subparts for reasons unrelated 
to Medicare statutes, regulations or policies: 
 
Consistent with the NPI Final Rule, covered organization health care providers designate 
subparts for reasons that are not necessarily related to Medicare statutes or regulations.  If a 
Medicare organization health care provider designates as subparts entities other than those that 
are enrolled Medicare providers, and those subparts obtain their own NPIs and use those NPIs to 
identify themselves in HIPAA standard transactions with Medicare, those NPIs will not identify 
enrolled Medicare providers.  Medicare is not required to enroll them. (NPI Final Rule, page 
3441:  If an organization health care provider consists of subparts that are identified with their 
own unique NPIs, a health plan may decide to enroll none, one, or a limited number of them (and 
to use only the NPIs of the one(s) it enrolls.)) 
 
Medicare uses NPIs to identify health care providers and subparts in HIPAA standard 
transactions.  (NPI Final Rule, page 3469: section 162.412(a):  A health plan must use the NPI 
of any health care provider (or subpart(s), if applicable) that has been assigned an NPI to identify  that health care provider on all standard transactions where that health care providers identifier 
is required.)  Medicare ensures that the NPIs it receives in HIPAA standard transactions are 
valid5.  Medicare rejects HIPAA standard transactions that contain invalid NPIs.  Valid NPIs, 
however, like the provider identifiers used today, must be known to Medicare.  Medicare is not 
permitted to make payments for services rendered by non-Medicare providers, nor is it permitted 
to reimburse providers that are not enrolled in the Medicare program.  Medicare returns, with 
appropriate messages, any HIPAA standard transactions containing valid but unrecognizable 
NPIs.4 
 
10.6.6  Final Adverse Actions 
(Rev. 11536, Issued: 08-05-22; Effective:09-06-22; Implementation:09-06-22) 
 
Unless stated otherwise, the instructions in this section 10.6.6 apply to the following sections of 
the Form CMS-855 and Form CMS-20134: 
 
  Final Adverse Actions/Convictions (Section 3 of the Form CMS-855A, Form CMS-855B, 
Form CMS-855I, Form CMS-855O, and Form CMS-20134, and Section 7 of the Form CMS-
855S) 
 
  Business Information section/Private Practice Business Information section of the Form 
CMS-855I 
 
  Organizational Ownership and/or Managing Control Final Adverse Legal Action History 
Section (Section 5 of the Form CMS-855A, Form CMS-855B, and Form CMS-20134, and 
Section 8 of the Form CMS-855S) 
 
  Individual Ownership and/or Managing Control Final Adverse Legal Action History Section 
(Section 6 of the Form CMS-855A, Form CMS-855B, Form CMS-855I, and Form CMS-
20134, and Section 9 of the Form CMS-855S)  
 
For purposes of this section 10.6.6, the terms final adverse action and adverse legal action 
(as those terms are explained in section 10.6.6(F) of this chapter) will be collectively referred to 
as ALA(s), unless otherwise noted.  In addition, references to Form CMS-855 do not include 
the Form CMS-855R; this means that the contractor need not review the validation databases 
(e.g., OIG) described in this section 10.6.6 for Form CMS-855R submissions.) 
 
A.  Prior Approval 
 
The contractor shall send the application (if applicable) and ALA information to CMS (in 
accordance with section 10.6.6(I) below) for review for potential administrative action if: 
 
  If the provider/supplier discloses its ALA on the Form CMS-855 or Form CMS-20134; 
 
 
4 The check-digit algorithm will determine the validity of an NPI.  This is not the same as knowing the health care provider being 
identified by a particular NPI.    If the provider/supplier discloses the ALA of an associated individual/entity on the Form 
CMS-855 or Form CMS-20134; or 
 
  The contractor discovers---on its own volition and regardless of whether the 
provider/supplier is submitting a Form CMS-855 or Form CMS-20134---a 
providers/suppliers ALA or that of an associated individual or entity of the 
provider/supplier. 
 
In this chapter, and unless otherwise noted, associated individuals/entities refer to parties listed 
under the Ownership Interest and/or Managing Control Information sections of the Form 
CMS-855 or Form CMS-20134.  
 
B.  Review of the Provider Enrollment, Chain and Ownership System (PECOS) 
 
If the contractor is reviewing a providers/suppliers Form CMS-855 or Form CMS-20134 
application for potential denial or revocation based on an ALA, the contractor shall search 
PECOS to determine whether the individual/entity with the ALA has any other associations (e.g., 
is listed in PECOS as an owner or managing employee of three Medicare-enrolled providers). 
This review requires searching the tax identification number (TIN) of the individual/entity and 
clicking Associates w/ Connections in PECOS.  The TIN is the social security number or 
employer identification number (EIN).  
 
If the contractor finds such an association and there are grounds to revoke the associated 
enrollment(s) of other provider(s)/supplier(s), the contractor shall submit the revocation 
referral(s) to CMS at ProviderEnrollmentRevocations@cms.hhs.gov.    
 
C.  Chain Home Offices, Billing Agencies, and Home Health Agency Nursing Registries 
 
If the contractor discovers that an entity listed in Section 7 of the Form CMS-855A, Section 8 of 
the Forms CMS-855A/B/I/20134, or Section 12 of the Form CMS-855A has had an ALA 
imposed against it, the contractor shall contact its Provider Enrollment & Oversight Group 
Business Function Lead (PEOG BFL) for guidance if needed.  For any ALA against individuals 
listed in Section 7 of the Form CMS-20134, the contractor shall refer to section 10.3.2.7 of this 
chapter, where this process is outlined in detail. 
 
D. Review of the U.S. Department of Health and Human Services (HHS) Office of 
Inspector General (OIG) Online Searchable Database and the System for Award 
Management (SAM)  
 
(NOTE: The required reviews described in this subsection (D) do not apply to (a) voluntary 
termination submissions, (b) Form CMS-855R submissions, and (c) associated 
individuals/entities being deleted/removed on the Form CMS-855 or Form CMS-20134.  
Moreover, the review requirement only applies to data that is reported via an actual submission.  
Data that has previously been reported (and thus is not part of the submission in question) need 
not be reviewed.  To illustrate, suppose a provider has 20 managing employees on file in 
PECOS.  It submits a change request to add two more managing officials.  The contractor need 
only review the two officials.  It need not check the other 20.)   
Except as otherwise stated in this section 10.6.6, the contractor shall review each submission of a 
Form CMS-855 or Form CMS-20134 for (1) any exclusion(s) by HHS OIG of the 
provider/supplier and (2) exclusion(s) of any associated individuals/entities listed in the 
Ownership Interest and/or Managing Control Information Sections (e.g., an owner, managing 
employee, or authorized official), regardless of whether the provider/supplier reported the 
exclusion on the application (as applicable).   
 
The OIG Online Searchable Database is located at exclusions.oig.hhs.gov; it includes all active 
exclusions for an individual or entity. The contractor shall verify the exclusion by entering the 
TIN of the excluded individual/entity and shall save that screenshot of the exclusion. (No 
screenshot is needed if no exclusion is involved.)  The contractor shall also search for (1) any 
waivers to the HHS OIG exclusion and (2) any conviction(s) that may be tied to an exclusion 
(see section 10.6.6(G) and the applicable Decision Tree tables in section 10.6.6(I) for more 
details.  In addition, if PECOS shows any associated enrollments (by TIN) of the excluded 
individual/entity that are not voluntarily withdrawn from Medicare, the contractor shall include 
this information in the ALA referral to CMS (as well as indicate whether CMS can take 
administrative action on the associated enrollment(s)).  
 
In addition---and except as otherwise stated in this section 10.6.6---the contractor shall review 
each submission of a Form CMS-855 or Form CMS-20134 and search the SAM (i.e., at 
SAM.gov; formerly, the General Services Administration Excluded Parties List System) for 
exclusions/debarments if there is no HHS OIG exclusionas identified on the OIG Online 
Searchable Databasefor the provider/supplier and for any associated individuals/entities listed 
under the Ownership Interest and/or Managing Control Information Sections (e.g., an owner, 
managing employee, or authorized official). Only if SAM populates an exclusion/debarment
that the OIG Online Searchable Database does not populateshall the contractor save that SAM 
screenshot when sending the ALA referral to CMS (even if the contractor learns from OIG that 
the exclusion is not active).   
 
When an entity or individual is listed as debarred in the SAM (i.e., at SAM.gov), the SAM 
record may identify associated entities and persons that are also debarred. To illustrate, suppose 
John Smith is identified as debarred. The SAM record may also list individuals and entities 
associated with John Smith that are debarred as well, such as John Smith Company, Smith 
Consulting, Jane Smith, and Joe Smith. 
 
If the contractor learns via the Form CMS-855 or Form CMS-20134 verification process, a 
Unified Program Integrity Contractor (UPIC) referral, or other similar means that a particular 
individual/entity is debarred or excluded, the contractor shall search the individual/entity in the 
SAM to see if the SAM record discloses any associated parties that are debarred or excluded. If 
associated parties are listed, the contractor  after verifying, via the instructions in this chapter, 
that the associated party is indeed debarred  shall check PECOS to determine whether the party 
is listed in any capacity.  If the party is listed, the contractor shall take all applicable steps 
outlined in this chapter with respect to revocation proceedings against the party and against any 
persons/entities with whom the party is associated.  For instance, using our example above, if the 
contractor confirms that Jane Smith is debarred and PECOS shows Jane Smith as an owner of 
Entity X, the contractor shall, as applicable, send an ALA referral to CMS for review for 
potential administrative action against X as outlined in this section 10.6.6.     
In instances where an HHS OIG exclusion populates SAM but not the OIG Online Searchable 
Database, this could mean that the provider/supplier (or associated individual/entity) has been 
reinstated but the SAM has not been accordingly updated.  In such cases, the contractor shall 
contact the appropriate OIG official to (1) verify whether the exclusion is still active, (2) 
determine the date of reinstatement (if applicable), and (3) request the reinstatement letter from 
HHS OIG (if applicable). The contractor can find the appropriate OIG official on the Exclusion 
Record of an individual/entity on SAM by clicking on the respective Excluding Agency (as the 
respective contact information would populate there). The contractor shall, as applicable, include 
this information and the reinstatement letter (if available) when sending the ALA referral to 
CMS. 
 
E.  Disclosure of ALA 
 
This section 10.6.6(E) discusses the disclosure and non-disclosure of ALAs on the Form CMS-
855 and Form CMS-20134 as well as required documentation.   
 
1.  ALA Disclosed 
 
a.   Non-Felonies 
 
If the provider/supplier discloses a non-felony ALA on the Form CMS-855/20134, the 
provider/supplier must furnish documentation concerning (i) the type of reported non-felony 
ALA, (ii) the date the non-felony ALA occurred, and (iii) what court or governing/administrative 
body imposed the action.  (This documentation is referenced in Section 3 of the Form CMS-
855/20134.)  The provider/supplier must furnish the documentation regardless of whether the 
non-felony ALA occurred in a state different from that in which the provider/supplier seeks 
enrollment or is enrolled.  The contractor shall develop for any such documentation that the 
provider/supplier fails to submit using the general developmental procedures outlined in this 
chapter.   
 
b.  Felony Convictions 
 
(As a reminder, this subsection (E)(1)(b) applies only if the felony was disclosed.)   
 
(i)  Acquisition 
 
For felony conviction documentation (and except as stated in subsection (E)(1)(b)(ii) below), the 
contractor shall: 
 
  Develop for any required documentation (as described in subsection (E)(1)(a)(i) through (iii) 
above and on Section 3 of the Form CMS-855) that the provider/supplier fails to submit using 
the general developmental procedures outlined in this chapter; and 
  
  Follow the instructions in subsection (E)(3) regarding the acquisition of the felony-specific 
documentation discussed therein.   
  (ii)  Potential Overlap 
 
In all instances discussed in this subsection (E)(1)(b), the contractor shall secure the mandatory 
documentation subsection (E)(3)(b) below.  If the mandatory documentation captures the same 
information described in subsection (E)(1)(a)(i) through (iii) above, however, the contractor need 
not obtain the separate/additional (E)(1)(a)(i) through (iii) documentation. For instance, suppose 
the mandatory documentation identifies the court that imposed the action.  The contractor need 
not obtain additional documentation verifying this data (as stated in subsection (E)(1)(a)(i) 
through (iii) above and Section 3 of the Form CMS-855).  If, however, the mandatory 
documentation does not contain the data in subsection (E)(1)(a)(i) through (iii), the contractor 
shall develop for this information if the felony was reported. 
 
2.  ALA Is Not Disclosed 
 
This section (E)(2) applies to situations where the contractor discovers an ALA that was not 
reported on the Form CMS-855/20134.   
 
a.  Non-Felonies 
 
For ALAs other than felony convictions, the contractor need not develop for ALA 
documentation unless CMS instructs otherwise. 
 
b.  Felony Conviction 
 
For felony conviction documentation, the contractor shall follow the instructions in section 
10.6.6(E)(3). 
 
 
3.  Special Requirements Concerning Felony Documentation 
 
a.  Introduction 
 
(This subsection (E)(3) applies (i) only to felony convictions and (ii) regardless of whether the 
felony conviction was reported on the Form CMS-855/20134.) 
 
If, in felony conviction situations, the provider/supplier does not submit the mandatory 
documentation described in section 10.6.6(E)(3)(b) below (and, as applicable, the documentation 
in subsection (E)(1)(a)(i) through (iii) above), the contractor shall directly develop for the 
documentation with the provider/supplier using the existing development procedures outlined in 
this chapter; prior approval or instruction from CMS to develop in this scenario is not needed. 
After obtaining the documents (or after an unsuccessful attempt), the contractor shall submit the 
felony referral, application, and any supporting document(s) to CMS for review. The 
provider/supplier must fully submit all of the requested documentation within 30 calendar days 
of the date of the development request. If the provider/supplier fails to do so, the contractor shall 
reject the application, upon PEOG approval; PEOG will then determine, if applicable, whether a 
revocation is warranted.    
 
b.   Documentation to Be Submitted   
Mandatory  When sending the felony referral for review (and except as otherwise stated in this 
chapter), the contractor shall obtain from the provider/supplier and submit to CMS the following 
documentation:  
 
  Judgment and/or sentencing order (as applicable); 
  Any amended judgment and/or amended sentencing order (if applicable); and 
  Jury verdict form or guilty plea acceptance document (as applicable; availability may vary 
from court to court). Note that some courts may incorporate the jury verdict or guilty plea 
entry/acceptance directly into the judgment and/or sentencing order. Also, some courts may 
not have a separate jury verdict form or guilty plea entry/acceptance, in which case the 
judgment and/or sentencing order suffices.  
 
Not Required but Encouraged  The following documentation is optional, though the contractor 
is encouraged to, if possible, secure and submit this material to CMS; the data below could help 
furnish valuable background and context to CMS regarding the case. 
 
  Any document showing the courts dismissal of charges (if applicable) 
  Plea agreement (if applicable) 
  Docket report/case summary 
  Information or indictment 
  Any amended information document(s) or superseding indictment(s)  
  Police criminal complaint and/or affidavit of probable cause 
 
4.  Additional Policies 
 
a.  Reinstatements - If the individual or entity in question was excluded or debarred but has since 
been reinstated, the contractor shall confirm the reinstatement through HHS OIG or, in the case 
of debarment, through the federal agency that took the action. The appropriate OIG contact for 
such reinstatement verification requests is sanction@oig.hhs.gov. SAM.gov provides the 
appropriate contact for the federal agency that took debarment action on the screenshot page of 
that action (when searching the individual/entity).   
 
b.  Scope of Disclosure  All ALAs that occurred under the legal business name (LBN) and TIN 
of the disclosing entity (e.g., applicant, Section 5 owner) must be reported.  
 
Example (A) - Smith Pharmacy, Inc. had 22 separately enrolled locations in 2017. Each location 
was under Smiths LBN and TIN. In 2018, two locations were excluded by the OIG and then 
subsequently revoked by CMS. Smith submits a Form CMS-855S application for a new location 
on Jones Street. Suppose, however, that each of Smiths locations had its own LBN and TIN. 
The Jones Street application need not disclose the two revocations from 2018. 
 
Example (B)  A home health agency (HHA), hospice, and hospital are enrolling under 
Corporation Xs LBN and TIN. X is listed as the provider in Section 2 of each applicants Form 
CMS-855A.  All three successfully enroll.  Six months later, Company Xs enrollment for the 
HHA is revoked due to an OIG exclusion.  Both the hospice and the hospital must report that X 
was excluded on a Form CMS-855A change request because X is under the providers LBN and  TIN. Assume now that X seeks to enroll an ambulatory surgical center (ASC) under Xs LBN 
and TIN. The exclusion would have to be reported in Section 3 of the ASCs initial Form CMS-
855B. 
 
Example (C)  Company Y is listed as the provider/supplier for two HHAs and two suppliers of 
durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). These four 
providers/suppliers are under Ys LBN and TIN. Each provider/supplier is located in a different 
state. All are enrolled.  Ys enrollment for one of the DMEPOS suppliers is revoked due to a 
felony conviction. Y now seeks to enroll an ASC in a fifth state. Y must disclose its felony 
conviction even though the felony conviction occurred in a state different from that in which the 
ASC is located. 
 
c.  Timeframe  With the exception of felony and misdemeanor convictions (and unless stated 
otherwise in this chapter), all ALAs must be reported in the final adverse legal action section of 
the Form CMS-855 or Form CMS-20134 regardless of when the final adverse legal action 
occurred. 
 
d.  Evidence to Indicate ALA  There may be instances where the provider or supplier states on 
the Form CMS-855 or Form CMS-20134 that the person or entity has never had an ALA 
imposed against him/her/it, but the contractor finds evidence to indicate otherwise. In such cases, 
the contractor shall follow the decision tree in section 10.6.6(I) below. 
 
e.  MDPP Coaches - MDPP suppliers enrolling via the Form CMS-20134 are not required to 
report any ALA as it relates to MDPP coaches submitted on Section 7 of that form. 
 
F. Scope of a Reportable ALA  
 
Providers and suppliers shall disclose all reportable ALAs on their enrollment applications. To 
satisfy the reporting requirement, the provider/supplier shall complete the Final Adverse Legal 
Action section(s) (Form CMS-855 or Form CMS-20134) in its entirety and attach all applicable 
documentation concerning the ALA to the application. All ALAs must be reported, regardless of 
whether any records have been expunged or sealed or any appeals are pending.   
 
ALAs that must be disclosed on the Form CMS-855 or Form CMS-20134 include:  
 
1. Felony conviction(s) within 10 years  
 
a.   Reporting  Providers/suppliers are required to report a felony (federal or state) when: (1) a 
conviction has occurred; and (2) the felony conviction date (e.g., the date of a courts acceptance 
of a guilty plea or the date of a jury verdict) is within 10 years from the submission date of a 
Form CMS-855 or Form CMS-20134 application.  
 
b.   When a Conviction Occurs - A conviction (as the term convicted is defined in 42 CFR 
1001.2) has occurred when: 
 
(A) A judgment of conviction has been entered against an individual or entity by a federal, state, 
or local court, regardless of whether:  
  (1) There is a post-trial motion or an appeal pending, or  
(2) The judgment of conviction or other record relating to the criminal conduct has been 
expunged or otherwise removed;  
(B) A federal, state, or local court has made a finding of guilt against an individual or entity;  
(C) A federal, state, or local court has accepted a plea of guilty or nolo contendere by an 
individual or entity; or  
(D) An individual or entity has entered into participation in a first offender, deferred 
adjudication, or other program or arrangement where judgment of conviction has been withheld. 
A felony conviction shall be reported by the provider/supplier even if the conviction has been 
sealed or expunged or there is an appeal or post-trial motion pending. Furthermore, in instances 
where the defendant pleads guilty to a felony and a court orders deferred 
adjudication/adjudication withheld/treatment in lieu of conviction/probation with a suspended 
imposition of sentence/pre-trial diversion, these dispositions generally fall under 42 CFR 
1001.2s definition of convicted. Consequently, the provider/supplier shall report these types of 
convictions on the Form CMS-855 or Form CMS-20134. 
 
c.  Additional Information 
 
For any submission of a Form CMS-855 or Form CMS-20134 for initial enrollment, reactivation, 
change of information, or revalidation---and except as stated in the following paragraph---the 
contractor shall review and use APS as a resource to determine if there are any felony 
convictions on which CMS can take administrative action. The contractor shall include any 
felony conviction(s) and/or ongoing criminal case(s) listed on APS in its referral email to CMS.   
 
(NOTE: The aforementioned APS review is not required for (a) voluntary termination 
submissions, (b) Form CMS-855R submissions, (c) associated individuals/entities being 
deleted/removed on the Form CMS-855, and (d) any individuals and entities listed on the 
application who have previously been reviewed against APS as part of any prior application 
submission.  Moreover, the APS review requirement only applies to data that is reported via an 
actual submission.  Data that has previously been reported (and thus is not part of the submission 
in question) need not be reviewed.) 
 
The aforementioned APS review would be to determine whether (a) the provider/supplier 
submitting the Form CMS-855 or Form CMS-20134 or (b) any associated individual/entity (e.g., 
owner or managing employee) listed in the Ownership Interest and/or Managing Control 
Information sections of the provider/suppliers Form CMS-855 or Form CMS-20134 has a 
felony conviction.  
 
2. Misdemeanor conviction within 10 years  
 
  Report a misdemeanor conviction (federal or state) when  
 
  A conviction has occurred;  
o
    The misdemeanor conviction date (e.g., the date of a courts acceptance of a guilty plea, 
o
or the date of a jury verdict) is within 10 years from the submission date of a Form CMS-
855 or Form CMS-20134 application; and  
 
  The misdemeanor is related to any of the following:  
o
 
  The delivery of an item/service under Medicare or a state health care program; 
 
  The abuse or neglect of a patient in connection with the delivery of a health care item 
or service; 
 
  Theft, fraud, embezzlement, breach of fiduciary duty or other financial misconduct in 
connection with the delivery of a health care item/service; 
 
  The interference with or obstruction of any investigation into any criminal offense 
described under 42 CFR 1001.101 or 1001.201; or 
 
  The unlawful manufacture, distribution, prescription or dispensing of a controlled 
substance.  
 
  A conviction has occurred when any of the criteria in 42 CFR 1001.2 (and as described in the 
second in bullet in (F)(1)(b) above) are met. 
 
  A misdemeanor conviction shall be reported even if the conviction has been sealed, 
expunged, or there is an appeal or post-trial motion pending.  
 
3.   Current or past suspension(s)/revocations(s)/voluntary surrender(s) in lieu of further 
disciplinary action of a medical license(s) 
 
  A medical license board suspends or revokes a medical license for any period of time; or 
 
  The provider voluntarily surrenders her/his medical license in lieu of further disciplinary 
action. 
 
4.   Current or past suspensions(s)/revocation(s) of an accreditation -- An accrediting body 
suspends or revokes an accreditation for any period of time.  
 
5.   Current or past exclusion(s) imposed by HHS OIG -- Items/services furnished, ordered, or 
prescribed by a specified individual/entity are not reimbursed under Medicare, Medicaid, and/or 
all other federal health care programs until the individual or entity is reinstated by the HHS OIG.  
 
6.   Current or past debarment(s) from participation in any federal executive branch 
procurement or non-procurement program -- An individual or entity is suspended throughout 
the executive branch of the federal government, as it applies to procurement and non-
procurement programs. An individual or entity will not be solicited from, contracts will not be 
awarded to, or existing contracts will not be renewed or otherwise extended to those individuals 
or entities with a debarment (e.g. GSA debarment).    
7. Medicaid exclusion(s), revocation(s) or termination(s) of any billing number -- A state 
terminates an active provider agreement or prohibits a provider from enrolling in the Medicaid 
program. Any Medicaid terminations shall be forwarded to 
ProviderEnrollmentRevocations@cms.hhs.gov for review by PEOG. 
 
G.  Reviewing for ALAs  
 
The contractor shall address the reporting of ALA in its review of initial enrollment, revalidation, 
reactivation, or change of information applications submitted by a provider or supplier. The 
contractor may receive information of ALAs not yet reported by the provider or supplier from 
CMS or other contractors via the application screening process. The contractor shall consider this 
information and take action as described in (but not limited to) this section 10.6.6 and other 
applicable sections of this chapter.  
Providers and suppliers shall include all reportable ALAs on their enrollment applications. This 
information must be reported by the provider/supplier on the initial/revalidation application and 
pursuant to the reporting requirements specified in 42 CFR  424.516 and section 10.4(J) of this 
chapter. Reportable ALAs are listed in section 10.6.6(F) above. All applicable ALAs shall be 
reported, regardless of whether any (1) records were expunged or sealed, (2) appeals are 
pending, or (3) waivers were granted.  
H.  Non-Reportable ALAs 
 
Non-reportable ALAs include, but are not limited to: license probations in which the state board 
does not prohibit the practice of medicine; malpractice suits; and felony or misdemeanor 
convictions that are not within the previous 10 years from the submission date of a Form CMS-
855 or Form CMS-20134 application. 
 
The contractor need not send an ALA referral to CMS for review if the provider/supplier 
previously reported that same ALA on a Form CMS-855 or Form CMS-20134 application that 
CMS had already reviewed. 
 
I.  ALA Decision Tree 
 
To assist the contractor in determining what actions to take when an ALA is involved, CMS has 
produced an ALA Decision Tree (see below) for the contractor to use as a guide.  Except as 
otherwise stated in this section 10.6.6, chapter 10 itself, or another CMS directive, the contractor: 
(1) shall follow the ALA Decision Tree when it receives ALA information regarding a provider 
or supplier (or discovers an ALA through independent research or other means); and (2) shall not 
develop with the provider or supplier for reported or unreported ALA(s).  Note that the term 
provider in the Decision Tree includes supplier unless noted otherwise. 
 
     
TABLE 1 -- INITIAL/REACTIVATION APPLICATIONS  LICENSE OR 
ACCREDITATION CURRENTLY SUSPENDED / REVOKED / VOLUNTARILY 
SURRENDERED IN SAME STATE  REPORTED 
 
Licensure Scenario  Did the  MAC Action  Notes 
provider 
report the 
ALA taken 
on their 
license /    
accreditation?  
 
Providers  Yes  The contractor shall send  The contractor shall 
accreditation/medical  the application and ALA  read board orders 
license is currently  information to   thoroughly to 
suspended / revoked /  ProviderEnrollmentRevoc determine if there is 
voluntarily  ations@cms.hhs.gov for  any other ALA 
surrendered in lieu of  review and   decision if  associated with the 
further disciplinary  there is an ALA in addition  license suspension, 
action by a state  to this licensure action revocation, or 
licensing authority,  reported or unreported voluntary surrender 
where the licensure  that precludes processing  (e.g., a felony 
action is in the same  the application. Refer to  conviction).  
state in which the  Tables 3  13.    
provider is enrolling.    The contractor shall 
If there are no other  not deny under 42 
ALAsbesides the  CFR  424.530(a)(1) 
licensure action here if the licensure 
that preclude processing  action is any of the 
the application-- the  following: (i) a 
contractor shall proceed  suspension is 
with denial under 42 CFR  stayed in its 
 424.530(a)(1) without  entirety; (ii) the 
sending to CMS for  license is placed on 
review.  probation by a state 
  board but the 
probation does not 
prohibit the practice 
of medicine; (iii) 
advertising / 
administrative  
penalties; or (iv) 
fines, violations, 
stipulations, 
reprimands. 
 
 
     
 
TABLE 2 -- INITIAL/REACTIVATION APPLICATIONS  LICENSE OR 
ACCREDITATION CURRENTLY OR PREVIOUSLY 
SUSPENDED/REVOKED/VOLUNTARILY SURRENDERED IN SAME STATE  NOT 
REPORTED 
 
Licensure  Did the  MAC Action  Notes 
Scenario  provider 
report the 
ALA taken 
on their 
license or   
accreditation?  
 
Providers  No  The contractor shall  Section 424.530 (a)(4) shall ONLY be 
accreditation    send the application  included as a denial reason if the 
/medical license  and ALA information  provider has never reported this ALA. 
is currently or  to   The contractor shall consider 
was previously  ProviderEnrollmentR whether other denial reasons exist. 
suspended /  evocations@cms.hhs Refer to Tables 3  13.  
revoked /  .gov for review and    
voluntarily  decision under 42  The contractor shall read board 
surrendered in  CFR  424.530(a)(4)  orders thoroughly to determine if 
lieu of further  and any other  there is any other ALA associated 
disciplinary  applicable denial  with the license suspension / 
action by a state  authorities.   revocation / voluntary surrender.  If 
licensing    the board order mentions another 
authority,    license suspension / revocation / 
where the  voluntary surrender from another 
licensure action  state, the contractor shall include 
is in the same  this information in its referral to 
state in which  CMS under  424.530(a)(4) and any 
the provider is  other applicable denial authorities; 
enrolling.  the contractor shall note whether 
revocation action is appropriate for 
any other enrollment.  
  
There is no reporting 
requirement for/if: (i) a 
suspension is stayed in its 
entirety; (ii) the license is placed 
on probation by a state board 
but the probation does not 
prohibit the practice of 
medicine; (iii) advertising / 
administrative penalties; or (iv) 
fines, violations, stipulations, 
reprimands. 
 
     
TABLE 3 -- INITIAL/REACTIVATION APPLICATIONS  LICENSE CURRENTLY 
SUSPENDED OR REVOKED IN DIFFERENT STATE  REPORTED 
 
Licensure  Did the  MAC Action  Notes 
Scenario  provider 
report the 
ALA taken 
on their 
license?  
 
Providers  Yes  The contractor shall  Denial under 42 CFR  
medical license    send the application  424.530(a)(14) is appropriate only if 
currently  and ALA information  the license suspension/revocation 
suspended /  to   action in the different state (i.e., 
revoked / in a  ProviderEnrollmentR the state other than that in which 
state different  evocations@cms.hhs the provider is enrolling) occurred 
from that in  .gov for review and   on or after March 17, 2020.  
which the  decision under 42   
provider is  CFR  424.530(a)(14)  The contractor shall read board 
enrolling.    and any other  orders thoroughly to determine if 
applicable denial  there is any other ALA associated 
authorities.   with the license suspension or 
  revocation (e.g., a felony 
  conviction). The contractor shall 
note whether revocation action is 
appropriate for any other 
enrollment.       
 
Note that voluntary surrenders in 
lieu of further disciplinary action 
do not give rise to denial under 
42 CFR  424.530(a)(14). 
 
 
 
 
     
 
TABLE 4 -- INITIAL/REACTIVATION APPLICATIONS  FELONIES 
 
Felony  Did the  MAC Action  Notes 
provider 
report the 
felony 
conviction? 
 
Provider or an  Yes or No  The contractor shall  A felony is defined as a crime 
individual/entity    send the application  that has a maximum penalty
listed on the  and ALA information  as specified in the criminal 
application as a 5  to   statuteby imprisonment for 
percent or  ProviderEnrollmentR a period of more than one 
greater owner,  evocations@cms.hhs year. 
partner,  .gov for review and    
managing  decision.     All felony convictions within 
employee, or    the preceding 10 years of the 
corporate    submission date of a Form 
director or  CMS-855 or Form CMS-20134 
officer has been  application shall be forwarded 
adjudged guilty  to CMS for review and 
of a felony.   decision, unless CMS instructs 
otherwise. 
 
 
 
 
   
  TABLE 5 -- INITIAL/REACTIVATION APPLICATIONS  MISDEMEANORS 
 
 
Misdemeanor  Did the  MAC Action  Notes 
 
provider 
report the 
 
misdemeanor 
conviction?  
 
 
 
  Provider/supplier  Yes or No  Process application  A misdemeanor is defined as a 
or an    unless another  crime that has a maximum 
  individual/entity  reported or  penaltyas specified in the 
listed on the  unreported ALA  criminal statuteby 
  application as a 5  precludes processing.  imprisonment for a period of 
percent or greater  Refer to Tables 1  4  not more than a year (i.e., one 
 
owner, partner,  and 6  13.   year or less). 
managing   
 
employee, or   
corporate director 
 
or officer has 
been adjudged 
 
guilty of a 
  misdemeanor 
related to health 
  care abuse or 
neglect of a 
  patient; financial 
misconduct; 
  interference with 
a criminal 
 
investigation; or 
unlawful 
 
manufacture, 
distribution, or 
 
dispensing of a 
controlled 
 
substance. 
 
 
     
  TABLE 6 -- INITIAL/REACTIVATION APPLICATIONS  ACTIVE OIG EXCLUSION 
- REPORTED 
 
Current  Did the  MAC Action  Notes 
 
Exclusion   provider 
report the 
 
exclusion?  
 
 
  Provider or an  Yes  Send application and  The contractor shall 
individual/entity    ALA information to  consider whether other 
 
listed on the  ProviderEnrollmentRev denial reasons exist besides 
application as a 5  ocations@cms.hhs.gov  42 CFR  424.530(a)(2). 
 
percent or  for review and decision.  Refer to Tables 1  5 and 8  
greater owner,  13.  
 
partner,   
managing  A waiver does not guarantee 
 
employee,  automatic enrollment into the 
  authorized  Medicare program. All 
official,  waivers shall be sent to 
  delegated  ProviderEnrollmentRevocations
official, medical  @cms.hhs.gov for review and 
  director,  decision, along with the 
supervising  corresponding ALA 
  physician, or  information and application. 
other health care 
 
personnel has an 
active OIG 
 
exclusion. 
 
 
 
 
 
 
 
 
 
 
 
   
  TABLE 7 -- INITIAL/REACTIVATION APPLICATIONS  ACTIVE 
EXCLUSION/DEBARMENT  NOT REPORTED 
 
 
Current  Did the  MAC Action  Notes 
 
Exclusion or  provider 
  Debarment   report the 
exclusion or 
  debarment?  
 
Provider or an  No  Send application and   
  individual/entity    ALA information to 
listed on the  ProviderEnrollmentRe
  application as a 5  vocations@cms.hhs.g
percent or  ov for review and 
  greater owner,  decision. 
partner, 
  managing 
employee, 
  authorized 
official, 
 
delegated 
official, medical 
 
director, 
supervising 
 
physician, or 
other health care 
 
personnel has an 
  active OIG 
exclusion or SAM 
  debarment. 
 
 
 
 
 
 
     
  TABLE 8 -- INITIAL/REACTIVATION APPLICATIONS  EXPIRED 
EXCLUSION/DEBARMENT - REPORTED 
 
Exclusion  Did the  MAC Action  Notes 
 
Period/Debarment  provider 
Period Has Expired  report the 
 
past 
exclusion or 
 
debarment?  
 
 
Provider or an  Yes  Process application   
  individual/entity    unless there is 
listed on the  another reported or 
  application as a 5  unreported ALA that 
percent or greater  precludes 
  owner, partner,  processing the 
managing employee,  application. Refer to 
  medical director,  Tables 1  7 and 11 
authorized official,   13.  
 
delegated official, 
supervising physician 
 
or other health care 
personnel had an 
 
OIG exclusion or a 
federal/SAM 
 
debarment (or an 
  exclusion by a federal 
agency other than 
  OIG) and has been 
reinstated by HHS 
  and/or OIG and/or 
the federal agency in 
  question.    
 
 
 
 
 
     
  TABLE 9 -- INITIAL/REACTIVATION APPLICATIONS  EXPIRED 
EXCLUSION/DEBARMENT  NOT REPORTED 
 
Exclusion  Did the  MAC Action  Notes 
 
Period/Debarment  provider 
Period Has Expired  report the 
 
past 
exclusion or 
 
debarment?  
 
 
Provider or an  No.  Send application and  The contractor shall consider 
  individual/entity    ALA information to  whether other denial reasons 
listed on the  ProviderEnrollmentRe exist besides 42 CFR  
  application as a 5  vocations@cms.hhs.g 424.530(a)(4). Refer to Tables 1 
percent or greater  ov for review and   7 and 10  13.   
  owner, partner,  decision.   
managing employee,  If CMS previously revoked this 
  medical director,  provider due to that prior OIG 
authorized official,  exclusion, debarment, or other 
 
delegated official,  federal action--and the 
supervising physician  provider or associated 
 
or other health care  individual/entity has been 
personnel had an  reinstated by OIG/HHS/federal 
 
OIG exclusion or a  agency--the contractor shall 
federal/SAM  process the application unless 
 
debarment (or an  there is another reported or 
  exclusion by a federal  unreported ALA that precludes 
agency other than  processing the application. 
  OIG) and has been   
reinstated by HHS 
  and/or OIG and/or 
the federal agency in 
  question.    
 
 
 
 
 
     
  TABLE 10 -- INITIAL/REACTIVATION APPLICATIONS  MEDICARE 
PAYMENT SUSPENSION  CURRENT OR PAST 
 
       
 
Medicare  Did the provider  MAC Action  Notes 
Payment  report the 
 
Suspension  Medicare 
Status   payment 
 
suspension? 
   
       
  Current Medicare  Yes or No  Process application  Providers are NOT 
payment  unless there is  required to report 
  suspension  another reported or  current Medicare 
unreported ALA that  payment suspensions to 
  precludes  CMS.  
processing the   
  application.  Refer to  The contractor shall consider 
Tables 1  9 and 11  whether other denial 
 
 13.   reasons exist. Refer to Tables 
1  9 and 11  13.   
 
  Past Medicare  Yes or No  Process application  Providers are NOT 
payment  unless there is  required to report past 
  suspension  another reported or  Medicare payment 
unreported ALA that  suspensions to CMS. 
  precludes   
processing the  The contractor shall consider 
  application. Refer to  whether other denial reasons 
Tables 1  9 and 11  exist. Refer to Tables 1  9 
 
 13.   and 11  13.  
 
 
 
 
 
     
  TABLE 11 -- INITIAL/REACTIVATION APPLICATIONS  MEDICARE REVOCATION 
 ALL PRIOR ENROLLMENT BAR(S) EXPIRED 
 
Medicare  Did the  MAC Action  Notes 
 
Revocation  provider 
report the 
 
Medicare 
revocation
 
?  
 
 
All prior  Yes or No  Process  Providers are NOT required to report 
  enrollment bar(s)    application unless  current or past Medicare revocations to 
have expired.  there is another  CMS. 
  reported or   
unreported ALA  The contractor shall consider whether 
  that precludes  other denial reasons exist. Refer to Tables 
processing the  1  10 and 13. 
  application. Refer   
to Tables 1  10  Under 42 CFR  424.530(a)(3), CMS can 
 
and 13.   still deny an application if there is a felony 
conviction within the preceding 10 years 
 
by a provider/supplier or by an 
individual/entity listed on the application 
 
as a 5 percent or greater owner or   
managing employee. This denial authority 
 
is still applicable and should be considered 
  by the contractor even if the previous 
Medicare revocation had a 3 year re-
  enrollment bar and the bar has expired. In 
such instances, the contractor shall send 
  the ALA information and application to 
CMS for review and decision at 
  ProviderEnrollmentRevocaions@cms.hhs.
gov.  
 
 
 
 
 
 
 
 
 
     
  TABLE 12 -- INITIAL/REACTIVATION APPLICATIONS  MEDICARE 
REVOCATION  ACTIVE REENROLLMENT BAR 
 
 
Medicare  Did the provider     
 
Revocation  report the  MAC Action  Notes 
  Medicare 
revocation? 
   
Enrollment bar is  Yes or No  Return the   
  active (in the  application. 
state in which the 
 
provider is 
enrolling or in 
 
another state) 
 
 
 
 
 
 
 
 
 
 
 
 
     
  TABLE 13 -- INITIAL/REACTIVATION APPLICATIONS - OTHER PROGRAM 
TERMINATION  CURRENT 
 
Other  Did the  MAC Action  Notes 
 
Program  provider 
Termination  report the 
 
other 
program 
 
termination?   
 
 
The provider is  Yes  Send application  Denial may be appropriate under 42 CFR  
  currently    and ALA  424.530(a)(14) if the provider is currently 
terminated or  information to  terminated/suspended/barred from 
  suspended (or  ProviderEnrollme participation in a state Medicaid program 
otherwise barred)  ntRevocations@c or any other federal health care program 
  from participation  ms.hhs.gov for  (e.g., TRICARE). The termination or 
in a state  review and  suspension must occur by letter dated on 
  Medicaid  decision  or after March 17, 2020.  
program or any   
 
other federal  The contractor shall consider whether 
health care  other denial reasons exist. Refer to Tables 
 
program.  1  12.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
  TABLE 14  REVALIDATIONS/CHANGE OF INFORMATION  APPLICATIONS  
PREVIOUS LICENSURE OR ACCREDITATION  SAME STATE  REPORTED 
 
 
 If the contractor discovers an ALA that has not been reported by a provider, the contractor shall, upon 
 
CMS approval, record the ALA in the PECOS Final Adverse Legal Actions Section and/or PECOS profile for 
the associated individual/entity (as appropriate). 
 
 
  If the contractor is inputting the ALA which has not been reported by the providerand if CMS does 
 
not take administrative action due to that ALAthe contractor shall select No for the Display in PI 
field, thereby making this ALA not visible in the provider interface (as applicable). 
 
 
  If the contractor is inputting the ALA which has not been reported by the providerand if CMS does 
 
take administrative action due to that ALAthe contractor shall select Yes for the Display in PI 
field, thereby making the ALA visible in the provider interface. 
 
 
Unless otherwise stated, the foregoing statements apply to Tables 14 through 24. 
   
Provider holds a  Did the  MAC Action  Notes 
 
valid accreditation  provider report 
/ medical license  the ALA taken 
 
in the state in  on their 
which it is  license/ 
 
revalidating or  accreditation? 
changing 
 
information 
 
Providers    The contractor shall check  The contractor shall 
 
accreditation/  Yes  whether the provider billed  read board orders 
medical license  for dates of service during  thoroughly to 
 
was previously  the period of license  determine if there is 
suspended/revoke susp/rev/VS in lieu of further  any other ALA (e.g., a 
 
d/ voluntarily  disciplinary action. If the  felony conviction) 
  surrendered in lieu  provider billed for dates of  associated with the 
of further  service during this period,  license susp/rev/VS.   
  disciplinary action  the contractor shall send the  If the board order 
by a state licensing  application and ALA  mentions another 
  authority, where  information to  license susp/rev/VS 
the licensure  ProviderEnrollmentRevocation from another state, 
  action is in the  s@cms.hhs.gov.  If the  the contractor shall 
same state in  provider did not bill during  include this 
 
which the provider  the period of license  information in its 
is currently  susp/rev/VS in lieu of further  referral to CMS and 
 
enrolled.  disciplinary action, the  note whether 
application shall be  revocation action is 
 
processed unless there is  appropriate for any 
another reported or  other enrollment. 
   
unreported ALA that   
precludes processing. Refer 
to Tables 15  24.   
  TABLE 15  REVALIDATION/CHANGE OF INFORMATION APPLICATIONS  
LICENSE PREVIOUSLY SUSPENDED/REVOKED/VOLUNTARY SURRENDERED - 
SAME STATE  NOT REPORTED 
 
Provider holds  Did the  MAC Action  Notes 
a valid  provider 
accreditation/ report the 
medical license  ALA taken 
in the state in  on its 
which it is  license or   
revalidating or  accreditation?  
changing   
information 
 
Providers  No  The contractor shall  The contractor shall check whether the 
accreditation/   send the application  provider billed for dates of service 
medical license  and ALA  during the period of license 
was previously  information to   susp/rev/VS in lieu of further 
suspended /  ProviderEnrollment disciplinary action. If the provider 
revoked /  Revocations@cms.h billed for dates of service during this 
voluntarily  hs.gov for review  period, there may be potential 
surrendered in  and  decision.  revocation action under 42 CFR  
lieu of further    424.535(a)(8). The contractor shall 
disciplinary  Section 424.530  note this information when sending a 
action by a  (a)(4) shall ONLY be  referral to CMS for review. 
state licensing  included as a denial   
authority,  reason if the  The contractor shall read board orders 
where the  provider has never  thoroughly to determine if there is any 
licensure  reported this ALA  other ALA associated with the license 
action is in the  and CMS did not  susp/rev/VS.  If the board order 
same state in  previously revoke  mentions another license susp/rev/VS 
which the  the provider for that  from another state, the contractor 
provider is  ALA. The contractor  shall include this information in its 
enrolling.  shall consider  referral to CMS and note whether 
whether other  revocation action is appropriate for 
denial reasons exist.  any other enrollment 
Refer to Tables 16    
24.   There is no reporting requirement 
  for/if: (i) a suspension is stayed in 
its entirety; (ii) the license is placed 
on probation by a state board but 
the probation does not prohibit the 
practice of medicine; (iii) 
advertising / administrative 
penalties; or (iv) fines, violations, 
stipulations, reprimands. 
 
 
     
TABLE 16 -- REVALIDATION/CHANGE OF INFORMATION APPLICATIONS  
  FELONIES 
 
   
Felony  Did the  MAC Action  Notes 
provider 
report the 
felony 
conviction?  
 
Provider or an  Yes or No  Send application and  A felony is defined as a crime 
individual/entity    ALA information to  that has a maximum penalty
listed on the  ProviderEnrollmentR as specified in the criminal 
application as a 5  evocations@cms.hhs statuteby imprisonment for 
percent or greater  .gov for review and  a period of more than one 
owner, partner,  decision.  year. 
managing   
employee, or  All felony convictions within 
corporate director  the preceding 10 years of the 
or officer has been  submission date of a Form 
adjudged guilty of a  CMS-855 or Form CMS-20134 
felony.  application shall be forwarded 
to CMS for review and 
decision, unless CMS instructs 
otherwise. 
 
   
  TABLE 17  REVALIDATION/CHANGE OF INFORMATION APPLICATIONS  
MISDEMEANORS 
 
 
Misdemeanor  Did the  MAC Action  Notes 
 
provider 
  report the 
misdemeanor 
  conviction?  
 
 
 
Provider or an  Yes or No  Process application  A misdemeanor is defined as a 
individual/entity    unless there is  crime that has a maximum 
 
listed on the  another reported or  penaltyas specified in the 
application as a 5  unreported ALA that  criminal statuteby 
 
percent or greater  precludes processing  imprisonment for a period of 
owner, partner,  the application. Refer  not more than a year (i.e., one 
 
managing  to Tables 14  16 and  year or less). 
  employee, or  18  24.    
corporate director   
  or officer has been 
adjudged guilty of 
  a misdemeanor 
that is related to 
  health care abuse 
or neglect of a 
 
patient; financial 
misconduct; 
 
interference with 
a criminal 
 
investigation; or 
unlawful 
 
manufacture, 
  distribution, or 
dispensing of a 
  controlled 
substance. 
   
 
 
 
 
 
 
   
  TABLE 18  REVALIDATION/CHANGE OF INFORMATION APPLICATIONS  
ACTIVE OIG EXCLUSION OR SAM DEBARMENT - REPORTED 
 
 
Current  Did the  MAC Action  Notes 
 
Exclusion or  provider 
  Debarment   report the 
exclusion?  
   
 
Provider or an  Yes  Send application and  The contractor shall consider 
  individual/entity    ALA information to  whether other denial reasons 
listed on the  ProviderEnrollmentRev exist besides 42 CFR  
  application as a 5  ocations@cms.hhs.gov  424.530(a)(2). Refer to Tables 
percent or  for review and decision.  14  17 and 19  24. A waiver 
  greater owner,  does not guarantee automatic 
partner,  enrollment into the Medicare 
  managing  program. All waivers shall be 
employee,  sent to 
  authorized  ProviderEnrollmentRevocations
official,  @cms.hhs.gov for review and 
 
delegated  decision, along with the 
official, medical  corresponding ALA information 
 
director,  and application. 
supervising 
 
physician, or 
other health care 
 
personnel has an 
  active OIG 
exclusion or SAM 
  debarment. 
 
 
 
 
 
     
  TABLE 19 -- REVALIDATION/CHANGE OF INFORMATION APPLICATIONS  
ACTIVE OIG EXCLUSION OR SAM DEBARMENT  NOT REPORTED 
 
 
Current  Did the  MAC Action  Notes 
 
Exclusion   provider 
  report the 
exclusion?  
   
 
Provider or an  No  Send application and  The contractor shall consider 
  individual/entity    ALA information to  whether other denial 
listed on the  ProviderEnrollmentRe reasons exist besides 42 CFR 
  application as a 5  vocations@cms.hhs.g  424.530(a)(2). Refer to 
percent or greater  ov for review and  Tables 14  17 and 20  24. 
  owner, partner,  decision.   
managing  All waivers shall be sent to 
  employee, medical  ProviderEnrollmentRevocations
director,  @cms.hhs.gov for review and 
  authorized official,  decision, along with the 
delegated official,  corresponding ALA information 
 
supervising  and application. 
physician, or other   
 
health care 
personnel has an 
 
active OIG 
exclusion or SAM 
 
debarment. 
 
 
 
 
 
 
 
 
 
 
 
 
   
  TABLE 20  REVALIDAT ION/CHANGE OF INFORMATION APPLICATIONS  
EXCLUSION/DEBARMENT  EXPIRED - REPORTED 
 
Exclusion or  Did the  MAC Action  Notes 
Debarment  provider 
Status  report the 
exclusion or 
debarment?  
 
Provider or an  Yes  Process application   
individual/entity    unless there is 
listed on the  another reported or 
application as a 5  unreported ALA that 
percent or greater  precludes processing 
owner, partner,  the application. Refer 
managing employee,  to Tables 14  19 and 
medical director,  21  24.  
authorized official, 
delegated official, 
supervising 
physician, or other 
health care 
personnel had an 
OIG exclusion or a 
federal/SAM 
debarment (or an 
exclusion by a federal 
agency other than 
OIG) and has been 
reinstated by OIG 
and/or HHS and/or 
the other federal 
agency.   
     
TABLE 21  REVALIDATION/CHANGE OF INFORMATION APPLICATIONS  
EXCLUSION/DEBARMENT  EXPIRED  NOT REPORTED 
 
Exclusion or  Did the  MAC Action  Notes 
Debarment  provider 
Status  report the 
exclusion or 
debarment?  
 
Provider or an  No  Send application  The contractor shall consider 
individual/entity    and ALA  whether other revocation 
listed on the  information to  reasons exist besides 42 CFR  
application as a 5  ProviderEnrollment 424.535(a)(4). Refer to Tables 
percent or greater  Revocations@cms.h 14  20 and 22  24.   
owner, partner,  hs.gov for review   
managing employee,  and decision.  If CMS previously revoked this 
medical director,  provider due to the prior OIG 
authorized official,  exclusion and the provider or 
delegated official,  associated individual/entity has 
supervising  been reinstated by OIG, the 
physician, or other  contractor shall process the 
health care  application unless there is 
personnel had an  another reported or 
OIG exclusion or a  unreported ALA that precludes 
federal/SAM  processing. 
debarment (or an   
exclusion by a federal 
agency other than 
OIG) and has been 
reinstated by OIG 
and/or HHS and/or 
other federal agency.     
   
  TABLE 22 -  REVALIDAT ION/CHANGE OF INFORMATION APPLICATIONS   
MEDICARE PAYMENT SUSPENSION  CURRENT OR PAST 
       
Medicare  Did the provider  MAC Action  Notes 
Payment  report the 
Suspension  Medicare 
Status    payment 
suspension? 
 
       
Current Medicare  Yes or No  Process application  Providers are NOT 
payment  unless there is  required to report 
suspension  another reported or  current or past 
unreported ALA that  Medicare payment 
precludes  suspensions to CMS.  
processing the   
application.  Refer to   
Tables 14  21 and   
23  24. 
Past Medicare  Yes or No  Process application  Providers are NOT 
payment  unless there is  required to report 
suspension  another reported or  current or past 
unreported ALA that  Medicare payment 
precludes  suspensions to CMS. 
processing the   
application. Refer to   
Tables 14  21 and 
23  24.      
TABLE 23 -- REVALIDATION/CHANGE OF INFORMATION APPLICATIONS  
MEDICARE REVOCATION  ACTIVE ENROLLMENT BAR  
       
Status  Did the provider  MAC Action  Notes 
report the 
Medicare 
revocation? 
 
       
Enrollment bar is  Yes or No  Send application and  The contractor shall consider 
active in the state  ALA information to  whether any revocation 
in which the  ProviderEnrollmentR reason(s) exist.  
provider is  evocations@cms.hhs. .  
submitting this  gov for review and   
application, or the  decision.   
enrollment bar is     
active in another 
state.    
  TABLE 24 -- REVALIDATION/CHANGE OF INFORMATION APPLICATIONS  
  OTHER PROGRAM TERMINATION (CURRENT)  
 
Other  Did the  MAC  Notes 
 
Program  provider  Action 
 
Termination  report the 
other 
program 
termination?  
 
The  Yes  Send  Revocation may be appropriate under 42 
provider/supplier    application and  CFR  424.535(a)(12) if the 
is currently  ALA  provider/supplier is currently 
terminated or  information to  terminated/suspended/barred from 
suspended (or  ProviderEnrollm participation in a state Medicaid program 
otherwise barred)  entRevocations or any other federal health care program 
from participation  @cms.hhs.gov  (e.g., TRICARE). 
in a state  for review and   
Medicaid  decision.  The state Medicaid program termination 
program or any  or suspension must occur by letter dated 
other federal  on or after January 1, 2011. 
health care   
program.   Any other federal health care program 
(e.g., TRICARE) termination or suspension 
must occur by letter dated on or after 
March 17, 2020.  
 
The contractor shall consider whether 
other revocation reasons exist. Refer to 
Tables 14  23.   
 
10.6.7  Owning and Managing Information  
(Rev. 10868; Issued: 07-14-21; Effective: 08-13-21; Implementation: 08-13-21) 
 
All references to provider(s) in sections 10.6.7.1 through 10.6.7.3 include supplier(s) 
(unless noted otherwise).     
10.6.7.1  Organizational Owning and Managing Information 
(Rev. 11682; Issued: 11-04-2022; Effective: 12-05-2022; Implementation: 12-05-2022) 
 
Except as stated otherwise, this section 10.6.7.1 only applies to the Organizational Ownership 
and/or Managing Control Section of the Forms CMS-855A, CMS-855B, CMS-855S and CMS-
20134; it is inapplicable to the Form CMS-855I.   
 
A.  Ownership Information Required in Forms CMS-855A, CMS-855B, CMS-855S and 
CMS-20134 
 
All organizations that have any of the following (referenced in (A)(1) through (A)(4) must be 
listed in the Organizational Ownership and/or Managing Control section of the Form CMS-855 
and CMS-20134. 
 
1.  5 percent or greater direct or indirect ownership interest in the provider 
 
(i)  Direct Ownership 
 
Examples of direct ownership are as follows:  
 
  The provider is a skilled nursing facility that is wholly (100%) owned by Company A.  
  A hospice wants to enroll in Medicare. Company X owns 50% of the hospice.  
 
In the first example, Company A is considered a direct owner of the skilled nursing facility, in 
that it actually owns the assets of the business. Likewise, Company X is a direct owner of the 
hospice mentioned in the second example. It has 50% actual ownership of the hospice. 
 
(ii) Indirect Ownership 
 
Many organizations that directly own a provider are themselves wholly or partly owned by other 
organizations (or even individuals). This often results from the use of holding companies and 
parent/subsidiary relationships.  Such organizations and individuals are considered indirect 
owners of the provider.  The term indirect ownership interest generally means any ownership 
interest in an entity that has an ownership in the ownership interest in an entity that has an 
ownership interest in the provider or supplier; this also includes an ownership interest in any 
entity that has an indirect ownership interest in the provider or supplier.  Using the first example 
in the Direct Ownership subsection above, if Company B owned 100% of Company A, 
Company B is considered indirect owner of the provider; in sum, a direct owner has an actual 
ownership interest in the provider (e.g., owns stock in the business, etc.), whereas an indirect 
owner has an ownership interest in an organization that owns the provider. 
 
(iii) Examples of Direct vs. Indirect Ownership 
 
The following scenario further illustrates the difference between direct and indirect ownership: 
  EXAMPLE 1:  The supplier listed in the Identifying Information of the Form CMS-855B is 
an ambulance company that is wholly (100 percent) owned by Company A.  Company A is 
considered to be a direct owner of the supplier (the ambulance company) in that it actually 
owns the assets of the business.  Now assume that Company B owns 100 percent of 
Company A.  Company B is considered an indirect owner - but an owner, nevertheless - of 
the supplier.   
 
In terms of the calculation and reporting of indirect ownership interests, consider this example 
from the Form CMS-855A (though note that individuals would need to be reported in the 
Individual Ownership and/or Managing Control section of the Form CMS-855A and Form CMS-
20134, discussed further below): 
 
   EXAMPLE 2 
 
LEVEL 3  Individual X  Individual Y 
  5%  30% 
LEVEL 2  Company C  Company B 
  60%   40% 
LEVEL 1  Company A   
  100%    
 
  Company A owns 100% of the Enrolling Provider  
  Company B owns 40% of Company A  
  Company C owns 60% of Company A  
  Individual X owns 5% of Company C  
  Individual Y owns 30% of Company B  
 
In Example 2, Company A (Level 1) is the direct owner of the provider identified in Section 
2 of the application. Companies B and C, as well as Individuals X and Y, are indirect owners 
of the provider. The calculation of ownership shares would be as follows:  
 
LEVEL 1  
 
Company A owns 100% of the Enrolling Provider. Company A must be reported.  
LEVEL 2  
 
To calculate the percentage of ownership held by Company C of the Enrolling Provider, 
multiply the percentage of ownership the LEVEL 1 owner has in the Enrolling Provider by 
the percentage of ownership the LEVEL 2 owner has in that LEVEL 1 owner.  
 
  Company A, the LEVEL 1 (or direct) owner, owns 100% of the provider. Company C, a 
LEVEL 2 owner, owns 60% of Company A. Accordingly, multiply 100% (or 1.0) by 
60% (.60). The result is .60.  Company C indirectly owns 60% of the Enrolling Provider 
and must be reported.     Repeat the same procedure for Company B, the other LEVEL 2 owner. Since Company B 
owns 40% of Company A, multiply this figure by 100% (again, the ownership stake 
Company A has in the Enrolling Provider). Company B thus owns 40% of the Enrolling 
Provider and must be reported.  
 
This process is continued until all LEVEL 2 owners have been accounted for. 
 
LEVEL 3  
 
To calculate the percentage of ownership that Individual X has in the Enrolling Provider, 
multiply the percentage of ownership the LEVEL 2 owner has in the Enrolling Provider by 
the percentage of ownership the LEVEL 3 owner has in that LEVEL 2 owner  Per Example 
2: 
  
  Company C owns 60% of the provider, and Individual X (Level 3) owns 5% of Company 
C.  Multiplying 60% (.60) by 5% (.05) results in .03. This means that Individual X owns 
3% of the provider and need not be reported as an owner.    
  Repeat this process for Company B, which owns 40% of the provider. Individual Y 
(Level 3) owns 30% of Company B.  Multiplying 40% (.40) by 30% (.30) results in .12, 
or 12%.  Since Individual Y owns 12% of the provider, Individual Y must be reported (in 
Section 6: Individuals).  
 
This process is continued until all owners in LEVEL 3 have been accounted for. This process 
must be repeated for Levels 4 and beyond. 
 
2.  5 percent or greater mortgage or security interest 
 
For purposes of enrollment, ownership also includes "financial control."  Financial control exists 
when: 
 
(a) An organization or individual is the owner of a whole or part interest in any mortgage, deed 
of trust, note, or other obligation secured (in whole or in part) by the provider or any of the 
property or assets of the provider, and 
 
(b) The interest is equal to or exceeds 5 percent of the total property and assets of the provider. 
 
All entities with at least a 5 percent mortgage, deed of trust, or other security interest in the 
provider must be reported in the Organizational Ownership and/or Managing Control section.  
This frequently will include banks, other financial institutions, and investment firms.  To 
calculate whether this interest meets the 5% threshold, divide the dollar amount of the 
mortgage/deed of trust/other obligation secured by the provider or any of the property or assets 
of the provider by the dollar amount of the total property and assets of the provider.   
 
EXAMPLE: Two years ago, a provider obtained a $20 million loan from Entity X to add a third 
floor to its facility. Various assets of the provider secure the mortgage. The total value of the 
providers property and assets is $100 million.   Using the above formula, divide $20 million (the dollar amount of the secured mortgage) by 
$100 million (the total property and assets of the Enrolling Provider). This results in .20, or 20%. 
Because Entity Xs interest represents at least 5% of the total property and assets of the Enrolling 
Provider, Entity X must be reported in this section. 
 
3.  Partnerships 
 
(a) Any general partnership interest in the provider, regardless of the percentage. This 
includes: (1) all interests in a non-limited partnership; and (2) all general partnership interests in 
a limited partnership.   
 
(b) For limited partnerships: 
 
  Form CMS-855A: Any limited partnership interest that is 10 percent or greater. 
 
  Form CMS-855B and Form CMS-20134: Any limited partnership interest, 
  regardless of the percentage. 
 
Only partnership interests in the enrolling provider need be disclosed in the Organizational 
Ownership and/or Managing Control section.  Partnership interests in the providers indirect 
owners need not be reported.  However, if the partnership interest in the indirect owner results in 
a greater than 5 percent indirect ownership interest in the enrolling provider, this indirect 
ownership interest would have to be disclosed in this section.  
 
See section 10.6.4(C) of this chapter for more information on the differences between general 
and limited partnerships. 
 
4.  Managing control of the provider  
 
A managing organization is one that exercises operational or managerial control over the 
provider, or conducts the day-to-day operations of the provider.  The organization need not have 
an ownership interest in the provider to qualify as a managing organization; for instance, the 
entity could be a management services organization under contract with the provider to furnish 
management services for one of the provider's practice locations. 
 
The organizations referred to above generally fall into one or more of the following categories:  
 
  Corporations  
  Partnerships and limited partnerships 
  Limited liability companies 
  Charitable and religious organizations 
  Governmental/tribal organizations 
  Banks and financial institutions  
  Investment firms 
  Holding companies 
  Trusts and trustees    Medical providers/suppliers 
  Consulting firms 
  Management services companies 
  Medical staffing companies 
  Non-profit entities 
 
In the Organizational Ownership and/or Managing Control section of the Form CMS-855 and 
CMS-20134, the provider must indicate the type(s) of organizational categories the reported 
entity falls into.   
 
B.  Special Requirements for Governmental and Tribal Entities 
 
If a federal, state, county, city or other level of government, or an Indian tribe, will be legally and 
financially responsible for Medicare payments received (including any potential overpayments), 
the name of that government or Indian tribe should be reported as an owner. The provider must 
submit a letter on the letterhead of the responsible government (e.g., government agency) or 
tribal organization attesting that the government or tribal organization will be legally and 
financially responsible for any outstanding debt owed to CMS.  This letter must be signed by an 
appointed or elected official of the government or tribal organization who has the authority to 
legally and financially bind the government or tribal organization to the laws, regulations, and 
program instructions of the Medicare program.  This governmental or tribal official, however, 
need not be an authorized or delegated official, or vice versa; that is, the person need not be one 
of the providers authorized or delegated officials listed in the Certification Statement Section of 
the Form CMS-855 or Form CMS-20134.  The only requirement is that the individual have the 
binding authority described above, and the contractor shall assume such authority exists unless 
there is evidence to indicate otherwise.   
 
In addition, governmental and tribal entities: 
 
   Must be identified in the Organizational Ownership and/or Managing Control section even if 
they are already listed in the Identifying Information section. 
 
   Governmental and tribal entities need not submit a copy of an IRS 501(c)(3) form if it is 
otherwise obvious to the contractor that the entity is a governmental or tribal entity.  The 
contractor can assume that the governmental or tribal entity is non-profit.  (See section 
10.6.7(D)(3) below and section 10.6.4(G) of this chapter for more information on non-profit 
entities.)  
 
C.  Submission of Diagram  
 
In addition to completing the Organizational Ownership and/or Managing Control section, the 
provider must submit an organizational structure diagram/flowchart identifying (1) all of the 
entities listed in this section; and (2) the relationships they have with the provider and each other.  
(This applies to the Form CMS-855A, CMS-855B, CMS-855S and CMS-20134.)  If the provider 
is a skilled nursing facility or opioid treatment program, it must also include in the 
diagram/flowchart all entities and individuals that have less than a 5 percent direct or indirect  ownership interest (and were thus not required to otherwise be listed in the Organizational or 
Individual Ownership and/or Managing Control sections). 
 
The aforementioned diagram/flowchart must be submitted for Form CMS-855 and CMS-20134: 
(1) initial enrollments; (2) revalidations; (3) reactivations; (4) certified provider and certified 
supplier changes of ownership based on the principles of 42  CFR 489.18; and (5) upon any 
contractor request.  Upon receiving the chart, the contractor shall review the data thereon to 
ensure it matches what the provider/supplier is reporting on the Form CMS-855/20134. If the 
data is inconsistent, the contractor shall develop for revised Form CMS-855/20134 data and/or a 
revised chart, as applicable.  If the data remains inconsistent after development, the contractor 
may reject the application.   
 
D.  Supporting Data/Contractor Request and Additional Information 
 
1.   IRS CP-575 - Owning/managing organizations need not furnish an IRS CP-575 document 
unless requested by the contractor (e.g., the contractor discovers a potential discrepancy 
between the organizations reported legal business name and tax identification number). 
 
2.   Proof of Owning/Managing Control and Percentages - Proof of ownership interest, 
partnership interest, managerial control, security interest, percentage of ownership or control, 
etc., need not be submitted unless the contractor requests it.  This also means that articles of 
incorporation, partnership agreements, etc., need not be submitted absent a contractors 
request. 
 
  In addition, the percentage of managing control need not be reported. 
 
3.   Non-Profit, Charitable and Religious Organizations  As mentioned in section 10.6.4(G) 
of this chapter, many non-profit organizations are charitable or religious in nature and are 
generally typically operated and/or managed by a board of trustees or other governing body.  
The actual name of the board of trustees or other governing body must be reported in the 
Organizational Ownership and/or Managing Control.  (Individual board members should be 
listed in the Individual Ownership and/or Managing Control section.)   
 
  Non-profit organizations typically do not have owners, and thus the latter would not need to 
be listed as such on the application.  To confirm its non-profit status, the provider must 
submit an IRS 501(c)(3) document.  If the non-profit entity does have owners, however, they 
would need to be disclosed in the Ownership and/or Managing Control section consistent 
with the instructions in section 10.6.7 et seq.   
 
4.   Duplicate Listing - Any entity listed as the provider in the Identifying Information section of 
the Form CMS-855A, CMS-855B and CMS-20134 need not be reported in the 
Organizational Ownership and/or Managing Control section.  The only exception involves 
governmental entities, which must be identified in the Organizational Ownership and/or 
Managing Control section even if they are already listed in the Identifying Information 
section. 
 
5.   Disregarded Entities - In general, a disregarded entity is a term the IRS uses for an LLC 
that  for federal tax purposes only  is effectively indistinguishable from its single  owner/member. The LLCs income and expenses are shown on the owners personal tax 
return. The LLC itself does not pay taxes.  
 
      If an enrolling provider claims that it is a disregarded entity, the contractor need not obtain 
written confirmation of this from the provider notwithstanding the instruction in the 
Supporting Documents section of the Form CMS-855 or CMS-20134 that such confirmation 
is required. As a disregarded entity does not receive a CP-575 form from the IRS confirming 
its legal business name (LBN) and tax identification number (TIN), the contractor may 
accept from the enrolling provider any government form (such as a W-9) that lists its LBN 
and TIN. The disregarded entitys LBN and TIN shall be listed in the Identifying 
Information/Business Information section of the Form CMS-855. 
 
6.  Ownership Disclosures 
 
Consistent with the foregoing policies in this section 10.6.7.1, CMS re-emphasizes the 
following: 
 
(i) The provider/supplier must disclose ALL persons and entities that meet the definition of 
owner in section 10.1.1 of this chapter  
(ii) The applicable ownership percentage must be disclosed for each owner listed  
(iii) There cannot be indirect owners without direct owners (i.e., the provider/supplier cannot 
list only indirect owners and no direct owners)  
(iv) The combined disclosed ownership percentages for the provider/suppliers organizational 
and individual direct owners cannot be greater than 100 percent   
 
(Requirements (ii) and (iv) are inapplicable to applications that do not capture percentages of 
ownership.) 
 
If the provider/suppliers ownership data does not meet the aforementioned requirements, the 
contractor shall develop for the correct/complete data (e.g., the direct ownership total is greater 
than 100 percent) consistent with the instructions in this chapter.  
 
10.6.7.2  Individual Owning and Managing Information 
(Rev. 11682; Issued: 11-04-2022; Effective: 12-05-2022; Implementation: 12-05-2022) 
 
A.  Owning and Managing Individuals Who Must Be Listed in this Section  
 
All individuals who have any of the following must be listed in this section: 
 
(i)  Ownership - A 5 percent or greater direct or indirect ownership interest in the provider. 
 
(ii)  Mortgage/Security Interest - A 5 percent or greater mortgage or security interest in the 
provider. 
 
(iii)  Partnership Interests  
    Any general partnership interest in the provider, regardless of the percentage.  This includes 
(1) all interests in a non-limited partnership and (2) all general partnership interests in a 
limited partnership. 
 
  Limited partnerships - For the CMS-855A, any limited partnership interest that is 10 percent 
or greater. For the Form CMS-855B, CMS-855S and CMS-20134, any limited partnership 
interest, regardless of the percentage. 
 
(iv) Managing Control of the Provider - For purposes of enrollment, such a person is 
considered to be a managing employee.  A managing employee is any individual, including a 
general manager, business manager, office manager or administrator, who exercises operational 
or managerial control over the provider's business, or who conducts the day-to-day operations of 
the business.  A managing employee also includes any individual who is not an actual W-2 
employee but who, either under contract or through some other arrangement, manages the day-
to-day operations of the business. 
 
(v) Corporate Officers and Directors/Board Members 
    
Officers and directors/board members must be listed in the Individual Ownership and/or 
Managing Control section if  and only if - the applicant is a corporation.  (For-profit and non-
profit corporations must list all of their officers and directors.  If a non-profit corporation has 
trustees instead of officers or directors, these trustees must be listed in this section of the Form 
CMS-855A, CMS-855B, CMS-855S and CMS-20134.)    
 
Only the enrolling providers officers and directors must be reported.  Board members of the 
providers indirect owners need not be disclosed to the extent they are not otherwise required to 
be reported (e.g., as an owner or managing employee) in this section. However, there may be 
situations where the officers and directors/board members of the enrolling providers corporate 
owner/parent also serve as the enrolling providers officers and directors/board members.  In 
such cases  and again assuming that the provider is a corporation  the indirect owners officers 
and directors/board members would have to be disclosed as the providers officers and 
directors/board members in this section.   
 
With respect to corporations, the term director refers to members of the board of directors.  If a 
corporation has, for instance, a Director of Finance who nonetheless is not a member of the 
board of directors, he/she would not need to be listed as a director/board member in this section.  
However, he/she may need to be listed as a managing employee in this section.    
 
(See sections 10.6.7.1(A) of this chapter for more information on direct and indirect ownership, 
mortgage and security interests, and partnerships.) 
 
 
B.  Specific Reporting Policies  
 
1.   Proof of Owning/Managing Control and Percentages - Proof of ownership interest, 
partnership interest, managerial control (including W-2s and other proof of employment), 
security interest, percentage of ownership or control, etc., need not be submitted unless the  contractor requests it.  This also means that articles of incorporation, partnership agreements, 
etc., need not be submitted absent a contractors request. 
 
2.   Government Entities  Government entities need only report their managing employees, for 
they do not have owners, partners, corporate officers, or corporate directors. 
 
3.   Minimum Number of Managing Employees - The provider must report all managing 
employees but must have at least one if it is completing the Form CMS-855A, CMS-855B, 
CMS-855S, or CMS-20134.  An individual completing the Form CMS-855I need not list a 
managing employee if he/she does not have one. 
 
4.   Practice Locations on the Form CMS-855I - All managing employees at all practice locations 
listed in the Business Information/Practice Location Information section of the Form CMS-
855I must be reported in the Managing Employee Information section.  The only exceptions 
to this are individuals who are (a) employed by hospitals, health care facilities, or other 
organizations shown in the Business Information/Practice Location Information section (e.g., 
the chief executive officer of a hospital listed in this section) or (ii) managing employees of 
any group/organization to which the practitioner will be reassigning his/her benefits; these 
persons need not be reported. 
 
5.   Partnership Interests Involving Indirect Owners - Only partnership interests in the enrolling 
provider need be disclosed. Partnership interests in the providers indirect owners need not be 
reported.  However, if the partnership interest in the indirect owner results in a greater than 5 
percent indirect ownership interest in the enrolling provider, this indirect ownership interest 
would have to be reported.  
 
6.   Ownership Disclosures  Concerning ownership disclosures, the contractor shall adhere to 
the instructions in section 10.6.7.1(D)(6). 
 
10.6.7.3  Owning and Managing Information  Tax Identification 
Numbers (TINs) 
(Rev. 10868; Issued: 07-14-21; Effective: 08-13-21; Implementation: 08-13-21) 
 
A.  General Disclosure Requirement 
 
Consistent with sections 1124 and 1124A of the Social Security Act, the provider must report 
the TINs (employer identification numbers (EIN) or social security numbers (SSN)) of all 
entities and individuals listed in the Organizational and Individual Ownership and/or 
Managing Control sections of the Form CMS-855 and Form CMS-20134. If the provider fails 
to do so, the contractor shall follow normal development procedures for requesting the TIN.   
 
When documentation of the providers TIN and/or legal business name (LBN) is required, 
the contractor may accept a CP-575, a federal tax department ticket, or any other pre-printed 
document from the IRS that identifies the TIN and/or LBN. 
 
Except as otherwise stated in this chapter, if a provider is changing its TIN the transaction 
shall be treated as a brand new enrollment as opposed to a change of information; the  provider must complete a full Form CMS-855 or CMS-20134 and a new enrollment record 
must be created in PECOS. 
 
B.  TIN Disclosure Requirements for Individuals Who Do Not Have (and Are Ineligible 
to Obtain) an Employer Identification Number or an SSN from the Social Security 
Administration (SSA) 
 
In following the normal development procedures for requesting an unreported but required TIN, 
the contractor shall undertake the applicable steps described in section 10.6.7.3(B)(1) and (2) 
below if it determines that the TIN was not furnished because the entity or person in question is 
not eligible to obtain a SSN from the SSA. 
 
1.   Contacting Provider 
 
The contractor shall ask the provider (via any means) whether the person or entity can obtain a 
TIN or, in the case of individuals, an individual taxpayer identification number (ITIN).  (Only one 
inquiry is needed.)   
 
a.    If the provider fails to respond to the contractors inquiry within 30 days, the contractor shall 
follow the instructions in section 10.6.7.3(B)(2) below.   
 
b.   If the provider states that the person or entity is able to obtain a TIN or ITIN, the contractor 
shall send an e-mail, fax, or letter to the provider stating that: (i) the person or entity must 
obtain a TIN/ITIN; and (ii) the provider must furnish the TIN/ITIN on the Form CMS-
855/20134 with a newly-signed certification statement within 90 days of the contractors 
request. 
 
c.    If the provider states that the person or entity cannot obtain a TIN or ITIN, the contractor shall 
send an e-mail, fax, or letter to the provider stating that: (i) the provider must submit written 
documentation to the contractor explaining why the person or entity cannot legally obtain a 
TIN or ITIN; and (ii) the explanation  which can be in any written format and may be 
submitted electronically or via fax  must be submitted within 30 days of the contractors 
request. 
 
2.   Provider Response  
 
If the provider timely submits the explanation in section 10.6.7.3(B)(1)(c) above, the contractor 
shall forward the explanation to its CMS Provider Enrollment & Oversight Group Business 
Function Lead (PEOG BFL); PEOG will notify the contractor as to how the application should be 
handled.  If the provider fails to timely respond to the contractors inquiry in either section 
10.6.7.3(B)(1)(a) or (c), the contractor shall  unless another CMS instruction directs otherwise - 
reject the application consistent with the procedures identified in this chapter. 
 
3.   Clock Stoppages  
 
When the contractor is required under section 10.6.7.3(B)(2) to contact PEOG, the 
application processing time clock is stopped.  It resumes on the date on which the contractor 
receives PEOGs decision, instruction, or final guidance, as applicable.  Interim  communication between the contractor and PEOG during such waiting periods (e.g., 
PEOG request for additional information from the contractor) does not restart the clock.  
Optional communications---that is, communications with PEOG that are not specifically 
directed under section 10.6.7.3(B)(2)---do not stop the processing clock.  
 
10.6.8  Billing Agencies 
(Rev. 10868; Issued: 07-14-21; Effective: 08-13-21; Implementation: 08-13-21) 
 
A billing agency is an entity or person that furnishes billing and collection services on behalf of a 
provider/supplier. A billing agency does not enroll in the Medicare program; rather, it submits 
claims to Medicare in the name and billing number of the provider/supplier that furnished the 
service(s).  To receive payment directly from Medicare on a provider/suppliers behalf, a billing 
agency must meet the conditions described in  1842(b)(6)(D) of the Social Security Act.  
 
The provider/supplier shall complete the Billing Agency section of the Forms CMS-855A, 
CMS-855B, CMS-855I, CMS-855S and CMS-20134 with information about all billing 
agents it utilizes.  (Note that the billing agency address can be listed as a PO Box on the 
Form CMS-855 and CMS-20134 applications.)  As all Medicare payments must be made via 
electronic funds transfer, the contractor need not verify the providers compliance with the 
Payment to Agent rules in CMS Pub. 100-04, chapter 1, section 30.2.  The only exception 
is if the contractor discovers that the special payments address in the Practice Location 
section of the providers Form CMS-855 or CMS-20134 application belongs to the billing 
agent or agency.  In this situation, the contractor may obtain a copy of the billing agreement 
if it has reason to believe that the arrangement violates the Payment to Agent rules. 
 
For further information on billing agencies, see CMS Pub. 100-04, chapter 1, section 30.2.4.  
 
10.6.9  Contact Persons  
(Rev. 11307; Issued: 03- 25-2022; Effective: 03-04-22; Implementation: 04-25-22) 
 
Unless stated otherwise in this chapter or in another CMS directive - or unless the provider 
requests that the contractor communicate with only a specific individual (e.g., an authorized 
official) or via specific means (e.g., only via the correspondence address e-mail) - the contractor 
has the discretion to use the contact persons collected via the Forms CMS-855A, CMS-855B, 
CMS-855I, CMS-855O, CMS-855R, CMS-855S and CMS-20134 for all written and oral 
communications (e.g., mail, e-mail, telephone) related to the providers Medicare enrollment.  
Such communication need not be restricted to a particular enrollment application of the 
providers that the contractor is currently processing.  Nor is the contractor required (again, 
unless either CMS or the provider directs otherwise) to send certain materials to the 
correspondence mailing or e-mail address rather than the contact persons mailing or e-mail 
address.   
 
The provider may have as many contact persons as it wishes. 
 
If the contractor discovers that a particular contact person qualifies as an owning or managing 
individual, the provider shall list the person in the Individual Ownership and/or Managing 
Control section of the application   
If multiple contact persons are listed, the contractor has the discretion to select the individual to 
contact unless the provider indicates otherwise via any means.  In addition: 
 
(i)  The contractor may use multiple contact persons throughout the enrollment process; it need 
not use the same individual for the entire duration unless, again, the provider indicates otherwise.  
 
(ii) All contact persons shall be stored in PECOS and shall not be removed unless the provider 
requests the removal via letter, e-mail, fax, or---if the applicable Form CMS-855 contains an 
option for deleting a contact person---the Form CMS-855.  Irrespective of whether the applicable 
Form CMS-855 contains such a deletion option, the contractor may accept end-dates of a contact 
person via telephone, email, fax, or mail from the provider, the authorized or delegated official, 
or a current contact person on file.  The contractor shall document in the comment section in 
PECOS who requested the termination, how it was requested (email, phone or fax) and when it 
was requested.  The addition of contact persons must still be reported via the appropriate Form 
CMS-855. 
 
10.6.10  Medicare Payment  
(Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Electronic Fund Transfers (EFT)  
 
If a provider does not have an established enrollment record in the Provider Enrollment, Chain 
and Ownership System (PECOS) and wants to change any of its EFT information (e.g., bank 
routing number), it must submit a complete Form CMS-855 or Form CMS-20134 before the 
contractor can effectuate the change. 
 
It is immaterial whether the provider or the bank was responsible for triggering a change to EFT 
data (e.g., bank routing number). 
 
Under 42 CFR  424.510(d)(2)(iv) and  424.510(e): 
 
(i)  All providers (including federal, state and local governments) enrolling in Medicare must use 
EFT in order to receive payments.  However, a revalidating provider/supplier need not submit 
the most current version of the Form CMS-588 with its application unless: (1) it has no Form 
CMS-588 on file at all; or (2) it is changing any of its existing Form CMS-588 data.   
 
(ii)  If a provider is already receiving payments via EFT and is located in a jurisdiction that is 
undergoing a change of Medicare contractors, the provider must continue to receive payments 
via EFT.  However, the change in contractors does not require the provider to submit a new 
Form CMS-588 unless CMS states otherwise. 
 
(iii)  For PECOS applications, the Form CMS-588 shall be submitted via PECOS. 
 
The contractor shall also follow the EFT instructions in sections 10.3(C)(2) and 10.6.23 of this 
chapter. 
  B. Assignment of Part B Provider Transaction Access Numbers (PTANs)  
 
1.  Paper Applications - The contractor shall only assign the minimum number of PTANs 
necessary to ensure that proper payments are made.  The contractor shall not assign additional 
PTAN(s) to a supplier merely because the individual or entity requests one - the only exception 
being for hospitals that request separate billing numbers for their hospital departments in the 
Identifying Information/Hospitals Only section of the Form CMS-855B.  However, a hospital 
requesting an additional PTAN must associate the new PTAN with a National Provider Identifier 
(NPI) in the Practice Location Information section of the Form CMS-855B. 
 
2.  PECOS Applications  See section 10.3 of this chapter for information regarding the issuance 
of PTANs  
 
C.  NPI-Legacy Combinations  
 
If the contractor determines that a provider is having claim payment issues due solely to an 
incorrect NPI-PTAN combination or NPI-CMS Certification Number (CCN) combination 
entered into PECOS, the contractor shall request that the provider submit the correct NPI-legacy 
combination via a Form CMS-855 or CMS-20134 change of information.  The change request 
can be faxed, although the contractor shall verify the faxed signature against the providers or 
authorized/delegated officials signature on file before any changes are made in PECOS.  
 
The contractor shall not use this process to resolve any enrollment issue other than the correction 
of the NPI-legacy identifier combination. Moreover, the contractor shall not use this process for 
providers that have not submitted a complete Form CMS-855 or CMS-20134 enrollment 
application during or after May 2006. For instance, assume a provider first enrolled in Medicare 
in December 2005 and has not submitted a complete enrollment application after that date. The 
provider would be unable to utilize the process described in this section. 
 
10.6.11  Participation (Par) Agreements and the Acceptance of Assignment  
General Information 
(Rev. 11307; Issued: 03- 25-2022; Effective: 03-04-22; Implementation: 04-25-22) 
 
All providers/suppliers must choose to be either Par or Non-Par when initially enrolling and must 
maintain the same Par status across all lines of business.  
 
Individual physicians and non-physician practitioners who reassign benefits to a clinic/group 
practice inherit the Par status established by the clinic/group practice.  However, if the individual 
physician or non-physician practitioner maintains a private practice (separate from the 
reassignment of benefits agreement), he/she may designate their own Par status.  See Publication 
100-04, chapter 1, section 30 for guidance on applying the correct Par status to clinic/group 
practices, organizations, and individuals in private practice. 
 
The contractor shall follow the instructions in CMS Publication 100-04, chapter 1, sections 30 
through 30.3.12.3 when handling issues related to par agreements and assignment.  Queries 
related to the interpretation of such instructions shall be referred to the responsible CMS 
component.   
Physicians and Part B organizations should be entered as Par in PECOS based on the submission 
of a signed Form CMS-460 (Medicare Participating Physician or Supplier Agreement) upon 
initial enrollment or during a change to their Par status during the annual Medicare Open 
Enrollment period. Non-Physician Practitioners that are considered mandatory participation and 
individual physicians and non-physician practitioners that reassign all of their benefits to a Par 
organization should not be entered as Par in PECOS. 
 
10.6.12  Opting-Out of Medicare  
(Rev. 11574; Issued: 08-25-22; Effective: 06-24-22; Implementation: 09-27-22) 
 
Physicians and practitioners are typically required to submit claims on behalf of beneficiaries for 
all items and services they provide for which Medicare payment may be made under Part B.  
They are also not permitted to charge beneficiaries in excess of the limits on charges that apply 
to the item or service being furnished.  However, certain types of physicians and practitioners 
may opt-out of Medicare.  A physician or practitioner who opts-out is not required to submit 
claims on behalf of beneficiaries and also is excluded from limits on charges for Medicare-
covered services.  Medicare does not pay anyone for services (except for certain emergency and 
urgent care services) furnished by an opt-out physician or practitioner.  Instead, opt-out 
physicians and practitioners sign private contracts with beneficiaries. Please refer to CMS Pub. 
100-02, Chapter 15, sections 40 - 40.39 for more information regarding the maintenance of opt-
out affidavits and the effects of improper billing of claims during an opt-out period.  
 
The instructions in this section 10.6.12 address the contractors processing of opt-out affidavits.  
(See Pub. 100-02, chapter 15, section 40.8 for private contract definitions and requirements.) 
 
A. Who May Opt-Out of Medicare 
 
Only the following physicians and practitioners (sometimes collectively referenced as eligible 
practitioners in this section) can opt-out of Medicare: 
 
Physicians who are: 
  Doctors of medicine or osteopathy,  
  Doctors of dental surgery or dental medicine,  
  Doctors of podiatry, or  
  Doctors of optometry who are legally authorized to practice dentistry, podiatry, optometry, 
medicine, or surgery by the state in which such function or action is performed.  
 
Non-physician practitioners who are 
 
  Physician assistants,  
  Nurse practitioners,  
  Clinical nurse specialists,  
  Certified registered nurse anesthetists,  
  Certified nurse midwives,  
  Clinical psychologists,  
  Clinical social workers, or     Registered dietitians or nutrition professionals who are legally authorized to practice by the 
state and otherwise meet Medicare requirements. 
 
(Organizations are not permitted to opt-out of Medicare.)   
 
This means that neither the eligible practitioner nor the beneficiary submits the bill to Medicare 
for services performed.  Instead, the beneficiary pays the eligible practitioner out-of-pocket and 
neither party is reimbursed by Medicare.  In fact, a private contract is signed between the eligible 
practitioner and the beneficiary that states, in essence, that neither can receive payment from 
Medicare for the services performed.  (The contract, though, must be signed before the services 
are provided so the beneficiary is fully aware of the eligible practitioners opt-out status.)  
Moreover, the eligible practitioner must submit an affidavit to Medicare expressing his/her 
decision to opt-out of the program.  The contractors provider enrollment unit must process these 
affidavits. 
 
Eligible practitioners who opt-out of Medicare are not the same as non-participating 
physicians/suppliers.  The latter are enrolled in Medicare and choose on a claim-by-claim basis 
whether they want to accept assignment unless the service can only be paid on an assignment-
related basis as required by law (e.g., for drugs, ambulance services, etc.).  Non-participating 
physicians/suppliers must therefore comply with Medicares mandatory claim submission, 
assignment, and limiting charge rules.  Opt-out eligible practitioners, on the other hand, are 
excused from the mandatory claim submission, assignment, and limiting charge rules, though 
only when they maintain compliance with all of the requirements for opting out. 
 
In an emergency care or urgent care situation, an eligible practitioner who has opted-out may 
treat a Medicare beneficiary with whom he or she does not have a private contract. In those 
circumstances, the eligible practitioner must complete a Form CMS-855 application. 
 
B.  Requirements for an Opt-out Affidavit 
 
1.  Affidavit Contents 
 
As stated in Pub. 100-02, chapter 15, section 40.9, the affidavit shall state that, upon signing the 
affidavit, the eligible practitioner agrees to the following requirements: 
 
  Except for emergency or urgent care services, during the opt-out period the eligible 
practitioner will provide services to Medicare beneficiaries only through private contracts, 
but for their provision under a private contract, would have been Medicare-covered services; 
 
  The eligible practitioner will not submit a claim to Medicare for any service furnished to a 
Medicare beneficiary during the opt-out period, nor will the eligible practitioner permit any 
entity acting on the eligible practitioners behalf to submit a claim to Medicare for services 
furnished to a Medicare beneficiary; 
 
  During the opt-out period, the eligible practitioner understands that he/she may receive no 
direct or indirect Medicare payment for services that the eligible practitioner furnishes to 
Medicare beneficiaries with whom the eligible practitioner has privately contracted, whether  as an individual, an employee of an organization, a partner in a partnership, under a 
reassignment of benefits, or as payment for a service furnished to a Medicare beneficiary 
under a Medicare Advantage plan; 
 
  An eligible practitioner who opts out of Medicare acknowledges that, during the opt-out 
period, the eligible practitioners services are not covered under Medicare and that no 
Medicare payment may be made to any entity for the eligible practitioners services, directly 
 
or on a capitated basis;
 
  On acknowledgment by the eligible practitioner to the effect that, during the opt- out period, 
the eligible practitioner agrees to be bound by the terms of both the affidavit and the private 
 
contracts that the eligible practitioner has entered into;
 
  Acknowledge that the eligible practitioner recognizes that the terms of the affidavit apply to 
all Medicare-covered items and services furnished to Medicare beneficiaries by the eligible 
practitioner during the opt-out period (except for emergency or urgent care services furnished 
to the beneficiaries with whom the eligible practitioner has not previously privately 
 
contracted) without regard to any payment arrangements the eligible practitioner may make;
 
  With respect to an eligible practitioner who has signed a Part B participation agreement, 
 
acknowledge that such agreement terminates on the effective date of the affidavit;
 
  Acknowledge that the eligible practitioner understands that a beneficiary who has not entered 
into a private contract and who requires emergency or urgent care services may not be asked 
 
to enter into a private contract with respect to receiving such services;
 
  Identify the eligible practitioner sufficiently so that the Medicare contractor c an ensure that 
no payment is made to the eligible practitioner during the opt-out period; and
 
  Be filed with all MACs that have jurisdiction over claims the eligible practitioner would 
otherwise file with Medicare; the initial two-year opt-out period will begin the date on which 
the affidavit meeting the requirements of 42 C.F.R.  405.420 is signed, provided the 
affidavit is filed within 10 days after t he eligible practitioner signs his or her first private 
contract with a Medicare beneficiary.
 
(See Pub. 100-02, chapter 15, section 40.9 for more information on the requirements of opt-out 
affidavits.  See also section 10.6.12(B)(5) below for acceptable opt-out formats.)   
 
The contractor shall review initial opt-out affidavits to ensure that they contain the following 
information about the eligible practitioner in order to create an affidavit record in PECOS: 
 
  Full name (first, middle and last), 
  Birthdate, 
  Address and telephone number, 
  License information and 
  NPI (if one has been obtained), and 
  SSN (if no NPI has been issued, though note that this cannot be an individual tax  identification number (ITIN)). 
 
If, in order to create a PECOS affidavit record, the contractor needs to obtain data that is missing 
from an affidavit, it may (1) obtain this information from other sources (such as the state license 
board) or (2) contact the eligible practitioner only one time directly. The contractor shall not use 
Internet-based PECOS or the Form CMS-855 to secure the data from the eligible practitioner, for 
the eligible practitioner is not enrolling in Medicare. If the eligible practitioner is requested to 
submit missing information to permit the processing of the affidavit and fails to do so within 30 
days, the contractor shall reject the opt-out affidavit. 
 
2.  Opting-Out and Ordering/Certifying/Referring 
 
If an eligible practitioner who wishes to opt-out elects to order/certify/refer Medicare items or 
services, the contractor shall develop for the following information (if not provided on the 
affidavit):  
 
  NPI (if one is not contained on the affidavit voluntarily); 
 
  Date of birth, and; 
 
  SSN (if not contained on the affidavit, though it cannot be an ITIN). 
 
If this information is requested but not received, the eligible practitioners affidavit can still be 
processed; however, he/she cannot be listed as an ordering/certifying/referring provider. 
 
3.  Adverse Actions 
 
The contractor shall review the List of Excluded Individuals and Entities (LEIE) and the System 
for Award Management (SAM) for all eligible practitioners who submit opt-out affidavits.  
Excluded eligible practitioners may opt-out of Medicare but cannot order certify/refer. 
 
As noted in 42 CFR  405.425(i) and (j), individuals who are revoked from Medicare cannot 
order, certify, or refer Part A or B services or items to Medicare beneficiaries if they opt-out of 
Medicare after revocation. 
 
4.  No Dual Status 
 
a.  Form CMS-855O - Eligible practitioners cannot be enrolled via the Form CMS-855O and 
actively opted-out simultaneously.  Prior to processing an initial Form CMS-855O or opt-out 
affidavit submission, therefore, the contractor shall confirm that an approved Form CMS-855O 
enrollment or valid opt-out affidavit does not exist in PECOS.  If an approved enrollment or 
affidavit indeed exists, the contractor shall return the pending application. 
 
b.  Form CMS-855I  A Form CMS-855I enrollment can simultaneously exist with a valid opt-
out affidavit only if the Form CMS-855I is to bill for emergency services.  If a Form CMS-855I 
is received and an opt-out affidavit is active, the contractor shall contact the eligible practitioner 
(via any means) to clarify if he/she submitted the application to solely bill for emergency  services provided to a beneficiary.  If so, the application shall be processed via normal 
procedures.  If not, the application may be returned.  (See Pub. 100-02, chapter 15, section 40.28 
for more information on emergency and urgent care services.)   
 
An eligible practitioner who has opted out of Medicare need not also enroll via the Form CMS-
855O if he/she wishes to order/refer/certify (e.g., providing the necessary information on his/her 
affidavit per this section 10.6.12).   
 
5.  Acceptable Opt-Out Affidavit Formats 
 
The contractor may provide a sample opt-out affidavit form for eligible practitioners to complete. 
The opt-out affidavit form must provide spaces for the eligible practitioners to furnish their 
personal information.  
 
Eligible practitioners may also create their own affidavit. If he/she elects to do so, he/she should 
include information found in section 10.6.12(B)(1) to ensure timely processing of the opt-out 
affidavit. 
 
The contractor and eligible practitioners may use the information below as an opt-out affidavit 
form. 
I, {Enter Physician/Non-Physician Practitioner Name}, being duly sworn, depose and say: 
 
  Opt-out is for a period of two years.  At the end of the two year period, my opt-out status will 
automatically renew.  If I wish to cancel the automatic extension, I understand that I must 
notify my Medicare Administrative Contractor (MAC) in writing at least 30 days prior to the 
start of the next two-year opt-out period. 
 
  Except for emergency or urgent care services (as specified in the Medicare Benefit Policy 
Manual Publication 100-02, Chapter 15 40.28), during the opt-out period I will provide 
services to Medicare beneficiaries only through private contracts that meet the criteria of 
40.8 for services that, but for their provision under a private contract, would have been 
Medicare-covered services. 
 
  I will not submit a claim to Medicare for any service furnished to a Medicare beneficiary 
during the opt-out period, nor will I permit any entity acting on my behalf to submit a claim 
to Medicare for services furnished to a Medicare beneficiary, except as specified in  40.28. 
 
  During the opt-out period, I understand that I may receive no direct or indirect Medicare 
payment for services that I furnish to Medicare beneficiaries with whom I have privately 
contracted, whether as an individual, an employee of an organization, a partner in a 
partnership, under a reassignment of benefits, or as payment for a service furnished to a 
Medicare beneficiary under Medicare Advantage. 
 
  I acknowledge that during the opt-out period, my services are not covered under Medicare 
and that no Medicare payment may be made to any entity for my services, directly or on a 
capitated basis.   
  I acknowledge and agree to be bound by the terms of both the affidavit and the private 
contracts that I have entered into during the opt-out period. 
 
  I acknowledge and understand that the terms of the affidavit apply to all Medicare-covered 
items and services furnished to Medicare beneficiaries by myself during the opt-out period 
(except for emergency or urgent care services furnished to the beneficiaries with whom I 
have not previously privately contracted) without regard to any payment arrangements I 
may make. 
 
  I acknowledge that if I have signed a Part B participation agreement, that such agreement 
terminates on the effective date of this affidavit. 
 
  I acknowledge and understand that a beneficiary who has not entered into a private contract 
and who requires emergency or urgent care services may not be asked to enter into a private 
contract with respect to receiving such services and that the rules of 40.28 apply if I furnish 
such services. 
 
  I have identified myself sufficiently so that the MAC can ensure that no payment is made to 
me during the opt-out period. If I have already enrolled in Medicare, I have included my 
Medicare PTAN, if one has been assigned. If I have not enrolled in Medicare, I have 
included the information necessary to opt-out. 
 
  I will file this affidavit with all MACs who have jurisdiction over claims that I would 
otherwise file with Medicare and the initial two- year opt-out period will begin the date the 
affidavit meeting the requirements of 42 C.F.R. 405.420 is signed, provided the affidavit is 
filed within 10 days after the physician/practitioner signs his or her first private contract with 
a Medicare beneficiary. 
 
Eligible practitioners should also be encouraged to include the following information (to 
complete an affidavit record in PECOS): NPI; Medicare Identification Number (if issued); SSN 
(not an ITIN); date of birth; specialty; e-mail address; any request to order/certify/refer.  
 
C.  Effective Date of an Opt-Out Period 
 
As noted in Pub. 100-02, chapter 15, section 40.17, eligible practitioners receive effective dates 
based on their participation status. 
 
1.  Eligible Practitioners Who Have Never Enrolled In Medicare 
 
Eligible practitioners need not enroll prior to opting-out of Medicare.  If a non-enrolled eligible 
practitioner submits an opt-out affidavit, the effective date of the opt-out period begins the date 
the affidavit is signed by the eligible practitioner.  
 
2.  Non-Participating Practitioners 
  If an eligible practitioner who is a non-participating provider decides to terminate his/her active 
Medicare billing enrollment and instead opt-out of Medicare, the effective date of the opt-out 
period begins the date the affidavit is signed by the eligible practitioner. 
 
3.  Participating Practitioners 
 
If an eligible practitioner who is a participating provider (one who accepts assignment for all 
their Medicare claims) decides to terminate his/her active Medicare billing enrollment and opt-
out of Medicare, the effective date of the opt-out period begins the first day of the next calendar 
quarter.  Per 42 CFR  405.410(d), an eligible practitioner may opt-out of Medicare at the 
beginning of any calendar quarter, provided that the affidavit described in 42 CFR  405.420 is 
submitted to the applicable contractor(s) at least 30 days before the beginning of the selected 
calendar quarter.  (The contractor shall, however, add 5 calendar days to the 30-day period to 
allow for mailing.)  An opt-out affidavit must therefore be submitted at least 30 days before the 
first day of the calendar quarter in order to receive January 1, April 1, July 1 or October 1 as the 
effective date.  If the opt-out affidavit is submitted within 30 days prior to January 1, April 1, 
July 1 or October 1, the effective date would be the first day of the next calendar quarter. (For 
example, an enrolled participating eligible practitioners opt-out affidavit was submitted on 
December 10. The eligible practitioners effective date could not be January 1, for the affidavit 
was not submitted at least 30 days prior to January 1. The effective date would be April 1.)  The 
eligible practitioner would need to remain enrolled as a participating supplier until the end of the 
next calendar quarter so that claims can be properly submitted until the opt-out period begins. 
 
4.  Opt-Out After Enrollment 
 
(This section 10.6.12(C)(4) applies notwithstanding any instruction to the contrary in this 
chapter.) 
 
If an enrolled physician or eligible practitioner is now opting-out, the existing PECOS 
enrollment record shall be end-dated the same day as the affidavit effective date. 
 
D. Emergency and Urgent Care Services 
 
If an eligible practitioner who has opted-out provides emergency or urgent care services, he/she 
must apply for enrollment via the Form CMS-855I.  Once he/she receives his/her PTAN, he/she 
must submit the claim(s) for any emergency or urgent care service furnished.  The contractor 
shall contact its PEOG BFL for additional guidance when this type of situation arises.  (See Pub. 
100-02, chapter 15, section 40.28 for more information on emergency and urgent care services.) 
 
E. Termination of an Opt-Out Affidavit 
 
As noted in Pub. 100-02, chapter 15, section 40.35, an eligible practitioner who has not 
previously opted-out may terminate his/her opt-out period early.  However, he/she must submit 
written notification thereof (with his/her signature) no later than 90 days after the effective date 
of the initial 2-year opt-out period.  To properly terminate an affidavit, moreover, the eligible 
practitioner must: 
  1.   Not have previously opted-out of Medicare (the eligible practitioner cannot terminate a 
renewal of his/her opt-out); 
2.   Notify all the MACs that the eligible practitioner has filed an affidavit no later than 90 days 
after the effective date of the affidavit; 
3.   Notify all beneficiaries (or their legal representation) with whom the eligible practitioner 
entered into private contracts of the eligible practitioners decision to terminate his/her opt-out 
and of the beneficiaries right to have claims filed on their behalf with Medicare for the services 
furnished during the period between the effective date of the opt-out and the effective date of the 
termination of the opt-out period and; 
4.   Refund to each beneficiary with whom the physician or practitioner has privately contracted 
all payments collected in excess of the Medicare limiting charge or deductibles and coinsurance. 
 
For eligible practitioners who were previously enrolled to bill Medicare for services, the 
contractor shall reactivate the eligible practitioners enrollment record in PECOS and reinstate 
his/her PTAN as if no opt-out affidavit existed. The eligible practitioner may bill for services 
provided during the opt-out period. 
 
For eligible practitioners who were not previously enrolled to bill Medicare for services, the 
contractor shall remove the affidavit record from PECOS; this will help ensure that the eligible 
practitioner can submit the appropriate application(s) (via PECOS or paper Form CMS-855 for 
individual and/or reassignment enrollment) in order to establish an enrollment record in PECOS 
and thus bill for services rendered during the opt-out period. 
 
F.  Opt-Out Period Auto-Renewal and Cancellation of the Opt-Out Affidavit 
 
1.  General Policies 
 
Eligible practitioners who initially opted-out or renewed an affidavit on or after June 16, 2015 
need not submit a renewal of their affidavit. The opt-out will be automatically renewed for 
another 2-year period.  Yet if the eligible practitioner decides to cancel his/her opt-out, he/she 
must submit a written notice to each contractor to which he or she would file claims (absent the 
opt-out) not later than 30 days before the end of the current 2 year opt-out period.  
 
If the eligible practitioner decides to enroll in Medicare after his/her opt-out is canceled, he/she 
must submit a Form CMS-855I application. The effective date of enrollment, however, cannot be 
before the cancellation date of the opt-out period. (For example, suppose an eligible practitioner 
submits a cancellation of her opt-out to end the period on March 31, which is two years from the 
eligible practitioners opt-out affidavit effective date. Her requested effective date of enrollment 
cannot be before April 1.) 
 
If the eligible practitioner submits a cancellation request within 30 days of the end of the current 
opt-out period or after the opt-out period automatically renews, the contractor shall return the 
cancellation request to the eligible practitioner and provide appeal rights.  
 
2.  Auto-Renewal Report and Opt-Out Renewal Alert 
 
The contractor shall issue an Opt-Out Renewal Alert Letter (found in section 10.7.14(E) of this 
chapter) to any eligible practitioner whose opt-out period is set to auto-renew.  For this purpose,  CMS will provide a monthly opt-out report to all contractors via the Share Point Ensemble site. 
The contractor shall access the report monthly through the Share Point Ensemble site. The 
contractor shall also review the opt-out report for opted-out eligible practitioners that will auto-
renew in the next three-and-a-half months.  In addition, the contractor shall issue an Auto-
Renewal Alert Letter to eligible practitioners at least 90 days prior to the auto-renewal date; the 
eligible practitioner will thus have at least 60 days prior to the date a cancellation notice must be 
submitted to cancel the current opt-out. 
 
The Opt-out Auto-Renewal Alert Letter will provide (1) the date on which the current opt-out 
period will be auto renewed and (2) the date by which the eligible practitioner will need to 
submit a cancellation request. The letter will also furnish the eligible practitioner appeal rights if 
he/she fails to submit a cancellation request and the opt-out renews. 
 
The contractor shall (1) complete the Opt-Out Renewal Alert Letter Report to include the date 
the Alert Letter was issued, (2) post its reports no later than the 15th of the following month to 
the Share Point Ensemble site, and (3) email its PEOG BFL when the report has been posted. 
 
If an opted-out eligible practitioner submits a Form CMS-855I and/or a CMS-855R without 
submitting a cancellation request of his or her opt-out, the contractor shall develop for the 
cancellation notice.  Once the cancellation notice is received, the contractor shall then process 
the application(s).  
 
If the eligible practitioner submits a cancellation request within 30 days of the end of the current 
opt-out period or after the opt-out period automatically renews, the contractor shall return the 
cancellation request to the eligible practitioner and provide appeal rights using the Late 
Cancellation Request return letter.  In addition, if the eligible practitioner submits a cancellation 
request more than 90 days prior to the auto-renewal date, the contractor shall return the 
cancellation request to the eligible practitioner using the Cancellation Request Received Too 
Early return letter.  
 
G.  Failure to Properly Cancel or Terminate Opt-Out 
 
Eligible practitioners who fail to properly cancel or terminate their opt-out may appeal the 
decision to continue (1) the auto-renewal of the opt-out or (2) the eligible practitioners initial 
opt-out period.   
 
Opt-out approval letters include appeal rights for eligible practitioners who initially opt-out and 
fail to properly terminate the opt-out within 90 days of the approval. 
 
10.6.13  Ordering/Certifying Suppliers  
(Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A. Ordering/Certifying Suppliers Background  
 
1.  Who Can Order/Certify 
  Pursuant to CMS Final Rule 6010-F (published April 27, 2012), to order or certify for Medicare 
items and services, a provider or supplier must be enrolled (i.e., in an approved or valid opt-out 
status) in PECOS. 
 
Generally, depending upon state law, the following physicians and non-physician practitioners 
are permitted to order or certify items or services for Medicare beneficiaries: 
 
  Doctors of medicine or osteopathy 
 
  Doctors of dental surgery or dental medicine 
 
  Doctors of podiatry 
 
  Doctors of optometry 
 
  Physician assistants 
 
  Certified clinical nurse specialists 
 
  Nurse practitioners 
 
  Clinical psychologists 
 
  Certified nurse midwives 
 
  Clinical social workers 
 
  Residents meeting eligibility criteria (Pursuant to CMS Final Rule CMS-6010-F, residents 
(as defined in 42 CFR  413.75 and which includes interns and fellows)who are enrolled 
in an accredited graduate medical education program in a state that licenses or otherwise 
enables such individual to practice or order these items or services may  enroll in Medicare 
to order and certify). 
 
Most physicians and non-physician practitioners enroll in Medicare so they can receive 
reimbursement for covered services to Medicare beneficiaries.  However, some physicians and 
non-physician practitioners who are not enrolled in Medicare via the Form CMS-855I may wish 
to order or certify items or services for Medicare beneficiaries.  These individuals can become 
eligible to do so by completing the Form CMS-855O via paper or PECOS. 
 
NOTE:  It is important to observe that physicians and non-physician practitioners that complete 
the Form CMS-855O do not and will not send claims to a Medicare contractor for services they 
furnish.  They are not afforded Medicare billing privileges for the purpose of submitting claims 
to Medicare directly for services that they furnish to beneficiaries.  Such persons may be: 
 
  Employed by the Department of Veterans Affairs (DVA)  
 
  Employed by the Public Health Service (PHS)   
  Employed by the Department of Defense (DOD) Tricare 
 
  Employed by the Indian Health Service (IHS) or a tribal organization 
 
  Employed by a federally qualified health center (FQHC), rural health clinic (RHC), or 
critical access hospital (CAH) 
 
  Licensed residents and physicians in a fellowship (see subsection B) 
 
  Dentists, including oral surgeons 
 
  Pediatricians 
 
B. Requirements for Suppliers to Maintain Ordering and Certifying Documentation  
 
1.  Background 
 
Under 42 CFR  424.516(f)(1), a provider or supplier that furnishes covered ordered items of 
durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), clinical laboratory, 
imaging services, or covered ordered/certified home health services is required to:  
 
  Maintain documentation (see next paragraph) for 7 years from the date of service, and 
 
  Upon the request of CMS or a Medicare contractor, provide access to that documentation. 
 
The documentation to be maintained includes written and electronic documents (including the 
National Provider Identifier (NPI) of the physician who ordered/certified the home health 
services and the NPI of the physician - or, when permitted, other eligible professional - who 
ordered items of DMEPOS or clinical laboratory or imaging services) relating to written orders 
and certifications and requests for payments for items of DMEPOS and clinical laboratory, 
imaging, and home health services.   
 
In addition, under  424.516(f)(2), a physician who orders/certifies home health services and the 
physician - or, when permitted, other eligible professional - who orders items of DMEPOS or 
clinical laboratory or imaging services is required to maintain the documentation described in the 
previous paragraph for 7 years from the date of service and to provide access to that 
documentation pursuant to a CMS or Medicare contractor request. 
 
If the provider, supplier, physician or eligible professional (as applicable) fails to maintain this 
documentation or to furnish this documentation upon request, the contractor may revoke 
enrollment under  424.535(a)(10).  
 
2.  Contractors Requests for Documentation of Ordering or Certifying  
 
Absent a CMS directive to the contrary, the contractor shall request the documentation described 
in subsection (A) if it has reason to believe that the provider, supplier, physician, or other eligible  professional (hereinafter collectively referred to as provider) is not maintaining the 
documentation in accordance with  424.516(f)(1) or (2).  Examples of when a request might be 
appropriate include, but are not limited to:  
 
  The contractor has detected an unusually high number of denied claims involving the 
provider, or the Fraud Prevention System has generated an alert with respect to the 
provider.  
 
  The provider has been the subject of a recent Unified Program Integrity Contractor 
referral.  
 
  The provider maintains an elevated surety bond amount.  
 
These are, of course, only examples of when a request could perhaps be warranted.  Ultimately, 
the contractor would have to consider the surrounding circumstances of each case, including 
those involving situations not addressed in the aforementioned examples.  The contractor may 
always contact its PEOG BFL if it is uncertain as to whether a particular documentation request 
should be made. 
 
NOTE:  Documentation cannot be requested for written orders and certifications dated prior to 
July 6, 2010. 
 
3.  Requirement for Providers and Suppliers to Maintain and Provide Access to 
Documentation 
 
Under  424.516(f), CMS or a Medicare contractor may request access to documentation 
described in 424.516(f).  The term access to documentation means that the documentation is 
actually provided or made available in the manner requested by CMS or a Medicare contractor.  
All providers and suppliers who either furnish, order, or certify the items described in section 
10.6.13(B)(1) are subject to this requirement and are individually responsible for maintaining 
these records and providing them upon request. 
 
For example, if a Medicare contractor requests copies of all orders for wheelchairs from an 
ordering physician for all beneficiaries with dates of service from November 1, 2014 through 
November 10, 2014, the ordering physician must provide the copies, in full, according to the 
specific request.  If copies cannot be provided because the physician or other eligible 
professional did not personally maintain the records or can only be partially provided, then the 
requirement to maintain this documentation and provide access to it will not have been met and 
the provider, supplier, physician, or other eligible professional may be revoked under  
424.535(a)(10). 
 
Examples of Sufficient and Deficient Access may include, but are not limited to: 
 
Sufficient Access: 
 
  All documentation requested 
    Documentation specific to the order(s) or certification(s), as requested 
 
  Documentation for the dates of service or billing periods requested 
 
Deficient Access 
 
  Providing none of the requested documentation 
 
  Providing none of the requested documentation 
 
  Providing similar documentation that does not contain the order or certification requested 
 
  Providing other documents NOT requested by CMS or a Medicare contractor and/or not 
specifically directing attention to the requested documentation 
 
The CMS recognizes that providers and suppliers often rely upon an employer or another entity 
to maintain these records on their behalf.  However, it remains the responsibility of the 
individual or entity to whom/which the request has been made to provide documentation.  All 
individuals and entities subject to this documentation requirement are responsible for ensuring 
that documents are provided upon request and may ultimately be subject to the revocation basis 
associated with non-compliance with the documentation request. 
 
4.  Process to Request Documentation of Ordering or Certifying 
 
If the contractor believes that a request for documentation is warranted, it shall prepare and send 
a request letter (refer to model letters at the end of this chapter) to the provider via certified mail. 
If the provider:  
 
  Fails to respond within 30 calendar days of the contractors request (i.e., a complete non-
response), the contractor shall revoke enrollment using  424.535(a)(10) as the basis.  
Prior approval from the contractors PEOG BFL is not necessary. A 1-year re-enrollment 
bar shall be imposed. 
 
  Timely furnishes documentation that the contractor nevertheless deems inadequate, the 
contractor shall send a developmental letter via mail, the PCV, e-mail, or fax to the 
provider that requests more sufficient documentation.  If the provider fails to submit such 
documentation (either via a complete non-response or by submitting additional inadequate 
documentation), the contractor shall refer the matter (including the documentation 
submitted to date) to its PEOG BFL.  CMS will determine whether a revocation is 
warranted and will notify the contractor via e-mail of its decision.  
 
  Furnishes documentation that the contractor deems adequate, the contractor need not take 
further action other than to upload the documentation and the documentation request 
letter(s) in PECOS.   
 
5.  Additional Guidance Regarding Documentation of Ordering or Certifying 
  The contractor shall also abide by the following:  
 
a.  When preparing the letter referred to in section 10.6.13(B)(4) above, the contractor shall use 
the appropriate model language in section 10.7.17 and 10.7.17 (A) of this chapter.  Note, 
however, that while the letters request copies of orders, the contractor has the discretion to ask 
for different or additional documentation (e.g., documentation that supports the legitimacy of a 
particular service or the payment of a particular claim).  Copies of orders need not be requested 
in every situation.  As alluded to in section 10.6.13(B)(2) above, the contractor would have to 
examine the facts of each case in determining the type(s) of documentation to be requested.  
 
b.  There may be situations in which CMS directs the contractor to request documentation in a 
particular case. The contractor shall follow the instructions in this section 10.6.13(B) with 
respect to doing so. 
 
c. The contractor shall contact its CMS PEOG BFL if it has questions as to whether particular 
submitted documentation is adequate or legitimate  specifically, whether it falls within the 
category of documentation described in section 10.6.12(B)(3) above. 
 
10.6.14  Application Fees  
(Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
(The contractor shall review section 10.3 of this chapter for special instructions regarding 
application fee and waiver submissions with PECOS applications.)   
 
A.  Background 
 
Pursuant to 42 CFR  424.514 - and with the exception of physicians, non-physician 
practitioners, physician group practices, non-physician group practices, and Medicare Diabetes 
Prevention Program (MDPP) suppliers  institutional providers that are (1) initially enrolling in 
Medicare, (2) adding a practice location, or (3) revalidating their enrollment information per 42 
CFR  424.515 (regardless of whether the revalidation application was requested by CMS or 
voluntarily submitted by the provider or supplier), must submit with their application: 
 
  An application fee in an amount prescribed by CMS, and/or 
 
  A request for a hardship exception to the application fee. 
 
For purposes of this requirement, the term institutional provider, as defined in 42 CFR  
424.502, means any provider or supplier that submits a paper Medicare enrollment application 
using the Form CMS-855A, Form CMS-855B (not including physician and non-physician 
practitioner organizations), Form CMS-855S, or associated Internet-based Provider Enrollment, 
Chain and Ownership System (PECOS) enrollment application.  A physician, non-physician 
practitioner, physician group, or non-physician practitioner group that is enrolling as a supplier 
of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) via the Form 
CMS-855S application must submit the required application fee with its Form CMS-855S form. 
  For a list of fee requirements broken out by provider/supplier and application type, refer to the 
Application Fee Matrix.  
 
Except as otherwise noted, nothing in this section 10.6.14 supersedes any other CMS directive to 
the contractor pertaining to application fees. 
 
(For purposes of this section 10.6.14, the term provider will be used in lieu of institutional 
provider.) 
 
B.  Contractor Activities Upon Receipt 
 
Upon receipt of a paper or PECOS application from a provider that is otherwise required to 
submit an application fee, the contractor shall first determine whether the application is an initial 
enrollment, a revalidation, or involves the addition of a practice location.  If the application does 
not fall within any of these categories, the contractor shall process the application as normal.  If 
it does fall within one of these categories, the contractor shall undertake the following: 
 
1.  Determine whether the provider has: (1) paid the application fee via Pay.gov (all payments 
must be made via Pay.gov); and/or (2) included a hardship exception request with the application 
or certification statement.   
 
2.  Outcomes 
 
i.  The provider has neither paid the fee nor submitted the hardship exception request-- The 
contractor shall send a development letter to the provider notifying it that: (A) it has 30 days 
from the date of the letter to pay the application fee via Pay.gov and any other items that may be 
missing or needed; and (B) failure to do so will result in the rejection of the providers 
application (for initial enrollments and new practice locations) or revocation of the providers 
Medicare billing privileges (for revalidations).   
 
ii.  The provider has submitted a hardship exception request but has not paid a fee - The 
contractor shall send the request and all documentation accompanying the request via e-mail to 
its PEOG BFL.  If CMS: 
 
  Denies the hardship exception request  CMS will notify the provider in the decision 
letter (on which the contractor will be copied) that the application fee must be paid within 
30 calendar days from the date of the letter.  During this 30-day period, the contractor 
shall determine whether the fee has been submitted via Pay.gov.  If the fee is not paid 
within 30 calendar days, the contractor shall deny the application (initial enrollments and 
new locations) pursuant to 42 CFR  424.530(a)(9) or revoke the providers Medicare 
billing privileges under 42 CFR  424.535(a)(6) (revalidations). 
 
(The contractor shall begin processing the application as normal if, at any time during 
this 30-day period: (1) for paper applications, the provider submits a Pay.gov receipt as 
proof of payment; or (2) for PECOS applications, the provider pays the fee via PECOS.)   
    Approves the hardship exception request - CMS will notify the provider of such in the 
decision letter (on which the contractor will be copied).  The contractor shall continue 
processing the application as normal. 
 
iii.  Has submitted a hardship exception request and has paid a fee - The contractor shall send the 
request and all documentation accompanying the request via regular mail, fax, or e-mail to its 
PEOG BFL.  As the fee has been paid, the contractor shall begin processing the application 
as normal. 
 
3.  PECOS Applications 
 
(For PECOS applications, the provider must submit any required application fee (i.e., initials, 
revalidations, new practice locations) or hardship waiver via PECOS at the time it submits its 
application; otherwise, PECOS will not accept the application.  Some of the instructions in 
subsection (B)(2) may therefore be inapplicable to PECOS applications.)   
 
As stated in section 10.3 of this chapter, application fees can be combined if multiple enrollment 
records are implicated by the submission (e.g., consolidated application), but each application 
still requires a separate fee.  To illustrate, suppose an entity is enrolling 5 different IDTFs, and 
the fee amount is $631 per IDTF.  The provider can submit separate $631 fees or can combine 
them into a $3,155 payment.  In the case of hardship waivers, however, 5 separate hardship 
waivers  one for each enrollment  must be submitted; they cannot be combined into one waiver 
request. 
 
C.  Fee Amount 
 
1.  General Background 
 
Except as stated in subsection (C)(2), the application fee must be in the amount prescribed by 
CMS for the calendar year (1) in which the application is submitted (for PECOS applications) or 
(2) of the postmark date (for paper applications).  The current fee amount can be found via 
PECOS at the following link: https://pecos.cms.hhs.gov/pecos/feePaymentWelcome.do 
 
Fee amounts for future years will be adjusted by the percentage change in the consumer price 
index (for all urban consumers) for the 12-month period ending on June 30 of the prior year.  
CMS will give the contractor and the public advance notice of any change in the fee amount for 
the coming calendar year. 
 
2.  Transition to Subsequent Year 
 
There can be situations where the provider submits an application in the previous calendar year 
without a required fee, the contractor develops for the fee, and the provider submits the fee in the 
subsequent year.  The submitted fee must be that for the subsequent year and not the preceding 
year. 
 
D.  Non-Refundable 
  Per 42 CFR  424.514(d)(2)(v), the application fee is non-refundable unless it was submitted 
with one of the following: 
 
1.  A hardship exception request that is subsequently approved; 
 
2.   An application that was rejected prior to the contractors initiation of the screening process; 
or 
 
3.  An application that is subsequently denied as a result of the imposition of a temporary 
moratorium under 42 CFR  424.570. 
 
(For purposes of section 10.6.14(D) only, the term rejected includes applications that are 
returned.) 
 
In addition, the fee should be refunded if: (i) it was not required for the transaction in question 
(e.g., the provider submitted a fee with its application to report a change in phone number); or 
(ii) it was not part of an application submission. 
 
E.  Format 
 
The provider must submit the application fee electronically through 
https://pecos.cms.hhs.gov/pecos/feePaymentWelcome.do, either via credit card, debit card, or 
electronic check.   
 
Should the provider submit an application with a paper check or any other hard copy form of 
payment (e.g., money order), the contractor shall not deposit the instrument.  It shall 
instead treat the situation as a non-submission of the fee and follow the instructions in 
section 10.4(C) of this chapter (depending on whether a hardship exception request was 
submitted).  When sending the applicable letter requesting payment within 30 days, the 
contractor shall explain that all payments must be made via.Pay.gov, stamp the submitted 
paper check "VOID," and include the voided paper check with the letter. 
 
F.  Practice Locations 
 
DMEPOS suppliers, federally qualified health centers (FQHCs), independent diagnostic testing 
facilities (IDTFs), and certain other provider and supplier types described in this chapter must 
individually enroll each site.  The enrollment of each site thus requires a separate fee.  For all 
other providers (except physicians, non-physician practitioners, and physician and non-
physician practitioner groups, none of which are required to submit the fee), a fee must 
accompany any application that adds a practice location.  (This includes the addition of a hospital 
unit  such as a psychiatric unit  in the Practice Location section of the Form CMS-855A.)  If 
multiple locations are being added on a single application, however, only one fee is required; 
indeed, the fee for providers that are not required to separately enroll each location is based on 
the application submission, not the number of locations listed on a single application. 
 
G.  Other Application Fee Policies 
 
1.  PECOS Enrollment Records    
a.  Paper Applications - The fee is based on the Form CMS-855 application submission, not on 
how enrollment records are created in PECOS.  For instance, suppose a hospital submits an 
initial Form CMS-855A.  In the Identifying Information/hospital type section of the application, 
the hospital indicates that it has a psychiatric unit and a rehabilitation unit.  Separate PECOS 
enrollment records must be created for each unit.  However, only one application fee is required 
because only one Form CMS-855A application was submitted. 
 
b.  PECOS Applications  In a similar vein, the fee is based on the number of applications 
involved.  Even if the provider submits one set of data into PECOS, it may involve several 
different applications, thus requiring separate fees.  To illustrate, assume a provider exists in 
Tennessee, Arkansas, and Missouri, each of which is in a separate contractor jurisdiction. As 
discussed in section 10.3 of this chapter, the group may submit a consolidated application (e.g., 
one set of data encompassing all three enrollments), which PECOS would then split into three 
separate applications.  Three fees must be paid, however, because three separate enrollment 
applications are involved.   
 
2.  Group Practices/Clinics 
 
A physician/non-physician practitioner clinic or group practice enrolling via the Form CMS-
855B is exempt from the fee even if it is tribally-owned/operated or hospital-owned.  Yet if a 
hospital is adding a physician/non-physician practitioner clinic or group practice to its Form 
CMS-855A enrollment, a fee is required because the hospital is adding a practice location. 
 
3.  Change of Ownership via Form CMS-855B or Form CMS-855S  
 
A provider or supplier need not pay an application fee if the application is reporting a change of 
ownership via the Form CMS-855B or Form CMS-855S. (For providers and suppliers reporting 
a change of ownership via the Form CMS-855A, the ownership change does not necessitate an 
application fee if the change does not require the provider or supplier to enroll as a new provider 
or supplier.) 
 
4.  Reporting a Change in Tax Identification Number  
 
A provider need not pay an application fee if the application is reporting a change in TIN for a 
Part A, Part B, or DMEPOS provider or supplier.  
 
5.  Requesting a Reactivation 
 
A provider need not pay an application fee to reactivate Medicare billing privileges unless the 
provider/supplier was deactivated for failing to respond to a revalidation request, in which case 
the resubmitted application constitutes a revalidation (not a reactivation) application, hence 
requiring a fee. 
 
6.  Changing the Physical Location of an Existing Practice Location 
 
A provider need not pay an application fee when changing the physical location of an existing 
practice location (as opposed to reporting an additional/new practice location).   
The application fee requirement is separate and distinct from the site visit requirement and risk 
categories discussed in this chapter.  Physicians, non-physician practitioners, physician groups, 
and non-physician practitioner groups are exempt from the application fee even if they fall 
within the high level of categorical screening per 42 CFR  424.518.  Likewise, physical 
therapists enrolling as individuals or group practices need not pay an application fee even though 
they fall within the moderate level of categorical screening and are subject to a site visit. 
 
H.  Refund Requests 
 
Unless otherwise approved by CMS, the provider must request a refund no later than 150 days from 
the date it submitted its application.  In its request, the provider shall include documentation 
acceptable to process the refund request.  For credit card refunds, the provider shall include its 
Pay.gov receipt or the Pay.gov tracking ID number. 
 
If a refund is requested and the fee was paid via ACH Debit, the contractor shall collect from the 
provider a completed Authorization and Payment Information Form for Electronic Funds 
Transfer form (previously furnished to contractors) and submit it to the 
PEMACReports@cms.hhs.gov mailbox.  In the subject line of this e-mail, the contractor shall: 
(1) identify the providers legal business name, National Provider Identifier (NPI), and the 
Pay.gov Tracking ID; and (2) include the completed, previously-mentioned form. 
 
 
 
 
I.  Institutional Provider and Fee:  Year-to-Year Transition 
 
There may be isolated instances where, at the end of a calendar year, a provider pays the fee 
amount for that year (Year 1) but the submission date (for Internet-based PECOS applications) or 
the application postmark date (for paper applications) falls in the beginning of the following year 
(Year 2). Assuming that Year 2s fee is higher than Year 1s, the provider must pay the Year 2 
fee.  The contractor shall thus: (1) send an e-mail to its PEOG BFL requesting a full refund of the 
fee and including any pertinent documentation in support of the request; and (2) send a letter to 
the provider notifying it that (i) it has 30 days from the date of the letter to pay the correct fee 
amount (i.e., the Year 2 amount) via Pay.gov and (ii) failure to do so will result in the rejection 
of the providers application (for initial enrollments and new practice locations) or revocation of 
the providers Medicare billing privileges (for revalidations). The letter shall also state that 
because a hardship exception request was not submitted with the original application, CMS will 
not consider granting a hardship exception in lieu of the fee. 
 
J.  Hardship Exception 
 
1.  Background 
 
A provider requesting a hardship exception from the application fee must include with its 
enrollment application a letter (and any supporting documentation) that describes the hardship 
and why the hardship justifies an exception.  If a paper Form CMS-855 application is submitted,  the hardship exception letter must accompany the application; if the application is submitted via 
PECOS, the hardship exception letter must accompany the application (i.e., the provider must 
upload the letter and supporting documentation into PECOS).   Hardship exception letters shall 
not be considered if they were submitted separately from the application.  If the contractor 
receives a hardship exception request separately from the application or certification statement, it 
shall: (1) return it to the provider; and (2) notify the provider via letter, e-mail or telephone that it 
will not be considered. 
 
2.  Criteria for Determination 
 
The application fee generally should not represent a significant burden for an adequately 
capitalized provider.  Hardship exceptions should not be granted when the provider simply 
asserts that the imposition of the application fee represents a financial hardship.  The provider 
must instead make a strong argument to support its request, including furnishing comprehensive 
documentation (which may include, without limitation, historical cost reports, recent financial 
reports such as balance sheets and income statements, cash flow statements, tax returns, etc.). 
 
Other factors that may suggest that a hardship exception is appropriate include the following:  
 
a.  Considerable bad debt expenses, 
 
b.  Significant amount of charity care/financial assistance furnished to patients,  
 
c.  Presence of substantive partnerships (whereby clinical and/or financial integration are 
present) with those who furnish medical care to a disproportionately low-income population,  
 
d.  Whether an institutional provider receives considerable amounts of funding through 
disproportionate share hospital payments, or 
 
e.  Whether the provider is enrolling in a geographic area that is a Presidentially-declared disaster 
under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. 5121-
5206 (Stafford Act).  
 
Upon receipt of a hardship exception request with the application, the contractor shall send the 
request and all documentation accompanying the request via regular mail, fax, or e-mail to its 
PEOG BFL.  CMS has 60 calendar days from the date of the contractors receipt of the hardship 
exception request to determine whether it should be approved; during this period, the contractor 
shall not commence processing the providers application.  CMS will communicate its decision 
to the provider and the contractor via letter, after which the contractor shall carry out the 
applicable instructions in section 10.6.14(K) below. 
 
If the provider fails to submit appropriate documentation to support its request, the contractor 
need not contact the provider to request it.  The contractor can simply forward the request as is 
to its PEOG BFL.  It is ultimately the providers responsibility to furnish the necessary 
supporting evidence at the time it submits its hardship exception request. 
 
K.  Appeals of Hardship Determinations 
  A provider may appeal CMS denial of its hardship exception request via the procedures outlined 
below: 
 
1.  If the provider is dissatisfied with CMS decision to deny a hardship exception request, it may 
file a written reconsideration request with CMS within 60 calendar days from receipt of the 
notice of initial determination (e.g., CMS denial letter).  The request must be signed by the 
individual provider or supplier, a legal representative, or any authorized official within the entity.  
Failure to file a reconsideration request within this timeframe is deemed a waiver of all rights to 
further administrative review. 
 
The reconsideration request should be mailed to: 
 
Centers for Medicare & Medicaid Services 
Center for Program Integrity 
Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop: AR-19-51   
Baltimore, MD 21244-1850 
 
Notwithstanding the filing of a reconsideration request, the contractor shall still implement the 
post-hardship exception request instructions in this section 10.6.14(K).  A reconsideration 
request, in other words, does not stay the implementation of section 10.6.14(K)s instructions.  
 
The CMS has 60 calendar days from the date of the reconsideration request to render a decision.  
The reconsideration shall be: (a) conducted by a CMS staff person who was independent from 
the initial decision to deny the hardship exception request; and (b) based on CMS review of the 
original letter and documentation submitted by the provider. 
 
Upon receipt of the reconsideration, CMS will send a letter to the provider to acknowledge 
receipt of its request.  In its acknowledgment letter, CMS will advise the requesting party that the 
reconsideration will be conducted and a determination issued within 60 days from the date of the 
request. 
 
If CMS denies the reconsideration, it will notify the provider of this via letter, with a copy to the 
contractor.  If CMS approves the reconsideration request, it will notify the provider of this via 
letter, with a copy to the contractor, after which the contractor shall process the application as 
normal, or, to the extent applicable: 
 
i.  If the application has already been rejected, request that the provider resubmit the application 
without the fee, or 
  
ii.  If Medicare billing privileges have already been revoked, reinstate said billing privileges in 
accordance with existing instructions and request that the provider resubmit the application 
without the fee. 
 
Corrective Action Plans (CAPs) may not be submitted in lieu of or in addition to a request for 
reconsideration of a hardship exception request denial.   
2.  If the provider is dissatisfied with the reconsideration determination regarding the application 
fee, it may request a hearing before an Administrative Law Judge (ALJ).  Such an appeal must 
be filed, in writing, within 60 days from receipt of the reconsideration decision. ALJ requests 
should be sent to:  
 
Department of Health and Human Services 
Departmental Appeals Board (DAB) 
Civil Remedies Division, Mail Stop 6132 
330 Independence Avenue, S.W. 
Cohen Bldg, Room G-644 
Washington, D.C. 20201 
ATTN: CMS Enrollment Appeal  
 
Failure to timely request an ALJ hearing is deemed a waiver of all rights to further administrative 
review. 
 
If the ALJ reverses PEOGs reconsideration decision and approves the hardship exception 
request but the application has already been rejected, the contractor  once PEOG informs it of 
the ALJs decision - shall notify the provider via letter, e-mail, or telephone that it may resubmit 
the application without the fee.  If the providers Medicare billing privileges have already been 
revoked, the contractor shall reinstate said billing privileges in accordance with existing 
instructions and request that the provider resubmit the application without the fee. 
 
3.  If the provider is dissatisfied with the ALJs decision, it may request Board review by the 
Departmental Appeals Board (DAB).  Such request must be filed within 60 days after the date of 
receipt of the ALJs decision.  Failure to timely request a review by the DAB is deemed a waiver 
of all rights to further administrative review. 
 
If the DAB reverses the ALJs decision and approves the hardship exception request but the 
application has already been rejected, the contractor - once PEOG informs it of the DABs 
decision - shall notify the provider via letter, e-mail, or telephone that it may resubmit the 
application without the fee.  If the providers Medicare billing privileges have already been 
revoked, the contractor shall reinstate said billing privileges in accordance with existing 
instructions and request that the provider resubmit the application without the fee. 
 
To the extent permitted by law, a provider dissatisfied with a DAB decision may seek judicial 
review by timely filing a civil action in a United States District Court. Such requests shall be 
filed within 60 days from receipt of the notice of the DABs decisi(Rev. 12209; Issued: 08-17-
23; Effective: 09-18-23; Implementation: 09-18-23) 
 
(The contractor shall review section 10.3 of this chapter for special instructions regarding 
application fee and waiver submissions with PECOS applications.)   
 
A.  Background 
 
Pursuant to 42 CFR  424.514 - and with the exception of physicians, non-physician 
practitioners, physician group practices, non-physician group practices, and Medicare Diabetes  Prevention Program (MDPP) suppliers  institutional providers that are (1) initially enrolling in 
Medicare, (2) adding a practice location, or (3) revalidating their enrollment information per 42 
CFR  424.515 (regardless of whether the revalidation application was requested by CMS or 
voluntarily submitted by the provider or supplier), must submit with their application: 
 
  An application fee in an amount prescribed by CMS, and/or 
 
  A request for a hardship exception to the application fee. 
 
For purposes of this requirement, the term institutional provider, as defined in 42 CFR  
424.502, means any provider or supplier that submits a paper Medicare enrollment application 
using the Form CMS-855A, Form CMS-855B (not including physician and non-physician 
practitioner organizations), Form CMS-855S, or associated Internet-based Provider Enrollment, 
Chain and Ownership System (PECOS) enrollment application.  A physician, non-physician 
practitioner, physician group, or non-physician practitioner group that is enrolling as a supplier 
of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) via the Form 
CMS-855S application must submit the required application fee with its Form CMS-855S form. 
 
For a list of fee requirements broken out by provider/supplier and application type, refer to the 
Application Fee Matrix.  
 
Except as otherwise noted, nothing in this section 10.6.14 supersedes any other CMS directive to 
the contractor pertaining to application fees. 
 
(For purposes of this section 10.6.14, the term provider will be used in lieu of institutional 
provider.) 
 
B.  Contractor Activities Upon Receipt 
 
Upon receipt of a paper or PECOS application from a provider that is otherwise required to 
submit an application fee, the contractor shall first determine whether the application is an initial 
enrollment, a revalidation, or involves the addition of a practice location.  If the application does 
not fall within any of these categories, the contractor shall process the application as normal.  If 
it does fall within one of these categories, the contractor shall undertake the following: 
 
1.  Determine whether the provider has: (1) paid the application fee via Pay.gov (all payments 
must be made via Pay.gov); and/or (2) included a hardship exception request with the application 
or certification statement.   
 
2.  Outcomes 
 
i.  The provider has neither paid the fee nor submitted the hardship exception request-- The 
contractor shall send a development letter to the provider notifying it that: (A) it has 30 days 
from the date of the letter to pay the application fee via Pay.gov and any other items that may be 
missing or needed; and (B) failure to do so will result in the rejection of the providers 
application (for initial enrollments and new practice locations) or revocation of the providers 
Medicare billing privileges (for revalidations).     
ii.  The provider has submitted a hardship exception request but has not paid a fee - The 
contractor shall send the request and all documentation accompanying the request via e-mail to 
its PEOG BFL.  If CMS: 
 
  Denies the hardship exception request  CMS will notify the provider in the decision 
letter (on which the contractor will be copied) that the application fee must be paid within 
30 calendar days from the date of the letter.  During this 30-day period, the contractor 
shall determine whether the fee has been submitted via Pay.gov.  If the fee is not paid 
within 30 calendar days, the contractor shall deny the application (initial enrollments and 
new locations) pursuant to 42 CFR  424.530(a)(9) or revoke the providers Medicare 
billing privileges under 42 CFR  424.535(a)(6) (revalidations). 
 
(The contractor shall begin processing the application as normal if, at any time during 
this 30-day period: (1) for paper applications, the provider submits a Pay.gov receipt as 
proof of payment; or (2) for PECOS applications, the provider pays the fee via PECOS.)   
 
  Approves the hardship exception request - CMS will notify the provider of such in the 
decision letter (on which the contractor will be copied).  The contractor shall continue 
processing the application as normal. 
 
iii.  Has submitted a hardship exception request and has paid a fee - The contractor shall send the 
request and all documentation accompanying the request via regular mail, fax, or e-mail to its 
PEOG BFL.  As the fee has been paid, the contractor shall begin processing the application 
as normal. 
 
3.  PECOS Applications 
 
(For PECOS applications, the provider must submit any required application fee (i.e., initials, 
revalidations, new practice locations) or hardship waiver via PECOS at the time it submits its 
application; otherwise, PECOS will not accept the application.  Some of the instructions in 
subsection (B)(2) may therefore be inapplicable to PECOS applications.)   
 
As stated in section 10.3 of this chapter, application fees can be combined if multiple enrollment 
records are implicated by the submission (e.g., consolidated application), but each application 
still requires a separate fee.  To illustrate, suppose an entity is enrolling 5 different IDTFs, and 
the fee amount is $631 per IDTF.  The provider can submit separate $631 fees or can combine 
them into a $3,155 payment.  In the case of hardship waivers, however, 5 separate hardship 
waivers  one for each enrollment  must be submitted; they cannot be combined into one waiver 
request. 
 
C.  Fee Amount 
 
1.  General Background 
 
Except as stated in subsection (C)(2), the application fee must be in the amount prescribed by 
CMS for the calendar year (1) in which the application is submitted (for PECOS applications) or  (2) of the postmark date (for paper applications).  The current fee amount can be found via 
PECOS at the following link: https://pecos.cms.hhs.gov/pecos/feePaymentWelcome.do 
 
Fee amounts for future years will be adjusted by the percentage change in the consumer price 
index (for all urban consumers) for the 12-month period ending on June 30 of the prior year.  
CMS will give the contractor and the public advance notice of any change in the fee amount for 
the coming calendar year. 
 
2.  Transition to Subsequent Year 
 
There can be situations where the provider submits an application in the previous calendar year 
without a required fee, the contractor develops for the fee, and the provider submits the fee in the 
subsequent year.  The submitted fee must be that for the subsequent year and not the preceding 
year. 
 
D.  Non-Refundable 
 
Per 42 CFR  424.514(d)(2)(v), the application fee is non-refundable unless it was submitted 
with one of the following: 
 
1.  A hardship exception request that is subsequently approved; 
 
2.   An application that was rejected prior to the contractors initiation of the screening process; 
or 
 
3.  An application that is subsequently denied as a result of the imposition of a temporary 
moratorium under 42 CFR  424.570. 
 
(For purposes of section 10.6.14(D) only, the term rejected includes applications that are 
returned.) 
 
In addition, the fee should be refunded if: (i) it was not required for the transaction in question 
(e.g., the provider submitted a fee with its application to report a change in phone number); or 
(ii) it was not part of an application submission. 
 
E.  Format 
 
The provider must submit the application fee electronically through 
https://pecos.cms.hhs.gov/pecos/feePaymentWelcome.do, either via credit card, debit card, or 
electronic check.   
 
Should the provider submit an application with a paper check or any other hard copy form of 
payment (e.g., money order), the contractor shall not deposit the instrument.  It shall 
instead treat the situation as a non-submission of the fee and follow the instructions in 
section 10.4(C) of this chapter (depending on whether a hardship exception request was 
submitted).  When sending the applicable letter requesting payment within 30 days, the 
contractor shall explain that all payments must be made via.Pay.gov, stamp the submitted 
paper check "VOID," and include the voided paper check with the letter.   
F.  Practice Locations 
 
DMEPOS suppliers, federally qualified health centers (FQHCs), independent diagnostic testing 
facilities (IDTFs), and certain other provider and supplier types described in this chapter must 
individually enroll each site.  The enrollment of each site thus requires a separate fee.  For all 
other providers (except physicians, non-physician practitioners, and physician and non-
physician practitioner groups, none of which are required to submit the fee), a fee must 
accompany any application that adds a practice location.  (This includes the addition of a hospital 
unit  such as a psychiatric unit  in the Practice Location section of the Form CMS-855A.)  If 
multiple locations are being added on a single application, however, only one fee is required; 
indeed, the fee for providers that are not required to separately enroll each location is based on 
the application submission, not the number of locations listed on a single application. 
 
G.  Other Application Fee Policies 
 
1.  PECOS Enrollment Records  
 
a.  Paper Applications - The fee is based on the Form CMS-855 application submission, not on 
how enrollment records are created in PECOS.  For instance, suppose a hospital submits an 
initial Form CMS-855A.  In the Identifying Information/hospital type section of the application, 
the hospital indicates that it has a psychiatric unit and a rehabilitation unit.  Separate PECOS 
enrollment records must be created for each unit.  However, only one application fee is required 
because only one Form CMS-855A application was submitted. 
 
b.  PECOS Applications  In a similar vein, the fee is based on the number of applications 
involved.  Even if the provider submits one set of data into PECOS, it may involve several 
different applications, thus requiring separate fees.  To illustrate, assume a provider exists in 
Tennessee, Arkansas, and Missouri, each of which is in a separate contractor jurisdiction. As 
discussed in section 10.3 of this chapter, the group may submit a consolidated application (e.g., 
one set of data encompassing all three enrollments), which PECOS would then split into three 
separate applications.  Three fees must be paid, however, because three separate enrollment 
applications are involved.   
 
2.  Group Practices/Clinics 
 
A physician/non-physician practitioner clinic or group practice enrolling via the Form CMS-
855B is exempt from the fee even if it is tribally-owned/operated or hospital-owned.  Yet if a 
hospital is adding a physician/non-physician practitioner clinic or group practice to its Form 
CMS-855A enrollment, a fee is required because the hospital is adding a practice location. 
 
3.  Change of Ownership via Form CMS-855B or Form CMS-855S  
 
A provider or supplier need not pay an application fee if the application is reporting a change of 
ownership via the Form CMS-855B or Form CMS-855S. (For providers and suppliers reporting 
a change of ownership via the Form CMS-855A, the ownership change does not necessitate an 
application fee if the change does not require the provider or supplier to enroll as a new provider 
or supplier.)   
4.  Reporting a Change in Tax Identification Number  
 
A provider need not pay an application fee if the application is reporting a change in TIN for a 
Part A, Part B, or DMEPOS provider or supplier.  
 
5.  Requesting a Reactivation 
 
A provider need not pay an application fee to reactivate Medicare billing privileges unless the 
provider/supplier was deactivated for failing to respond to a revalidation request, in which case 
the resubmitted application constitutes a revalidation (not a reactivation) application, hence 
requiring a fee. 
 
6.  Changing the Physical Location of an Existing Practice Location 
 
A provider need not pay an application fee when changing the physical location of an existing 
practice location (as opposed to reporting an additional/new practice location). 
 
The application fee requirement is separate and distinct from the site visit requirement and risk 
categories discussed in this chapter.  Physicians, non-physician practitioners, physician groups, 
and non-physician practitioner groups are exempt from the application fee even if they fall 
within the high level of categorical screening per 42 CFR  424.518.  Likewise, physical 
therapists enrolling as individuals or group practices need not pay an application fee even though 
they fall within the moderate level of categorical screening and are subject to a site visit. 
 
H.  Refund Requests 
 
Unless otherwise approved by CMS, the provider must request a refund no later than 150 days from 
the date it submitted its application.  In its request, the provider shall include documentation 
acceptable to process the refund request.  For credit card refunds, the provider shall include its 
Pay.gov receipt or the Pay.gov tracking ID number. 
 
If a refund is requested and the fee was paid via ACH Debit, the contractor shall collect from the 
provider a completed Authorization and Payment Information Form for Electronic Funds 
Transfer form (previously furnished to contractors) and submit it to the 
PEMACReports@cms.hhs.gov mailbox.  In the subject line of this e-mail, the contractor shall: 
(1) identify the providers legal business name, National Provider Identifier (NPI), and the 
Pay.gov Tracking ID; and (2) include the completed, previously-mentioned form. 
 
 
 
 
I.  Institutional Provider and Fee:  Year-to-Year Transition 
 
There may be isolated instances where, at the end of a calendar year, a provider pays the fee 
amount for that year (Year 1) but the submission date (for Internet-based PECOS applications) or 
the application postmark date (for paper applications) falls in the beginning of the following year 
(Year 2). Assuming that Year 2s fee is higher than Year 1s, the provider must pay the Year 2  fee.  The contractor shall thus: (1) send an e-mail to its PEOG BFL requesting a full refund of the 
fee and including any pertinent documentation in support of the request; and (2) send a letter to 
the provider notifying it that (i) it has 30 days from the date of the letter to pay the correct fee 
amount (i.e., the Year 2 amount) via Pay.gov and (ii) failure to do so will result in the rejection 
of the providers application (for initial enrollments and new practice locations) or revocation of 
the providers Medicare billing privileges (for revalidations). The letter shall also state that 
because a hardship exception request was not submitted with the original application, CMS will 
not consider granting a hardship exception in lieu of the fee. 
 
J.  Hardship Exception 
 
1.  Background 
 
A provider requesting a hardship exception from the application fee must include with its 
enrollment application a letter (and any supporting documentation) that describes the hardship 
and why the hardship justifies an exception.  If a paper Form CMS-855 application is submitted, 
the hardship exception letter must accompany the application; if the application is submitted via 
PECOS, the hardship exception letter must accompany the application (i.e., the provider must 
upload the letter and supporting documentation into PECOS).   Hardship exception letters shall 
not be considered if they were submitted separately from the application.  If the contractor 
receives a hardship exception request separately from the application or certification statement, it 
shall: (1) return it to the provider; and (2) notify the provider via letter, e-mail or telephone that it 
will not be considered. 
 
2.  Criteria for Determination 
 
The application fee generally should not represent a significant burden for an adequately 
capitalized provider.  Hardship exceptions should not be granted when the provider simply 
asserts that the imposition of the application fee represents a financial hardship.  The provider 
must instead make a strong argument to support its request, including furnishing comprehensive 
documentation (which may include, without limitation, historical cost reports, recent financial 
reports such as balance sheets and income statements, cash flow statements, tax returns, etc.). 
 
Other factors that may suggest that a hardship exception is appropriate include the following:  
 
a.  Considerable bad debt expenses, 
 
b.  Significant amount of charity care/financial assistance furnished to patients,  
 
c.  Presence of substantive partnerships (whereby clinical and/or financial integration are 
present) with those who furnish medical care to a disproportionately low-income population,  
 
d.  Whether an institutional provider receives considerable amounts of funding through 
disproportionate share hospital payments, or 
  e.  Whether the provider is enrolling in a geographic area that is a Presidentially-declared disaster 
under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. 5121-
5206 (Stafford Act).  
 
Upon receipt of a hardship exception request with the application, the contractor shall send the 
request and all documentation accompanying the request via regular mail, fax, or e-mail to its 
PEOG BFL.  CMS has 60 calendar days from the date of the contractors receipt of the hardship 
exception request to determine whether it should be approved; during this period, the contractor 
shall not commence processing the providers application.  CMS will communicate its decision 
to the provider and the contractor via letter, after which the contractor shall carry out the 
applicable instructions in section 10.6.14(K) below. 
 
If the provider fails to submit appropriate documentation to support its request, the contractor 
need not contact the provider to request it.  The contractor can simply forward the request as is 
to its PEOG BFL.  It is ultimately the providers responsibility to furnish the necessary 
supporting evidence at the time it submits its hardship exception request. 
 
K.  Appeals of Hardship Determinations 
 
A provider may appeal CMS denial of its hardship exception request via the procedures outlined 
below: 
 
1.  If the provider is dissatisfied with CMS decision to deny a hardship exception request, it may 
file a written reconsideration request with CMS within 60 calendar days from receipt of the 
notice of initial determination (e.g., CMS denial letter).  The request must be signed by the 
individual provider or supplier, a legal representative, or any authorized official within the entity.  
Failure to file a reconsideration request within this timeframe is deemed a waiver of all rights to 
further administrative review. 
 
The reconsideration request should be mailed to: 
 
Centers for Medicare & Medicaid Services 
Center for Program Integrity 
Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop: AR-19-51   
Baltimore, MD 21244-1850 
 
Notwithstanding the filing of a reconsideration request, the contractor shall still implement the 
post-hardship exception request instructions in this section 10.6.14(K).  A reconsideration 
request, in other words, does not stay the implementation of section 10.6.14(K)s instructions.  
 
The CMS has 60 calendar days from the date of the reconsideration request to render a decision.  
The reconsideration shall be: (a) conducted by a CMS staff person who was independent from 
the initial decision to deny the hardship exception request; and (b) based on CMS review of the 
original letter and documentation submitted by the provider. 
  Upon receipt of the reconsideration, CMS will send a letter to the provider to acknowledge 
receipt of its request.  In its acknowledgment letter, CMS will advise the requesting party that the 
reconsideration will be conducted and a determination issued within 60 days from the date of the 
request. 
 
If CMS denies the reconsideration, it will notify the provider of this via letter, with a copy to the 
contractor.  If CMS approves the reconsideration request, it will notify the provider of this via 
letter, with a copy to the contractor, after which the contractor shall process the application as 
normal, or, to the extent applicable: 
 
i.  If the application has already been rejected, request that the provider resubmit the application 
without the fee, or 
  
ii.  If Medicare billing privileges have already been revoked, reinstate said billing privileges in 
accordance with existing instructions and request that the provider resubmit the application 
without the fee. 
 
Corrective Action Plans (CAPs) may not be submitted in lieu of or in addition to a request for 
reconsideration of a hardship exception request denial. 
 
2.  If the provider is dissatisfied with the reconsideration determination regarding the application 
fee, it may request a hearing before an Administrative Law Judge (ALJ).  Such an appeal must 
be filed, in writing, within 60 days from receipt of the reconsideration decision. ALJ requests 
should be sent to:  
 
Department of Health and Human Services 
Departmental Appeals Board (DAB) 
Civil Remedies Division, Mail Stop 6132 
330 Independence Avenue, S.W. 
Cohen Bldg, Room G-644 
Washington, D.C. 20201 
ATTN: CMS Enrollment Appeal  
 
Failure to timely request an ALJ hearing is deemed a waiver of all rights to further administrative 
review. 
 
If the ALJ reverses PEOGs reconsideration decision and approves the hardship exception 
request but the application has already been rejected, the contractor  once PEOG informs it of 
the ALJs decision - shall notify the provider via letter, e-mail, or telephone that it may resubmit 
the application without the fee.  If the providers Medicare billing privileges have already been 
revoked, the contractor shall reinstate said billing privileges in accordance with existing 
instructions and request that the provider resubmit the application without the fee. 
 
3.  If the provider is dissatisfied with the ALJs decision, it may request Board review by the 
Departmental Appeals Board (DAB).  Such request must be filed within 60 days after the date of 
receipt of the ALJs decision.  Failure to timely request a review by the DAB is deemed a waiver 
of all rights to further administrative review. 
  If the DAB reverses the ALJs decision and approves the hardship exception request but the 
application has already been rejected, the contractor - once PEOG informs it of the DABs 
decision - shall notify the provider via letter, e-mail, or telephone that it may resubmit the 
application without the fee.  If the providers Medicare billing privileges have already been 
revoked, the contractor shall reinstate said billing privileges in accordance with existing 
instructions and request that the provider resubmit the application without the fee. 
 
To the extent permitted by law, a provider dissatisfied with a DAB decision may seek judicial 
review by timely filing a civil action in a United States District Court. Such requests shall be 
filed within 60 days from receipt of the notice of the DABs decisi 
10.6.15  Risk-Based Screening  
(Rev. 11808; Issued: 01-24-23; Effective: 01-01-23; Implementation: 01-03-23) 
 
Consistent with 42 CFR  424.518, newly-enrolling and existing providers and suppliers will, 
beginning on March 25, 2011, be placed into one of three levels of categorical screening: limited, 
moderate, or high.  The risk levels denote the level of the contractors screening of the provider 
when it initially enrolls in Medicare, adds a new practice location, revalidates its enrollment 
information, or, in certain circumstances, changes all or part of its ownership. 
 
A.   Specific Screening Categories 
 
1.    Limited Risk  
The limited level of categorical screening consists of the following provider and supplier 
types: 
  Physicians 
  Non-physician practitioners other than physical therapists 
  Physician group practices 
  Non-physician group practices other than physical therapist group practices 
  Ambulatory surgical centers 
  Competitive Acquisition Program/Part B Vendors 
  End-stage renal disease facilities 
  Federally qualified health centers 
  Histocompatibility laboratories 
  Home infusion therapy suppliers  
  Hospitals (including critical access hospitals, rural emergency hospitals, Department of 
Veterans Affairs hospitals, and other federally-owned hospital facilities. 
  Health programs operated by an Indian Health Program (as defined in section 4(12) of the 
Indian Health Care Improvement Act) or an urban Indian organization (as defined in section 
4(29) of the Indian Health Care Improvement Act) that receives funding from the Indian 
Health Service pursuant to Title V of the Indian Health Care Improvement Act 
  Mammography screening centers 
  Mass immunization roster billers 
  Organ procurement organizations    Outpatient physical therapy/outpatient speech pathology providers enrolling via the Form 
CMS-855A 
  Pharmacies that are newly enrolling or revalidating via the Form CMS-855B application 
  Radiation therapy centers 
  Religious non-medical health care institutions 
  Rural health clinics 
For providers and suppliers in the limited category, the contractor shall process initial, 
revalidation, and new location applications in accordance with existing instructions. 
2.  Moderate Risk  
a.  General Information 
The moderate level of categorical screening consists of the following provider and supplier 
types: 
  Ambulance service suppliers 
  Community mental health centers (CMHCs) 
  Comprehensive outpatient rehabilitation facilities (CORFs) 
  Hospice organizations 
  Independent clinical laboratories 
  Independent diagnostic testing facilities 
  Physical therapists enrolling as individuals or as group practices 
  Portable x-ray suppliers (PXRSs) 
  Newly Enrolling Opioid Treatment Program (OTP) that were SAMSHA certified prior to 
October 24, 2018 
  Revalidating home health agencies (HHAs) 
  Revalidating DMEPOS suppliers 
  Revalidating MDPP suppliers 
  Revalidating OTP providers 
  Revalidating SNFs 
For providers and suppliers in the moderate level of categorical screening, the contractor shall 
(unless section 10.6.15(A)(4) of this chapter or another CMS directive applies): (1) process 
initial, revalidation, and new location applications in accordance with existing instructions; and 
(2) order an NSVC site visit through PECOS consistent with subsection 2(b) below.  (Unless 
stated otherwise in this chapter, the scope of the site visit shall be consistent with existing 
instructions.) 
b.  Provider/Supplier-Specific Information 
(i) Ambulance suppliers, independent clinical laboratories, physical therapists, and physical 
therapist groups  
If the supplier submits an initial application, revalidation application, or application to add a new  practice location, the contractor shall order a site visit.  (For new location additions, the site visit 
shall be of the new location.)  The contractor shall not make a final decision regarding the 
application (or, for initial applications, shall not convey Medicare billing privileges) prior to the 
completion of the NSVCs site visit and the contractors review of the results. 
(ii)  CMHCs, CORFs, Hospices and PXRSs  
For site visits regarding these four provider/supplier types, the contractor shall adhere to the site 
visit instructions in, respectively, sections 10.2.1.1, 10.2.1.2, 10.2.1.7, and 10.2.2.8 of this 
chapter. 
 
(iii)  IDTFs  
 
Initial applications - The NSVC will conduct site visits of initially enrolling IDTFs consistent 
with section 10.2.2(O)(15) of this chapter.  
 
Revalidations - The NVSC will conduct site visits of revalidating IDTFs (prior to the 
contractors final decision regarding the revalidation application) consistent with section 
10.2.2(I)(15) of this chapter.  
 
IDTF Code Changes - The NSVC will conduct site visits for IDTF code changes as specified in 
section 10.2.2(I)(17) of this chapter.  
 
(iv)  Revalidating HHAs and SNFs 
 
For site visits regarding revalidating HHAs and SNFs, the contractor shall adhere to the site visit 
instructions in, respectively, sections 10.2.1.6 and 10.2.1.14 of this chapter. 
(v)  Revalidating DMEPOS Suppliers 
A site visit of the DMEPOS supplier shall be conducted prior to the NSC making a final decision 
regarding the revalidation application.  
(vi)  Revalidating MDPP Suppliers  
If an MDPP supplier submits a revalidation application, the contractor shall order a site visit. The 
contractor shall not make a final decision regarding the revalidation application prior to the 
completion of the NSVCs site visit and the contractors review of the results.  
(vii)  Revalidating OTP Providers 
If an OTP provider submits a revalidation application, the contractor shall order a site visit. The 
contractor shall not make a final decision regarding the revalidation application prior to the 
completion of the NSVCs site visit and the contractors review of the results. 
3.  High Risk   a.  General Information 
Pursuant to 42 CFR  424.518, the high level of categorical screening consists of the following 
provider and supplier types:  
  Newly enrolling DMEPOS suppliers 
  Newly enrolling HHAs (including HHAs that must submit an initial enrollment application 
pursuant to  424.550(b)(1)) 
  Newly enrolling MDPP suppliers 
  Newly enrolling OTP providers that were SAMSHA certified after October 24, 2018 
  Newly enrolling SNFs 
  DMEPOS suppliers, HHAs, MDPP suppliers, OTP providers that were SAMSHA certified 
after October 24, 2018, and SNFs submitting either: (i) a change of ownership application 
pursuant to 42 CFR  489.18; or (ii) an application to report any new owner (regardless of 
ownership percentage, though consistent with the definition of owner in section 10.1.1 of this 
chapter) pursuant to a change of information or other enrollment transaction under title 42.   
 
For newly enrolling providers and suppliers in the high level of categorical screening: 
 
(i) The contractor shall process the application in accordance with existing instructions. 
 
(ii) The NSVC will perform a site visit.  The contractor shall not switch the providers 
enrollment record to Approved prior to the completion of the site visit and the contractors 
review of the results. 
 
(iii) Their 5 percent or greater direct and indirect owners must undergo fingerprint-based 
criminal background checks. The contractor shall not switch the providers enrollment record to 
Approved prior to the completion of fingerprinting and the contractors review of the results. 
 
(iv) The contractor shall, upon switching the providers or suppliers enrollment record to 
Approved, enter the providers risk category as moderate into PECOS. 
 
b.  Additional Considerations 
 
(i)  Enrolled DMEPOS suppliers that are adding another location will be classified as high for 
screening purposes.   
 
(ii) The addition of a new HHA branch falls within the moderate level of categorical 
screening.  A site visit of the branch shall thus be performed consistent with the instructions in 
this chapter (including those in section 10.2.1.6). 
 
(iii) The addition of a new MDPP supplier administrative location that does not result in a new 
PTAN does not require an additional site visit. Any additional MDPP supplier administrative 
location that results in a new PTAN, either due to being in a new jurisdiction or because of a new 
CDC organizational code, the contractors shall order a site visit of the location through PECOS. 
This is to ensure that the supplier is in compliance with CMSs enrollment requirements. The 
scope of the site visit will be consistent with section 15.19.2.2(B) of this chapter. The NSVC will  perform the site visit. The contractor shall not switch the providers enrollment record to 
Approved prior to the completion of the NSVCs site visit and the contractors review of the 
results.  
 
c.  Changes of/in Ownership 
 
As explained above and in more detail in section 10.6.21(E)(3), the high screening category 
includes DMEPOS suppliers, HHAs, MDPP suppliers, OTP providers that were SAMSHA 
certified after October 24, 2018, and SNFs submitting either: (i) a change of ownership 
application pursuant to 42 CFR  489.18; or (ii) an application to report any new owner 
(regardless of ownership percentage, though consistent with the definition of owner in section 
10.1.1 of this chapter) pursuant to a change of information or other enrollment transaction under 
title 42.  Accordingly, any change of/in ownership that meets all of the following criteria would 
fall under (i) or (ii) above: 
 
  Does not involve the triggering of an initial enrollment (e.g., an HHA change in majority 
ownership for which no exception applies requires a new enrollment); and  
  The change reports either: 
 
  For partnerships: A new partner (general or limited) who owns any percentage (even 1 
o
percent) of the provider/supplier; or 
  Excluding partnerships: A new direct or indirect owner of at least 5 percent of the 
o
provider/supplier. 
 
Upon receipt of an application described above, the contractor shall process it consistent with the 
instructions in this chapter and this section 10.6.15.  This includes requesting fingerprints from 
the new owner(s) if the owner has a 5 percent or greater direct or indirect ownership interest.  
However, the contractor need not also solicit them from the provider/suppliers existing owners; 
only the new owner(s) need be fingerprinted.   
 
(Note that if a new partner is being reported but the partner owns less than 5 percent of the 
provider/supplier, the provider/suppliers application must still be processed at the high 
screening level.  However, the new partner need not be fingerprinted.  This is because 
fingerprinting only applies to 5 percent or greater direct or indirect owners.  It is therefore 
possible that, in such a change of ownership transaction, no fingerprinting will have to be 
conducted at all.)   
 
The contractor shall also order a site visit of the provider/supplier consistent with existing 
instructions.  In terms of the timing of the HHA or SNF site visit, however, the contractor shall 
adhere to the following:  
 
  No State/SOG Location Approval Required  If the ownership change does not require state 
or SOG Location approval under existing CMS instructions (see sections 10.6.1.1, 10.6.1.2, 
10.6.22, and 10.6.22.1 of this chapter for more information on this topic), the site visit shall 
be ordered and performed prior to the contractors final decision regarding the application. 
  State/SOG Location Approval Required - If the ownership change requires state or SOG 
Location approval under existing CMS instructions, the site visit shall be ordered and  performed no later than 5 business days after the contractor receives notice of approval from 
the state or SOG Location but before the contractor switches the provider/suppliers 
enrollment record to an Approved status.   
 
(See section 10.6.21(E)(3) of this chapter for more information.) 
 
4.  Elevating Existing Providers and Suppliers into the High-Risk Screening Category 
 
a.  Criteria for Raising Providers/Suppliers to High-Risk 
 
Under  424.518(c)(3), CMS may adjust (or bump up) a particular provider or suppliers 
screening level from limited or moderate to high if any of the following occur: 
 
(i)  CMS imposes a payment suspension on a provider or supplier at any time within the last 10 
years; 
 
(ii)  The provider or supplier: 
 
  Has been excluded from Medicare by the Office of Inspector General;  
  Had its billing privileges revoked by a Medicare contractor within the previous 10 years and 
is attempting to establish additional Medicare billing privileges by: (A) enrolling as a new 
provider or supplier; or (B) obtaining billing privileges for a new practice location; 
  Has been terminated or is otherwise precluded from billing Medicaid; 
  Has been excluded from any federal health care program; or 
  Has been subject to any final adverse action (as defined in  424.502) within the previous 10 
years. 
 
(iii)  CMS lifts a temporary moratorium for a particular provider or supplier type, and a provider 
or supplier that was prevented from enrolling based on the moratorium applies for enrollment as 
a Medicare provider or supplier at any time within 6 months from the date the moratorium was 
lifted. 
 
b.  Extension of Application of a Provider/Suppliers Bump-Up 
 
Effective January 6, 2023 (and pursuant to  424.518(c)(4)), any screening level adjustment 
under  424.518(c)(3) also applies to all other enrolled and prospective providers and suppliers 
that have the same legal business name (LBN) and tax identification number (TIN) as the 
provider or supplier for which the screening level under  424.518(c)(3) was originally raised.  
To illustrate, suppose an entity is enrolled as an ambulance supplier, a CORF, and a home 
infusion therapy (HIT) supplier.  All three providers/suppliers are under the entitys TIN and 
LBN.  The HIT supplier is under a payment suspension and is thus bumped-up to high.  
Pursuant to  424.518(c)(4), the ambulance supplier and CORF will also be moved to high 
because they have the same LBN and TIN as the HIT supplier. 
 
c.  List of Bumped-Up Providers/Suppliers 
  CMS makes available to the contractor on a bi-monthly basis a list of current and former 
Medicare providers and suppliers within the contractors jurisdiction that have been bumped-
up pursuant to  424.518(c)(3) and (c)(4).  Upon receipt of an initial or revalidation application 
from a provider or supplier that otherwise falls within the limited or moderate screening category 
(and after the appropriate fee has been paid, etc.), the contractor shall determine whether the 
provider or supplier is on the bi-monthly high screening list.  If the provider or supplier is not 
on said list, the contractor shall process the application in accordance with existing instructions.  
If the provider or supplier is on the list, the contractor shall process the application using the 
procedures in the high screening category unless the provider is on the list solely because 
he/she/it was revoked for failing to timely respond to a revalidation request.  If such is the case, 
the contractor shall contact its CMS Provider Enrollment & Oversight Group Business Function 
Lead (PEOG BFL) for guidance as to how the situation should be handled. 
 
d.  Post-Moratorium Applications   
If the contractor receives an initial or new location application from a provider or supplier: (a) 
that is of a provider or supplier type that was subject to a moratorium and (b) within 6 months 
after the applicable moratorium was lifted, the contractor shall process the application using the 
procedures in the high screening category. 
B.  Changes of Information (Including Additions and Changes of Practice Locations) 
 
(This subsection (B) does not apply to ownership changes that qualify as a mere change of 
information (e.g., reporting a new 10 percent owner).)  These transactions are addressed in 
subsection (C) below.) 
 
1.  Limited 
Changes of information (including additions of practice locations) submitted by 
providers/suppliers in the limited level of categorical screening shall be processed consistent 
with existing instructions.  
2.  Moderate 
Changes of information submitted by providers/suppliers in the moderate level of categorical 
screening shall be processed consistent with existing instructions, although practice location 
additions and changes in a practice locations physical location also require a site visit as 
described in this section 10.6.15.  The site visit shall be performed consistent with the applicable 
instructions in this chapter (e.g., section 10.2.1.2 for CORFs). The contractor shall not make its 
final decision regarding the application prior to the completion of the site visit and the 
contractors review of the results. 
 
3.  High 
 
Except as stated below, changes of information submitted by providers/suppliers in the high 
level of categorical screening shall be processed consistent with existing instructions, although 
practice location additions and changes in a practice locations physical location also require a  site visit as described in this section 10.6.15.  The site visit shall be performed consistent with the 
applicable instructions in this chapter.  The contractor shall not make its final decision regarding 
the application prior to the completion of the site visit and the contractors review of the results. 
For purposes of this requirement: 
  A change of location includes situations in which the provider/supplier is switching suite 
numbers or floors within a building.  A site visit is required.  
 
  If the provider/suppliers physical location is not changing (e.g., the providers street name is 
changing but its actual office space is not), no site visit is required.  
 
  A DMEPOS supplier that is adding a new practice location falls within the high screening 
category.  This is because each location must be separately enrolled.  The enrollment of a 
new location thus constitutes an initial enrollment.  
 
  A DMEPOS supplier undergoing a change in TIN with no change in ownership falls within 
the moderate screening category. 
C.   Change of Ownership 
1.  Limited 
Changes of ownership (regardless of whether a new TIN is triggered) shall be processed 
consistent with existing instructions. 
2.  Moderate 
If a provider or supplier is undergoing a change of ownership resulting in a new TIN, the 
contractor shall: 
a.  Process the application consistent with existing instructions, and  
 
b.  Order a site visit through PECOS in accordance with the following: 
 
  For ownership changes that must be approved by the state or SOG Location under current 
CMS instructions (see sections 10.6.1.1, 10.6.1.2, 10.6.22, and 10.6.22.1) of this chapter), the 
site visit shall be ordered and performed after the contractor receives notice of approval from 
the state or SOG Location but before the contractor switches the provider/suppliers 
enrollment record to an Approved status.  The contractor shall not switch the 
provider/suppliers enrollment record to Approved prior to the completion of the NSVCs 
site visit and the contractors review of the results. 
 
  For ownership changes that do not require state or SOG Location approval under current 
CMS instructions, the site visit shall be ordered and performed prior to the contractors final 
decision regarding the application. 
  3.  High 
 
See subsection (A)(3)(c) for information on processing changes of/in ownership applications 
from DMEPOS suppliers, HHAs, MDPP suppliers, OTPs that have not been continuously 
SAMSHA-certified since October 24, 2018, and SNFs.   
 
D.  Reactivations  
a.  Limited 
Form CMS-855 reactivation applications submitted by providers and suppliers in the limited 
level of categorical screening shall be processed in accordance with existing instructions. 
b.  Moderate 
Form CMS-855 reactivation applications submitted by providers and suppliers in the moderate 
level of categorical screening  including existing DMEPOS suppliers, HHAs, MDPP suppliers, 
OTPs that have not been continuously SAMSHA-certified since October 24, 2018, and SNFs  
shall be processed in accordance with the screening procedures for this category.  A site visit will 
therefore be needed prior to the contractors final decision regarding the application. 
c.  High 
Form CMS-855 reactivation applications submitted by providers and suppliers in the high 
level of categorical screening shall be processed in accordance with the screening procedures for 
this category.  A site visit will therefore be needed prior to the contractors final decision 
regarding the application. 
10.6.16  Temporary Moratoria 
(Rev. 10524; Issued: 12-17-20; Effective: 11-13-20; Implementation: 11-13-20) 
 
Under 424.570(a), CMS may impose a moratorium on the enrollment of new Medicare 
providers and suppliers of a particular type or the establishment of new practice locations of a 
particular type in a particular geographic area.  The announcement of a moratorium will be made 
via the Federal Register, though the contractor will be separately notified of the moratorium. 
 
The contractor shall abide by all CMS directives and instructions issued pursuant to the 
imposition or lifting of a particular moratorium. 
 
10.6.17  Deceased Practitioners  
(Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Reports of Death from the Social Security Administration (SSA) 
 
Contractors, including DME MACs, will receive from CMS a monthly file that lists individuals 
who have been reported as deceased to the SSA.  To help ensure that Medicare maintains current  enrollment and payment information and to prevent others from utilizing the enrollment data of 
deceased individuals, the contractor shall undertake the activities in this section 10.6.17.  
 
B.  Erroneous Report of Death 
 
In the event of an erroneous report of death, the contractor shall contact its PEOG BFL for 
guidance.  
 
C.  Verification Activities for Individuals Other than Physicians, Non-Physician 
Practitioners, and/or DMEPOS Suppliers  
 
(If the person is an owner, sole owner of his/her professional corporation or professional 
association, managing employee, director, officer, authorized official, etc., the contractor shall 
verify and document in PECOS that the person is deceased using the process described in section 
10.6.17(D)(1).)  
Once the contractor verifies the report of death, it shall notify the provider or supplier 
organization with which the individual is associated that it needs to submit a Form CMS-855 
change request that deletes the individual from the provider or suppliers enrollment record. If 
the provider fails to submit this information within 90 calendar days of the contractors request, 
the contractor shall deactivate the providers Medicare billing privileges in accordance with 42 
CFR  424.540(a)(2). (For DMEPOS Suppliers - If a DMEPOS supplier fails to submit this 
information within 30 calendar days of the contractors request, the contractor shall deactivate 
the suppliers billing privileges in accordance with 42 CFR  424.57(c)(2).)   The contractor 
need not, however, solicit a Form CMS-855 change request if the organization is enrolled with 
another contractor.  Instead, the contractor shall notify (via fax or e-mail) the contractor with 
which the organization is enrolled of the situation, at which time the latter contractor shall take 
actions consistent with this section 10.6.17.  
D.  Reports of Death from Third-Parties 
 
1.  Verification of Death 
 
If a contractor (including DME MACs) receives a report of death from a third-party (e.g., state 
provider association, state medical society, academic medical institution, etc.), the contractor 
shall verify that the physician, non-physician practitioner, or DMEPOS supplier is deceased by:  
 
  Obtaining oral or written confirmation of the death from an authorized or delegated official 
of the group practice to which the physician, non-physician practitioner or DMEPOS supplier 
had reassigned his or her benefits; 
 
  Obtaining an obituary notice from the newspaper;  
 
  Obtaining oral or written confirmation from the state licensing board (e.g., telephone, e-mail, 
computer screen printout);  
 
  Obtaining oral or written confirmation from the State Bureau of Vital Statistics; or   
  Obtaining a death certificate, Form SSA-704, or Form SSA-721 (Statement of Funeral 
Director). 
 
All verification shall be documented in PECOS per section 10.6.19(I) (and, as applicable, section 
10.3) of this chapter; in addition, any documents that were used to confirm the death (e.g., 
obituary notice) shall be uploaded into PECOS.  
 
2.  Deceased Individuals:  Post-Confirmation Actions 
 
Once the contractor verifies the death, it shall: 
 
a.  Undertake all actions normally associated with the deactivation of a suppliers billing 
privileges.  
 
b.  Search PECOS to determine whether the individual is listed therein as an owner, managing 
employee, director, officer, partner, authorized official, or delegated official of another supplier. 
 
c.  If the person is not in PECOS, no further action with respect to that individual is needed. 
 
d.  If the supplier is indeed identified in PECOS as an owner, sole owner of his/her professional 
corporation or professional association, officer, etc., the contractor shall notify the organization 
with which the person is associated that it needs to submit a Form CMS-855 change request that 
deletes the individual from the entitys enrollment record.  If a provider fails to submit this 
information within 90 calendar days of the contractors request, the contractor shall deactivate 
the providers billing privileges in accordance with  424.540(a)(2).  (For DMEPOS Suppliers - 
If a DMEPOS supplier fails to submit this information within 30 calendar days of the 
contractors request, the contractor shall deactivate the suppliers billing privileges in accordance 
with  424.57(c)(2).)  The contractor need not, however, ask for a Form CMS-855 change 
request if the organization is enrolled with another contractor.  Instead, the contractor shall notify 
(via fax or e-mail) the contractor with which the organization is enrolled of the situation, at 
which time the latter contractor shall take actions consistent with this section 10.6.17. 
 
E.  Deceased Individuals:  Education & Outreach 
 
Contractors (including DME MACs) shall conduct outreach to state provider associations, state 
medical societies, academic medical institution, and group practices, etc., regarding the need to 
promptly inform contractors of the death of physicians and non-physician practitioners 
participating in the Medicare program. 
 
F.  Process to Deactivate NPI Due to a Death   
 
1.  Trustees/Legal Representatives 
 
The trustee/legal representative of a deceased physician, non-physician practitioner, or DMEPOS 
suppliers estate may deactivate the NPI of the deceased provider by providing written 
documentation to the NPI enumerator.   
2.  Special Payment Address:  Process to Update to an Estate Upon a Death 
 
In situations where a physician, non-physician practitioner, or DMEPOS supplier has died, the 
contractor can make payments to the individuals estate per the instructions in Pub. 100-04, 
chapter 1.  When the contractor receives a request from the trustee or other legally-recognized 
representative of the physician, non-physician practitioner, or DMEPOS suppliers estate to 
change the deceaseds special payment address, the contractor shall, at a minimum, ensure that 
the following information is furnished:  
 
  Form CMS-855 change of information request that updates the Special Payment address in 
the application.  The Form CMS-855 can be signed by the trustee/legal representative.  
 
  Any evidence  within reason - verifying that the physician, non-physician practitioner, or 
DMEPOS supplier is in fact deceased.  
 
  Legal documentation verifying that the trustee/legal representative has the legal authority to 
act on behalf of the provider, non-physician practitioner, or DMEPOS suppliers estate. 
 
The policies in this section 10.6.17(F) and (G) apply only to physicians, non-physician 
practitioners. and DMEPOS suppliers who operated their business as sole proprietors.  It does 
not apply to solely-owned corporations, limited liability companies, etc., nor to situations in 
which the physician or non-physician practitioner reassigned his or her benefits to another entity. 
 
All verification shall be documented in PECOS per section 10.6.19(I) of this chapter; in addition, 
any documents that were used to confirm the death (e.g., obituary notice) shall be uploaded into 
PECOS.  
 
G.  Other Enrollment Information  
   
1.  Reassignment and Revoked/Deceased Physicians and Non-Physician Practitioners 
 
There are situations where a physician/non-physician practitioner (the owning 
physician/practitioner) owns 100% of his/her own practice, employs another physician (the 
employed physician/practitioner) to work with him/her, and accepts reassigned benefits from 
the employed physician/practitioner. Should the sole proprietor or sole owner die or have his/her 
billing privileges revoked and the provider/supplier fails to submit an updated Form CMS-855 
within 90 days, the practice is automatically dissolved for purposes of Medicare enrollment and 
all reassignments to the practice are automatically terminated as well.  Neither the owning 
physician/practitioner nor the practice is enrolled in Medicare any longer and the enrollments for 
both shall be deactivated in accordance with the deactivation procedures outlined in this chapter. 
(It is immaterial whether the practice was established as a sole proprietorship, a professional 
corporation, a professional association, or a solely-owned limited liability company.)  In 
addition, the contractor shall end-date the reassignment using, as applicable, the date of death or 
the effective date of the revocation. 
  Besides deactivating the enrollments of the owning physician/practitioner and the practice, the 
contractor shall notify the employed physician/practitioner that:  
 
a.  The practices billing privileges have been deactivated;  
 
b.  Any services furnished by him/her on behalf of the practice after the date of the owning 
physician/practitioners death or date of revocation or deactivation will not be paid; and   
 
c.  If the employed physician/practitioner wishes to provide services at the former practices 
location, he/she must submit a Form CMS-855I change of information request to add the owning 
physician/practitioners practice location as a new location of the employed 
physician/practitioner.  For purposes of this section 10.6.17(G)(1)(c) only, submission of an 
initial Form CMS-855I and a terminating Form CMS-855R application are not required  even if 
the employed physician/non-physician practitioner had reassigned all of his/her benefits to the 
practice. 
 
H.  Proof of Life Documentation 
 
On rare occasions, erroneous death information may be received through the DMF process that 
results in systematic enrollment deactivations in PECOS or records populated on the Deceased 
Associates reports in PECOS for contractor deactivation actions.  In order for the 
providers/suppliers to reactivate their enrollments and have the date of death removed from their 
PECOS records, the contractor shall request documentation that supports proof of life (for 
example, Retirement, Survivors, and Disability Insurance document issued by SSA).  If the 
provider/supplier is unable to obtain such documentation, the contractor shall submit a request to 
their PEOG BFL containing the provider/suppliers name, date of birth, and SSN so that CMS 
can confirm proof of life with SSA. 
10.6.18  Appeals Process 
(Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
A. Review Procedures for Determinations that Affect Participation in the 
Medicare Program 
 
1. Background 
 
This review process of initial determinations applies to all providers and suppliers and ensures 
that all current and prospective providers and suppliers receive a fair and full opportunity to be 
heard. With the implementation of the appeals provision of Section 936 of the Medicare 
Prescription Drug Modernization and Improvement Act (MMA), all providers and suppliers that 
wish to appeal will be given the opportunity to request Administrative Law Judge (ALJ) review 
of a reconsideration decision within the Civil Remedies Division of the Departmental Appeals 
Board (CRD DAB). Providers and suppliers may thereafter seek review of the ALJ decision in 
the Appellate Division of the Departmental Appeals Board (DAB) and may then request judicial 
review in Federal District Court. 
 
For purposes of this chapter, in accordance with 42 C.F.R.  498.3, an initial determination  includes: (1) the denial of enrollment in the Medicare program; (2) the revocation of a providers 
or suppliers Medicare billing privileges; and (3) the effective date of participation in the 
Medicare program. 
 
Any corrective action plan (CAP) or reconsideration request that purports to challenge an 
enrollment action other than the initial determinations identified above (including inclusion on 
the CMS Preclusion List and Opt-Out Status) shall be forwarded to CMS at 
ProviderEnrollmentAppeals@cms.hhs.gov for review within 10 business days of the date of 
receipt. The Medicare Administrative Contractor (MAC) shall take no action on the providers or 
suppliers information on its enrollment record regarding an appeal submission for revocations 
forwarded to CMS for processing unless otherwise instructed by the Provider Enrollment and 
Oversight Group (PEOG). 
 
A provider or supplier dissatisfied with the initial determinations referenced above, may 
challenge the determination. All properly submitted requests shall be reviewed at the enrollment 
level. As a result, if one letter attempts to challenge the initial determination for a group 
enrollment in addition to individual practitioner enrollment(s), each enrollment shall receive a 
separate decision. All submissions shall be processed in the order in which they are received. All 
CAPs and/or reconsideration requests will be reviewed by an individual separate and apart from 
the individual involved in the implementation of the initial determination. 
 
Depending on the regulatory authority under which an initial determination is issued, providers 
and suppliers may be entitled to submit a CAP and/or a reconsideration request. A CAP is a plan 
that allows a provider or supplier an opportunity to demonstrate compliance with all applicable 
Medicare requirements by correcting the deficiencies (if possible) that led to the initial 
determination, specifically either the denial of enrollment into the Medicare program under 42 
C.F.R.  424.530(a)(1) or the revocation of Medicare billing privileges pursuant to 42 C.F.R.  
424.535(a)(1). While CAPs may only be submitted in response to a denial under 42 C.F.R.  
424.530(a)(1) or a revocation under 42 C.F.R.  424.535(a)(1), all initial determinations allow 
for the submission of a reconsideration request. A reconsideration request allows the provider or 
supplier an opportunity to demonstrate that an error was made in the initial determination at the 
time the initial determination was implemented. In contrast to a CAP, a reconsideration request 
does not allow a provider or supplier the opportunity to correct the deficiencies that led to the 
initial determination. 
 
Any CAPs and/or reconsideration requests received in response to initial determinations 
involving the following, either in whole or in part, shall be forwarded to CMS for review within 
10 business days of the date of receipt. The CAP and/or reconsideration request shall be sent to 
the PEOG Provider Enrollment Appeals inbox at ProviderEnrollmentAppeals@cms.hhs.gov. 
 
  All CAPs and reconsideration requests for certified providers/suppliers (as 
defined in Sections 10.2.1 and 10.2.2 of this chapter) and institutional 
providers/suppliers which have been revoked (as defined in Section 
10.4(M)(2)(e) of this chapter); 
 
  CAPs and reconsideration requests for Independent Diagnostic Testing 
Facilities;   
  CAPs and reconsideration requests for Medicare Diabetes Prevention 
Programs (MDPP); 
 
  CAPs and reconsideration requests for Opioid Therapy Programs (OTPs); 
 
  Reconsideration requests for enrollment denials pursuant, in whole or in 
part, to 42 C.F.R.  424.530(a)(2), (3), (6), (11), (12), (13), and (14); 
 
  Reconsideration requests for revocations pursuant, in whole or in part, to 
42 C.F.R.  424.535(a)(2), (3), (4), (7), (8), (10), (12), (13), (14), (17), 
(18), (19), (20), (21) and (22); 
 
  Requests for reversals of denials pursuant to 42 C.F.R.  424.530(c) 
and/or revocations pursuant to 42 C.F.R.  424.535(e); 
 
  Reconsideration requests for revocations pursuant, in whole or in part, to 
42 C.F.R.  424.535(j); 
 
  Reconsideration requests challenging the addition of years to an existing 
re-enrollment bar; 
 
  Reconsideration requests challenging whether an individual or entity other 
than the provider or supplier that is the subject of the second revocation 
was the actual subject of the first revocation; 
 
  Reconsideration requests challenging an individual or entity being 
included on the CMS Preclusion List as defined in  422.2 or  423.100; 
and 
 
  Reconsideration requests regarding opt-out status. 
 
If the provider or supplier is denied enrollment or has its Medicare billing privileges revoked, 
under 42 C.F.R.  424.530(a)(1) or 42 C.F.R.  424.535(a)(1), (5) or (9), in conjunction with any 
denial or revocation reason(s) listed above, those CAPs and/or reconsideration requests should 
also be forwarded to CMS at ProviderEnrollmentAppeals@cms.hhs.gov for review within 10 
business days of the date of receipt and the determination will be rendered by CMS. If the 
provider or supplier only submits a CAP for the noncompliance portion of any initial 
determinations listed above, the CAP must be sent to CMS at 
ProviderEnrollmentAppeals@cms.hhs.gov for review within 10 business days of the date of 
receipt, even if the provider or supplier does not submit a reconsideration request. The MAC 
shall not process the CAP if it is required to be forwarded to CMS. If the provider or supplier 
later submits a reconsideration request, the reconsideration request must also be sent to CMS at 
ProviderEnrollmentAppeals@cms.hhs.gov within 10 business days of the date of receipt. 
 
All CAPs and reconsideration requests received by the MACs that are not specifically identified 
above as being required to be forwarded to CMS for review, shall be processed and a decision  rendered by the MACs. However, CMS may exercise its discretion to review any CAP and/or 
reconsideration request and issue a decision regardless of the basis for the initial determination. 
 
(NOTE: This includes all CAPs and reconsideration requests for DMEPOS suppliers that fit the 
criteria identified above. In addition, as also indicated above, CAPs may only be submitted for 
denials pursuant to 42 C.F.R.  424.530(a)(1) and revocations pursuant to 42 C.F.R.  
424.535(a)(1). However, in the event a CAP is submitted for revocations pursuant, in whole or in 
part, to 42 C.F.R.  424.535(a)(2), (3), (4), (7), (8), (10), (12), (13), (14), (17), (18), (19), (20), 
(21), or (22) the submission should still be forwarded to CMS within 10 business days of the date 
of receipt to the PEOG Provider Enrollment Appeals inbox at 
ProviderEnrollmentAppeals@cms.hhs.gov.) 
 
PEOG shall notify the MAC via email when it receives a CAP and/or reconsideration request for 
a provider or supplier that has not been previously forwarded to PEOG by the MAC. The MAC 
shall not take any action on a provider or suppliers information on its enrollment record if there 
is a CAP and/or reconsideration request pending for a revocation action unless otherwise 
instructed by PEOG. The MAC shall email ProviderEnrollmentAppeals@cms.hhs.gov with any 
inquiries, questions, or requests. 
 
All documentation related to CAPs and reconsideration requests (including, but not limited to, 
the decisions) shall be saved in PDF format. The date on the CAP and reconsideration request 
decisions should be the same date as the date the decision is issued to the 
provider/supplier/representative. 
 
2. Reopening and Revising CAP and Reconsideration Determinations 
 
Once a CAP and/or reconsideration decision is issued, the MAC shall not reopen and revise a 
CAP and/or reconsideration decision without PEOGs prior approval, even if the MAC rendered 
the CAP or reconsideration decision independently. The MAC shall send all requests to reopen 
and revise a CAP and/or reconsideration decision to ProviderEnrollmentAppeals@cms.hhs.gov 
and await further instruction before taking any action regarding the CAP and/or reconsideration 
decision.  
 
3. Requests to the MACs 
 
The MAC shall work with and provide PEOG and the Office of General Counsel (OGC), when 
applicable, all necessary documentation related to any and all CAPs, reconsideration requests, 
ALJ appeals, DAB appeals, or requests for judicial review. 
 
The following are examples of information the MAC may be asked to provide. This is not an 
exhaustive list. 
 
  A copy of the initial determination letter; 
 
  A chronological timeline outlining: (1) the processing of applications; (2) 
the date they began providing services at the newest assigned location; 
and (3) if there were development requests;   
  The hearing officers decision as well as the provider or suppliers CAP 
and/or reconsideration request; 
 
  A complete copy of all application Form CMS-855s, and any supporting 
documentation submitted with the provider or suppliers application; 
 
  All background information and investigative data the hearing officer used 
to make their decision. Including any on-site visit reports; the MACs 
recommendation for administrative action based on the on-site visit; 
 
  Contact information for the person(s) who signed both the revocation and 
reconsideration decision letters. 
 
The MAC shall supply PEOG or OGC with all requested documentation within 5 business days 
of receipt of the request, unless requested sooner. 
 
All requested documentation shall be provided in PDF format (if possible) and saved with a file 
name that identifies the content of the document. 
 
If a CAP and/or reconsideration decision requires the MAC to take action on a providers or 
suppliers enrollment, such as reinstating the providers or suppliers enrollment to an active 
status, the MAC shall complete all updates to the providers or suppliers enrollment within 10 
business days of the date the CAP and/or reconsideration decision is issued unless additional 
documentation is needed to update the enrollment. If a CAP or reconsideration decision requires 
the provider or supplier to submit further information before the enrollment can be updated, such 
as an enrollment application, the MAC shall allow 30 calendar days for the provider or supplier 
to submit the necessary information. The MAC shall complete all updates to the providers or 
suppliers enrollment within 10 business days of the date of receipt of the additional 
information/documentation. If the provider or supplier does not submit the necessary information 
within 30 calendar days, the MAC shall contact PEOG by emailing 
ProviderEnrollmentAppeals@cms.hhs.gov for further instruction.   
 
4. Timing of CAP and Reconsideration Request Submissions 
 
A provider or supplier who wishes to submit a CAP must file its request in writing within 35 
calendar days of the date of the initial determination. A provider or supplier who wishes to 
submit a reconsideration request must file its request in writing within 65 calendar days of the 
date of the initial determination. The date on which CMS or the MAC receives the submission is 
considered to be the date of filing. See section D below for information on calculating timely 
submissions. 
 
The mailing and email address for all CAPs and reconsideration requests to be rendered by CMS 
identified in section 10.6.18(A) is: 
 
Centers for Medicare & Medicaid Services  
Center for Program Integrity  Provider Enrollment & Oversight Group  
Attn: Division of Provider Enrollment Appeals  
7500 Security Boulevard 
Mailstop AR-19-51  
Baltimore, MD 21244-1850 
 
Failure to timely request a reconsideration is deemed a waiver of all rights to further 
administrative review, and may result in the dismissal of any untimely submitted reconsideration 
request. The time limit may be extended if good cause for late filing is shown. Good cause may 
be found when the record clearly shows or the party alleges and the record does not negate that 
the delay in filing was due to circumstances outside of the providers or suppliers control such 
as the following: 
 
  Unusual or unavoidable circumstances, the nature of which 
demonstrate that the individual could not reasonably be expected to 
have been aware of the need to file timely; or 
 
  Destruction by fire, or other damage, of the individuals records when 
the destruction was responsible for the delay in filing. 
 
If a reconsideration request is not timely filed, as required in 42 C.F.R.  498.22, CMS will make 
a determination as to whether good cause exists. If a MAC receives an untimely CAP and/or 
reconsideration request that it believes is entitled to a good cause exception related to 
untimeliness, the hearing officer must request approval from PEOG by emailing 
ProviderEnrollmentAppeals@cms.hhs.gov with an explanation as to why good cause is believed 
to exist before making a finding of good cause or taking any other action regarding the CAP 
and/or reconsideration request. The MAC shall not take action on the CAP and/or 
reconsideration request until it receives a response from CMS regarding the good cause 
exception request.  
 
5. Time Calculations 
 
Per 42 C.F.R.  498.22(b)(3), the date of receipt of an initial determination is presumed to be 5 
calendar days after the date on the initial determination notice unless there is a showing that it 
was, in fact, received earlier or later. 
 
A CAP must be received by the MAC or CMS within 35 calendar days of the date of the initial 
determination. A reconsideration request must be received by the MAC or CMS within 65 
calendar days of the date of the initial determination. If the 35th day (for a CAP) or 65th day (for a 
reconsideration request), falls on a weekend, or Federally recognized holiday, the CAP and/or 
reconsideration request shall be considered timely filed if received on the next business day. In 
the case of an email submission of a CAP and/or reconsideration request, the filing date is 
presumed to be the date of receipt of the email. Consider the following example: 
 
An initial determination letter is dated April 1. The provider is presumed to have received the 
initial determination on April 6. The provider submits a CAP and/or reconsideration request by 
mail that is received on June 10, 65 calendar days after April 6. This is considered timely  because it is presumed that the provider did not receive the initial determination letter until April 
6. 
 
It is the provider or suppliers responsibility to timely update its enrollment record to reflect any 
changes to the provider or suppliers enrollment information, including its correspondence 
address. Failure to timely update a correspondence address or other address included in the 
enrollment record does not constitute an in fact showing that an initial determination letter was 
received after the presumed date of receipt.  
 
6. Signatures 
 
A CAP and/or reconsideration request must be submitted in the form of a letter that is signed by 
the individual provider, supplier, the authorized or delegated official, or a properly appointed 
representative, as defined in 42 C.F.R.  498.10. If the representative is an attorney, the attorney 
must include a statement that he or she has the authority to represent the provider or supplier. 
This statement is sufficient to constitute notice. If the representative is not an attorney, the 
provider or supplier must file written notice of the appointment of a representative with the 
contractor. This notice of appointment must be signed by the individual provider or supplier, or 
the authorized or delegated official. The signature need not be original and can be electronic. 
 
Authorized or delegated officials for groups cannot sign and submit a CAP and/or 
reconsideration request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her behalf. 
 
(NOTE: The provider or suppliers contact person (as listed in section 13 of the Form CMS- 
855) does not qualify as a representative for purposes of signing a reconsideration request 
without the requisite appointment statement and signature by the individual provider or supplier.) 
 
If the CAP and/or reconsideration request is not appropriately signed or if a statement from the 
attorney or written notice of representation is not included in the submission, the MAC shall send 
a development request for a proper signature or the missing statement/written notice (using the 
applicable model letter) before dismissing the CAP and/or reconsideration request. The MAC 
shall allow 15 calendar days from the date of the development request letter for the CAP and/or 
reconsideration request submitter to respond to the development request. 
 
If the CAP and/or reconsideration request submission is not appropriately signed and no 
response is timely received to the development request (if applicable), the MAC shall dismiss the 
CAP and/or reconsideration request using the applicable model dismissal letter.  
 
7. Representative for CAP and/or Reconsideration Request 
 
Per 42 C.F.R.  498.10, a provider or supplier may appoint as its representative any individual 
that is not disqualified or suspended from acting as a representative in proceedings before the 
Secretary of the Department of Health and Human Services or otherwise prohibited by law to 
engage in the appeals process. If this individual is an attorney, the attorneys statement that he or 
she has the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative. If the representative is not an attorney, the individual provider, supplier, or  authorized or delegated official must file written notice of the appointment of its representative 
with CMS or the MAC. Once a representative has been properly appointed, the representative 
may sign and/or submit a CAP, reconsideration request, request for reversal, or a request for 
good cause exception on behalf of the provider or supplier.     
 
8. Submission of Enrollment Application while a CAP and/or Reconsideration Request is 
Pending/Submission Timeframe has not Expired 
 
If a provider or suppliers enrollment application is denied, the provider or supplier must wait 
until the time period in which to submit a CAP and/or reconsideration request has ended before 
submitting a new enrollment application, change of information, or provides any additional 
information to update their enrollment record. If the MAC receives an enrollment application, 
change of information, or additional information to update a providers or suppliers enrollment 
record prior to the conclusion of the time period in which to submit a CAP and/or 
reconsideration request, the MAC shall return the application unless the application is received 
as part of the providers or suppliers CAP and/or reconsideration request submission. The MAC 
shall not modify the enrollment record of a provider or supplier that currently has a pending CAP 
and/or reconsideration request for revocations or is still within the submission time period for 
denials unless instructed by CMS to do so. Any applications received while the provider or 
supplier is in a revoked status should be returned to the provider or supplier and not processed 
pursuant to Section 10.4(H)(1). 
 
B. Corrective Action Plans (CAPs) 
 
1. Background 
 
A CAP is a plan that allows a provider or supplier an opportunity to demonstrate compliance by 
correcting the deficiencies (if possible) that led to the initial determination. CAPs may only be 
submitted in response to enrollment denials pursuant to 42 C.F.R.  424.530(a)(1) and revocation 
of Medicare billing privileges pursuant to 42 C.F.R.  424.535(a)(1). 
  
2. Requirements for CAP Submission 
 
CAP submission: 
 
(a) Must contain, at a minimum, verifiable evidence that the provider or 
supplier is in compliance with all applicable Medicare requirements; 
 
(b) Must be received within 35 calendar days from the date of the initial 
determination (see section 10.6.18(A)(4) for clarification on timing). The 
contractor shall accept a CAP via hard-copy mail, email, and/or fax; 
 
(c) Must be submitted in the form of a letter that is signed by the individual 
provider or supplier, the authorized or delegated official that has been 
reported within your Medicare enrollment record, or a properly appointed 
representative; 
  (d) Should include all documentation and information the provider or supplier 
would like to be considered in reviewing the CAP. 
 
(e) For denials, the denial must be based on 42 C.F.R.  424.530(a)(1); 
 
i. For denials based on multiple grounds of which one is  424.530(a)(1), 
the CAP may only be accepted with respect to  424.530(a)(1), but not 
with respect to the other grounds. If the provider or supplier submits a 
CAP that does not comply with this paragraph, the MAC shall address this 
in the acknowledgement email or letter sent to the provider or supplier 
using the model acknowledgement letter (If multiple grounds are involved 
of which one is  424.530(a)(1), the MAC shall: 
 
A. Only consider the portion of the CAP pertaining to  424.530(a)(1). The 
other denial bases may only be reviewed as a reconsideration. 
 
(f) For revocations, the revocation must be based on 42 C.F.R.  
424.535(a)(1); 
 
i. Consistent with  405.809, CAPs for revocations based on grounds 
other than  424.535(a)(1) shall not be accepted. 
 
A. For revocations based on multiple grounds of which one is  
424.535(a)(1), the CAP may be accepted with respect to 
424.535(a)(1), but not with respect to the other grounds. If the 
provider or supplier submits a CAP that does not comply with this 
paragraph, the MAC shall address this in the acknowledgment email or 
letter sent to the provider or supplier using the model acknowledgment 
letter. (If multiple grounds are involved of which one is  
424.535(a)(1), the MAC shall: 
 
1. Only consider the portion of the CAP pertaining to  
424.535(a)(1). The other revocation bases may only be reviewed 
as a reconsideration. 
 
3.  Receipt Acknowledgment of CAP 
 
If the MAC receives an acceptable CAP for a provider or supplier, the MAC shall use the model 
acknowledgment letter to email (if a valid email address is available) and send a hard-copy letter 
to the address included on the CAP submission letter or if no address is listed on the CAP 
submission letter, then the return address on the envelope from which the CAP was submitted 
within 14 calendar days of the date of receipt of the CAP, informing the provider, supplier, or its 
representative that a CAP decision will be rendered within 60 calendar days of the date of receipt 
of the CAP. If no address is listed in the CAP, then an acknowledgment letter should be sent to 
the correspondence address on the providers or suppliers enrollment record. 
 
If the providers or suppliers CAP cannot be accepted due to untimeliness, an improper 
signature (including a failure to respond to development for the required statement or signed  declaration from a representative), or any other reason, the MAC shall not send the provider or 
supplier an acknowledgment email or letter. Instead, the MAC shall dismiss the CAP using the 
applicable model dismissal letter. 
 
4. Dismissing a CAP 
 
A CAP shall be dismissed when the provider or supplier does not have the right to submit a CAP 
for the initial determination, or when the provider or supplier submitted the CAP improperly or 
untimely (see Section 10.6.18(B)(2)). As a result, the CAP shall not be reviewed. The MAC shall 
use the model dismissal letter when dismissing a CAP. All unacceptable CAPs shall be 
dismissed as soon as possible. 
 
If a provider or supplier concurrently submits a CAP and reconsideration request, but the initial 
determination being appealed does not afford CAP rights or the CAP submission is untimely, the 
MAC shall dismiss the CAP using the No CAP Rights Dismissal Model Letter or Untimely CAP 
Dismissal Model Letter and review the reconsideration request in accordance with the instruction 
in Section 10.6.18(C). 
 
5. CAP Analysis 
 
The MAC shall only review the CAP as it relates to denial of enrollment pursuant to 42 C.F.R.  
424.530(a)(1) or a revocation of billing privileges pursuant to  424.535(a)(1). The MAC must 
determine whether or not the information and documentation submitted with the CAP establishes 
that the provider or supplier has demonstrated compliance with all applicable Medicare rules and 
requirements by correcting the deficiency that led to the initial determination. If the MAC finds 
that the CAP corrects the deficiency that led to the initial determination, then the MAC shall 
overturn the initial determination as it relates to the denial reasons under 42 C.F.R.  
424.530(a)(1) or revocation under 42 C.F.R.  424.535(a)(1). If the denial of enrollment is 
overturned completely, the MAC shall continue processing the previously denied enrollment 
application in accordance with standard processing procedures. If the revocation is overturned 
completely, the MAC shall reinstate the providers or suppliers enrollment to an approved status 
based on the date the provider or supplier came into compliance. Consider the following 
example: 
 
Example 1: A provider or supplier is denied enrollment under 42 C.F.R.  424.530(a)(1) or 
revoked under 42 C.F.R.  424.535(a)(1) because its required license has been suspended. The 
provider timely submits a CAP in which it provides evidence that its licensure has been 
reinstated and is currently active. After confirming the status of current licensure, the MAC 
should render a favorable CAP decision because the provider or supplier has corrected the 
licensure issue that led to enrollment denial or revocation. 
 
If the provider or supplier submitted a CAP for reasons in addition to 42 C.F.R.  424.535(a)(1), 
the MAC shall include in the decision letter that the CAP was reviewed only in regards to the 42 
C.F.R.  424.535(a)(1) basis. 
 
If the provider or supplier does not submit information that establishes compliance with all 
applicable Medicare rules and requirements by correcting the deficiency that led to the initial 
determination, the MAC need not contact the provider or supplier for the missing information or  documentation. The MAC shall instead deny the CAP. Under 42 C.F.R.  405.809(a)(2), with 
respect to the revocation basis, the supplier has only one opportunity to correct all deficiencies 
that served as the basis of its revocation through a CAP. 
 
6.  Processing and Approval of CAPs 
 
The time to submit a reconsideration request continues to run even though the MAC has received 
a CAP and is reviewing the CAP. Therefore, the time period in which to submit a reconsideration 
request does not stop once a CAP is received and while the CAP is being reviewed. The provider 
or supplier must submit a reconsideration request within 65 days of the date of the initial 
determination, even if a CAP is timely submitted and accepted. 
 
The hearing officer shall issue a written decision within 60 calendar days of the date of receipt of 
the accepted CAP. The hearing officer shall email and mail a hard copy of the CAP decision to 
the provider or supplier or the individual that submitted the CAP, unless an email address is 
unavailable or the email is returned, then only a hard copy letter shall be mailed to the return 
address on the reconsideration request/envelope or the mailing address on the 
providers/suppliers enrollment record if no return address is included on the reconsideration 
request. The MAC should also send the CAP decision letter via fax if a valid fax number is 
available. 
 
If the MAC approves a CAP, it shall notify the provider or supplier by issuing a favorable 
decision letter following the applicable model CAP letter. The MAC shall continue processing 
the enrollment application under standard processing timelines or restore billing privileges (as 
applicable) within 10 business days of the date of the CAP decision or the date of receipt of 
additional documentation, if needed. 
 
For denials  and unless stated otherwise in another CMS directive or instruction  the effective 
date is the later of either the date of the filing of the enrollment application or the date on which 
services were first rendered. Consider the following examples: 
 
a. Denials 
 
A physicians initial enrollment application is denied on March 1, 2018. The physician submits a 
CAP showing that, as of March 20th, the physician was in compliance with all Medicare 
requirements. If the MAC or CMS approves the CAP, the effective date of for the physicians 
Medicare billing privileges should be March 20th, as that is the day on which the physician came 
into compliance with all Medicare requirements. The 30-day retrospective billing provision 
should not be applied in this situation because the rule assumes that the provider was in 
compliance with Medicare requirements during the 30-day period. This was not the case here. 
The physician was not in compliance with all Medicare requirements until March 20. 
 
b. Revocations  
 
A physicians medical license is suspended on June 1st. The physicians Medicare enrollment is 
revoked under 42 C.F.R.  424.535(a)(1) on June 15th. The physician then submits a CAP 
showing that, as of July 1st, the physician is currently licensed. If the MAC or CMS approves the  CAP, the effective date for reactivation of the physicians Medicare billing privileges should be 
July 1st as that is the day on which physician came into compliance with all Medicare 
requirements. The 30-day retrospective billing provision does not be apply in this situation. 
 
The MAC shall ensure that the applicable CMS Regional Office is notified of the outcome of any 
CAP decision that involves the revocation of Medicare billing privileges for a certified provider 
or supplier. 
 
If additional information/documentation is needed prior to reinstating the provider or supplier, 
the MAC shall document these next steps in their CAP decision letter. The MAC shall not 
reinstate the providers or suppliers enrollment until the requested information is received and 
processed. If the additional information/documentation is not received within 30 calendar days of 
the date of the CAP decision letter, the MAC shall contact the provider or supplier via the 
applicable model letter to again request the additional information/documentation within 10 
calendar days of not receiving a response. If no response is received within 30 calendar days of 
the second request for additional information/documentation, the MAC shall contact 
ProviderEnrollmentAppeals@cms.hhs.gov within 10 calendar days for further instruction. 
 
7. Withdrawal of CAP 
 
The provider, supplier, or the individual who submitted the CAP may withdraw the CAP at any 
time prior to the mailing of the CAP determination. The withdrawal of the CAP must be 
postmarked prior to the CAP determination date. The request to withdraw the CAP must be made 
in writing, signed, and filed with the MAC or CMS. If the MAC receives a request to withdraw a 
CAP, it shall send a letter or e-mail to the provider or supplier acknowledging receipt of the 
request to withdraw the CAP and advising that the request has been dismissed, utilizing the 
applicable model letter. 
 
8. Concurrent Submission of CAP and Reconsideration Request 
 
If a provider or supplier submits a CAP and a reconsideration request concurrently in response to 
any denial of enrollment under 42 C.F.R.  424.530(a)(1) or any revocation of billing privileges 
under 42 C.F.R.  424.535(a)(1), the MAC shall first process and make a determination 
regarding the CAP, only as it relates to the denial and/or revocation under 42 
C.F.R.  424.530(a)(1) or 42 C.F.R.  424.535(a)(1). If the MAC renders a favorable decision as 
it relates to 42 C.F.R.  424.530(a)(1) or 42 C.F.R.  424.535(a)(1), the MAC shall only render a 
reconsideration decision on the remaining authorities not addressed by the favorable CAP 
decision. Processing timelines still apply. 
 
If a CAP and a reconsideration request (see Section 10.6.18(B)(8)below) are submitted 
concurrently, the MAC shall coordinate the review of the CAP and reconsideration request to 
ensure that the CAP is reviewed and a decision rendered before a reconsideration decision is 
rendered (if the initial determination is not resolved in its entirety by the CAP decision). 
 
If the CAP is approved and resolves the basis for the initial determination in its entirety, the 
model CAP decision letter shall be sent to the provider or supplier with a statement that the 
reconsideration request will not be evaluated because the initial determination has been  overturned. If the CAP decision does not fully resolve the initial determination or results in a gap 
in the providers or suppliers billing privileges, the MAC shall also process the reconsideration 
request. 
 
If the CAP is denied: 
 
  There are no further appeal rights; therefore, the CAP decision cannot be 
appealed. As a result, do not include further appeal rights for a CAP only 
decision. 
 
  The MAC shall notify the provider or supplier of the denial of the CAP via 
the applicable CAP model letter. 
 
  The provider or supplier may continue with the appeals process if it has 
filed a reconsideration request or is preparing to submit such a request and 
has not exceeded the timeframe in which to do so. 
 
  The reconsideration request, if properly submitted, shall be processed. 
 
C. Reconsideration Requests 
 
1. Background 
 
A reconsideration request allows the provider or supplier an opportunity to demonstrate that an 
error was made in the initial determination at the time the initial determination was implemented. 
In contrast to a CAP, a reconsideration request does not allow a provider or supplier the 
opportunity to correct the deficiencies that led to the initial determination. 
 
2. Requirements for Reconsideration Request Submission 
 
a. Must contain, at a minimum, state the issues, or the findings of fact with which the affected 
party disagrees, and the reasons for disagreement; 
 
b. Must be received within 65 calendar days from the date of the initial determination (see 
Section 10.6.19(A)(4) for clarification on timing). The contractor shall accept a reconsideration 
request via hard-copy mail, email, and/or fax; 
 
c. Must be submitted in the form of a letter that is signed by the individual provider or supplier, 
the authorized or delegated official that has been reported within your Medicare enrollment 
record, or a properly appointed representative; 
 
d. Should include all documentation and information the provider or supplier would like to be 
considered in reviewing the reconsideration request; 
 
3. Receipt Acknowledgement of Reconsideration Request 
 
Upon receipt of a properly submitted reconsideration request, the MAC shall send an email (if a 
valid email address is available) and hard-copy letter, to the individual that submitted the  reconsideration request to acknowledge receipt of the reconsideration request using the 
applicable model acknowledgment letter within 14 calendar days of the date of receipt of the 
reconsideration request. The MAC shall send a hard-copy letter to the address listed in the 
reconsideration request submission or the return address listed on the reconsideration request 
submission envelope if no address is included on the reconsideration request letter. If no address 
is listed in the reconsideration request or on the envelope, then an acknowledgment letter should 
be sent to the correspondence address on the providers or suppliers enrollment record. In the 
acknowledgment letter/email (if applicable), the MAC shall advise the requesting party that the 
reconsideration request will be reviewed and a determination will be issued within 90 calendar 
days from the date of receipt of the reconsideration request. The MAC shall include a copy of the 
acknowledgment letter and email (if applicable) in the reconsideration file. If the reconsideration 
should have been submitted to CMS, the MAC shall not send the provider or supplier an 
acknowledgment email or letter. Instead, the MAC shall forward the appeal to CMS within 10 
business days of the date of receipt of the reconsideration request (as specified in Section 
10.6.18(A)(1)). 
 
If the providers or suppliers reconsideration request cannot be accepted due to untimeliness, an 
improper signature (including a failure to respond to development for the required statement or 
signed declaration from a representative, or any other reason), the MAC shall not send the 
provider or supplier an acknowledgment email or letter. Instead, the MAC shall dismiss the 
reconsideration request using the applicable model dismissal letter. 
 
4. Reconsideration Determination 
 
The MAC shall review all documentation in the record relevant to the initial determination and 
issue a written determination within 90 calendar days of the date of receipt of the accepted 
reconsideration request. 
 
A proper reconsideration request must be received by the MAC or CMS within 65 calendar days 
of the date of the initial determination. Refer to Section 10.6.18(A)(4) for receipt date 
determinations. However, consistent with 42 C.F.R.  498.24(a), the provider or supplier, may 
submit corrected, new, or previously omitted documentation or other facts in support of its 
reconsideration request at any time prior to the reconsideration decision being issued. The 
hearing officer must determine whether an error was made in the initial determination at the time 
the initial determination was implemented, based on all of the evidence presented. This includes: 
 
  The initial determination itself, 
 
  The findings on which the initial determination was based, 
 
  The evidence considered in making the initial determination, and 
 
  Any other written evidence submitted under  498.24(a), taking into account 
facts relating to the status of the provider or supplier subsequent to the 
initial determination. 
 
If the appealing party has additional information that it would like the hearing officer to consider  during the reconsideration or, if necessary, an administrative law judge (ALJ) to consider during 
a hearing, the party must submit that information with its request for reconsideration. This is the 
partys only opportunity to submit information during the administrative appeals process; the 
party will not have another opportunity to do so unless an ALJ specifically allows the party to do 
so under 42 C.F.R.  498.56(e). 
 
5. Issuance of Reconsideration Determination 
 
The hearing officer shall issue a written decision within 90 calendar days of the date of receipt of 
the accepted reconsideration request. The hearing officer shall email and mail a hard copy of the 
reconsideration decision to the provider or supplier or the individual that submitted the 
reconsideration request, unless an email address is unavailable or the email is returned, then only 
a hard copy letter should be mailed to the return address on the reconsideration request/envelope 
or the mailing address on the providers/suppliers enrollment record if no return address is 
included on the reconsideration request. The MAC should also fax the CAP decision letter if a 
valid fax number is available. The reconsideration letter shall follow the applicable model letter 
and include: 
 
  The regulatory basis to support each reason for the initial determination; 
 
  A summary of the documentation that the provider or supplier provided, as 
well as any additional documentation reviewed as part of the 
reconsideration process; 
 
  The re-stated facts and findings, including the regulatory basis for the action 
as determined by the contractor in its initial determination; 
 
  A clear explanation of why the hearing officer is upholding or overturning 
the initial determination in sufficient detail for the provider or supplier to 
understand the hearing officers decision and, if applicable, the nature of the 
providers or suppliers deficiencies. This explanation should reference the 
specific regulations and/or sub- regulations supporting the decision, as well 
as any documentation reviewed; 
 
  If applicable, an explanation of how the provider or supplier does not meet 
the Medicare enrollment criteria or requirements; 
 
  Further appeal rights, regardless of whether the decision is favorable or 
unfavorable, procedures for requesting an ALJ hearing, and the addresses to 
which the written appeal must be mailed or e-mailed. Further appeal rights 
shall only be provided for reconsideration decisions. There are no further 
appeals rights related to CAP decisions; and 
 
  Information the provider or supplier must include with its appeal 
(name/legal business name; supplier number (if applicable); tax 
identification number/employer identification number (TIN/EIN); NPI; and 
a copy of the reconsideration decision).   
Example 1: If a provider or supplier submits a reconsideration request in response to a revocation 
pursuant to 42 C.F.R.  424.535(a)(5), the MAC shall review the initial determination, the 
enrollment application preceding the site visit, the site investigation report(s), the reconsideration 
request and supporting documentation, as well as any other relevant information, to determine if 
an error was made in the implementation of the initial determination (e.g., if an error was made 
during the site visit, or the site visit was conducted at the wrong location.) If the MAC finds that 
an error was made during the site visit, which found the provider or supplier to be non-
operational, the MAC shall order an additional site visit. If an additional site visit is ordered, the 
MAC shall await the findings of the site investigator, via the site visit report, before issuing a 
reconsideration decision. If the site visit report finds the provider or supplier to be operational 
then the MAC shall overturn the revocation of the providers or suppliers Medicare billing 
privileges as it relates to 42 C.F.R.  424.535(a)(5) using the applicable model letter. 
 
If the MAC overturns the initial determination, the MAC shall reinstate the providers or 
suppliers billing privileges to an approved status as of the effective date determined in the 
reconsidered determination or continue processing the enrollment application (as applicable). 
Unless otherwise instructed by PEOG, the MAC shall only send the favorable reconsideration 
decision to the provider or supplier, authorized or delegated official, or its representative at the 
return address included on the reconsideration request. The reconsideration decision is sufficient 
for providing notice to the provider or supplier of the enrollment action being taken. All 
enrollment updates shall be completed within 10 business days of the date the reconsideration 
decision was issued or the date of receipt of additional documentation, if needed. 
 
For initial enrollments, the effective date of Medicare billing privileges is based on the date the 
provider or supplier is found to be in compliance with all Medicare requirements or the receipt 
date of the application  subject, of course, to any applicable retrospective billing provisions. 
(See Section 10.6.2 of this chapter for more information.) The MAC shall use the receipt date of 
the reconsideration request as the receipt date entered in the Provider Enrollment, Chain and 
Ownership System (PECOS). For DMEPOS suppliers, the effective date is the date awarded by 
the NSC. 
 
The MAC shall ensure that the applicable CMS Regional Office is notified of the outcome of any 
reconsideration decision that involves the revocation of Medicare billing privileges for a certified 
provider or supplier. 
 
If additional information/documentation is needed prior to reinstating the provider or supplier, 
the MAC shall document these next steps in their reconsideration decision letter. The MAC shall 
not reinstate the providers or suppliers enrollment until the requested information is received 
and processed. If the additional information/documentation is not received within 30 calendar 
days of the date of the reconsideration decision letter, the MAC shall contact the provider or 
supplier via the applicable model letter to again request the additional 
information/documentation within 10 calendar days of not receiving a response. If no response is 
received within 30 calendar days of the second request for additional information/documentation, 
the MAC shall contact ProviderEnrollmentAppeals@cms.hhs.gov within 10 calendar days for 
further instruction. 
 
6. Withdrawal of Reconsideration Request   
The provider, supplier, or the individual who submitted the reconsideration request may 
withdraw the reconsideration request at any time prior to the mailing of the reconsideration 
decision. The withdrawal of a reconsideration request must be postmarked prior to the 
reconsideration decision date. The request to withdraw the reconsideration request must be made 
in writing, signed, and filed with the MAC or CMS. If the MAC receives a request to withdraw a 
reconsideration request, it shall send a letter or e-mail to the provider or supplier acknowledging 
receipt of the request to withdraw the reconsideration request and advising that the request has 
been dismissed, utilizing the applicable model letter. 
 
7. Requests for Reversal under 42 C.F.R.  424.530(c)/424.535(e) 
 
Under 42 C.F.R.  424.530(c)/424.535(e), a provider or supplier may request reversal of a denial 
of enrollment or revocation of billing privileges if the denial or revocation was due to adverse 
activity (sanction, exclusion, or felony) against an owner, managing employee, or an authorized 
or delegated official; or a medical director, supervising physician, or other personnel of the 
provider or supplier furnishing Medicare reimbursable services. The revocation may be reversed, 
at the discretion of CMS, if the provider or supplier terminates and submits proof that it has 
terminated its business relationship with the individual against whom the adverse action is 
imposed within 30 days of the initial determination. Information that may provide sufficient 
proof includes, but is not limited to, state corporate filings, IRS documentation, sales contracts, 
termination letters, evidence of unemployment benefits, board governance documents, and 
payroll records. 
 
If the MAC receives a CAP and/or reconsideration request from a provider or supplier to reverse 
or rescind a denial or enrollment or revocation due to the termination of the business relationship 
between the provider or supplier and the individual against whom the adverse action is imposed, 
the MAC shall not take any action. The MAC shall forward the CAP and/or reconsideration 
request to ProviderEnrollmentAppeals@cms.hhs.gov within 10 business days of receipt. The 
MAC shall not take any action pursuant to the request until further instruction is provided by 
CMS. 
 
8. Not Actionable CAPs and Reconsideration Requests 
 
If the issue in the initial determination is resolved prior to a CAP and/or reconsideration decision 
being rendered, the basis of the initial determination may become moot and the CAP and/or 
reconsideration request will be not actionable. The MAC will be notified if an action has been 
taken that would render a CAP and/or reconsideration request not actionable as CMS would 
contact the MAC to rescind the revocation or reinstate the provider or suppliers Medicare billing 
privileges. If the MAC receives such a notification, then the MAC shall review to determine if a 
CAP and/or reconsideration request has become not actionable. If so, the MAC shall send a hard 
copy letter should be mailed to the return address on the CAP or reconsideration request, as well 
as the providers or suppliers correspondence address using the applicable not actionable model 
letter. The MAC shall also send an email if a valid email address is available. The MAC may 
also send via fax if a valid fax number is available. The MAC shall attach a copy of the letter 
informing the provider or supplier of the enrollment action which led to the CAP and/or 
reconsideration request becoming not actionable. If there is a scenario not captured in the not 
actionable model letter and the MAC believes a CAP and/or reconsideration request has become  not actionable, the MAC should email ProviderEnrollmentAppeals@cms.hhs.gov for guidance. 
 
9. Requesting Guidance Related to CAPs and Reconsideration Requests 
 
If the MAC encounters a situation that is not addressed by these instructions, the MAC shall 
contact the ProviderEnrollmentAppeals@cms.hhs.gov inbox for guidance before taking any 
action. 
 
D. Further Appeal Rights for Reconsidered Determinations 
 
1. Administrative Law Judge (ALJ) Hearing 
 
The CMS or a provider or supplier dissatisfied with a reconsidered determination is entitled to 
review by an ALJ with the CRD DAB. The ALJ has delegated authority from the Secretary of 
the Department of Health and Human Services (DHHS) to exercise all duties, functions, and 
powers relating to holding hearings and rendering decisions. Such an appeal must be filed, in 
writing, within 60 days from receipt of the reconsideration decision. To request final ALJ 
review, the provider or supplier must file an appeal with the Civil Remedies Division of the 
Departmental Appeals Board within 60 calendar days after the date of receipt of this decision. A 
provider or supplier may file an appeal electronically at the Departmental Appeals Board 
Electronic Filing System Web site (DAB E-File) at https://dab.efile.hhs.gov/. 
 
To file a new appeal using DAB E-File, the provider or supplier must first register a new account 
by: 
 
(a) Clicking Register on the DAB E-File home page; 
(b) Entering the information requested on the Register New Account form; 
and 
(c) Clicking Register Account at the bottom of the form. If the provider or 
supplier has more than one representative, each representative must register 
separately to use DAB E-File on his/her/its behalf. 
 
The e-mail address and password provided during registration must be entered on the login 
screen at https://dab.efile.hhs.gov/user_sessions/new to access DAB E-File. A registered users 
access to DAB E-File is restricted to the appeals for which he or she is a party or authorized 
representative. 
 
Once registered, a provider or supplier may file an appeal by logging in and: 
 
  Clicking the File New Appeal link on the Manage Existing Appeals screen, 
and then clicking Civil Remedies Division on the File New Appeal screen; 
and  
 
  Entering and uploading the requested information and documents on the 
File New Appeal  Civil Remedies Division form. 
 
All documents must be submitted in PDF form. More detailed instructions on DAB E-File for 
CRD cases can be found by clicking the CRD E-File Procedures link on the File New Appeal  Screen for CRD appeals. 
 
Pursuant to 42 C.F.R.  405.809(a)(2), a provider or supplier may not appeal an adverse 
determination for a CAP, if one was made. 
 
Failure to timely request an ALJ hearing is deemed a waiver of all rights to further administrative 
review. 
 
Upon receipt of a request for an ALJ hearing, an ALJ at the CRD DAB will issue a letter by 
certified mail to the supplier, CMS and the OGC acknowledging receipt of an appeals request 
and detailing a scheduled pre-hearing conference. The OGC will assign an attorney to represent 
CMS during the appeals process; he/she will also serve as the DAB point of contact. Neither 
CMS nor the Medicare contractor are required to participate in the pre-hearing conference, but 
should coordinate among themselves and the OGC attorney prior to the pre-hearing to discuss 
any issues. The MAC shall work with and provide the OGC attorney with all necessary 
documentation. This includes compiling and sending all relevant case material to the OGC 
attorney upon the latters request within 5 calendar days of said request. 
 
Any settlement proposals, as a result of the pre-hearing conference, will be addressed with CMS. 
If CMS agrees to settle a provider enrollment appeal, CMS will notify the contractor of 
appropriate next steps (e.g. changing the effective date of billing privileges or reinstating a 
providers billing privileges). This may result in PEOG providing specific instructions to the 
contractor to modify model letter language to appropriately notify the provider of changes to its 
enrollment status, revocation effective date, or effective date of billing privileges. 
 
If an ALJ decision is rendered that overturns and/or modifies the initial determination 
establishing an effective date, revocation or denial of billing privileges, or remands a case back 
to CMS, this may also result in PEOG providing specific instructions to the contractor to draft 
and issue a revised reconsideration decision and/or modify the model letter language to 
appropriately notify the provider or supplier of changes to its enrollment status, revocation 
effective date, or effective date of billing privileges. 
 
The MAC shall complete all steps associated with the settlement or ALJ decision no later than 10 
business days from the date it received PEOGs specific instructions. 
 
2. Departmental Appeals Board (DAB) Hearing 
 
The CMS or a provider/supplier dissatisfied with the ALJ hearing decision may request a Board 
review by the DAB. Such a request must be filed within 60 days after the date of receipt of the 
ALJs decision. Failure to timely request a DAB review is deemed to be a waiver of all rights to 
further administrative review. 
 
The DAB will use the information in the case file established at the reconsideration level and any 
additional evidence introduced at the ALJ hearing to make its determination. The DAB may 
admit additional evidence into the record if the DAB considers it relevant and material to an 
issue before it. Before such evidence is admitted, notice is mailed to the parties stating that 
evidence will be received regarding specified issues. The parties are given a reasonable time to 
comment and to present other evidence pertinent to the specified issues. If additional information  is presented orally to the DAB, a transcript will be prepared and made available to any party 
upon request. 
 
When CMS receives a decision or order from the DAB, as appropriate, PEOG will notify the 
MAC of appropriate next steps (i.e. changing an effective date or reinstating a providers billing 
privileges). This may also result in PEOG providing specific instructions to the contractor to 
draft and issue a revised reconsideration decision and/or modify the model letter language to 
appropriately notify the provider of changes to its enrollment status, revocation effective date, or 
effective date of billing privileges. 
 
The MAC shall complete all steps associated with the DAB decision no later than 10 business 
days from the date it received PEOGs specific instructions. 
 
3. Judicial Review 
 
A supplier dissatisfied with a DAB decision may seek judicial review by timely filing a civil 
action in a United States District Court. Such a request shall be filed within 60 days from receipt 
of the notice of the DABs decision. 
 
 
E. External Monthly Reporting Requirements for CAPs and Reconsideration Requests 
 
Using the provider enrollment appeals reporting template, the MAC shall complete all columns 
listed for all appeal submissions except those submissions that are referred to CMS for 
processing (CAPs and reconsideration requests). No column shall be left blank. If the contractor 
is unable to complete all columns for a given appeal submission, the contractor shall contact 
ProviderEnrollmentAppeals@cms.hhs.gov within five business days of discovery to seek further 
guidance. 
 
The response in column A labelled, Initial Determination Type, shall be one of the following: 
 
  Denial: CAP or Reconsideration Request that challenges the denial of a 
Medicare enrollment application pursuant to 42 C.F.R.  424.530(a)(1)-(15). 
 
  Revocation: CAP or Reconsideration Request that challenges the 
revocation of Medicare billing privileges or provider/supplier number 
pursuant to 42 C.F.R.  424.535(a)(1)-(22). 
 
  Effective Date: Reconsideration request that challenges an initial 
determination that establishes an effective date of participation in the 
Medicare program, including the effective date of reactivation after 
deactivation. 
 
  Other: CAP or reconsideration request that does not fall under the three 
categories listed above. If other is listed, an explanation shall be provided in 
the Comments column N and N/A in column G.  
  The response in Column L labelled, Final Decision Result, shall be one of the following (If a 
final decision has not been issued, the column shall read as In Process. If the appeal 
submission is referred to CMS for processing then the appeal should not be included on the 
MAC Monthly Appeals Report 
 
1. Not Actionable: Appeal is no longer actionable (moot) because the basis for the initial 
determination has been resolved. (Ex: Fingerprints have received a passed designation, initial 
determination has been reopened and revised). 
 
2. Favorable (to provider/supplier): MAC has determined that an error was made in the 
implementation of the initial determination. Therefore, the initial determination was overturned 
and the enrollment record has been placed in approved status, the effective date modified, or 
application processing has continued. 
 
3. Unfavorable (to provider/supplier): MAC upholds the initial determination resulting in the 
enrollment remaining in a revoked or denied status, or the effective date remaining the same. 
 
4. Dismissed: The appeal does not meet the appeal submission requirements. (Ex: incorrect 
signature, untimely, not appealable, etc.) 
 
5. Rescinded: MAC has received instruction from CMS to rescind the initial determination and 
return the enrollment record to an approved status. 
 
6. Withdrawn: Provider/supplier has submitted written notice of its intent to withdraw its appeal 
(CAP or reconsideration request). 
 
The response in Column M labelled, Date Final Decision Issued, shall be In Process if a 
final decision has not been issued at the time the monthly report is sent to CMS.  
 
The response in Column K labelled, Date Receipt Acknowledgement Sent to 
Provider/Supplier/Legal Representative, shall be Not yet sent if a receipt acknowledgement 
email/letter has not been sent to the provider/supplier/legal representative at the time the monthly 
report is sent to CMS. The response shall be N/A if a receipt acknowledgement email/letter is 
not required for that case. 
The response in Column F labelled, MAC (Including Jurisdiction), shall be in one of the 
following formats: 
 
1.  CGS 
 
2.  FCSO 
 
3.  NGS JK 
 
4.  NGS J6 
 
5.  Palmetto JM 
 
6.  Palmetto JJ   
7.  NSC 
 
8.  WPS J8 
 
9.  WPS J5 
 
10. Noridian JE 
 
11. Noridian JF 
 
12. Novitas JL 
 
13. Novitas JH 
 
The response in Column G, Regulatory Authority (As identified on initial determination), shall 
be in the following format (the authorities will need to be modified based on the type of initial 
determination): 
 
  For Effective Date appeal: 424.520;  
  For Denial appeal with only one authority cited in the initial determination: 
424.530(a)(1-15); 
  For Denial appeal with multiple authorities cited in the initial 
determination: 424.530(a)(1-15)(1-15)  
  For Revocation appeal with only one authority cited in the initial 
determination: 424.535(a)(1-22) 
  For Revocation appeal with multiple authorities cited in the initial 
determination: 424.535(a)(1-22)(1-22). 
  For Other appeal: N/A with an explanation in the Comments column N. 
 
The reports shall be sent to CMS via email at ProviderEnrollmentAppeals@cms.hhs.gov no later 
than the 15th of each month; the report shall include the prior months appeal submissions, as 
well as outcomes for all submissions previously received that were not yet completed and 
reported to CMS (e.g., the February report shall cover all January CAPs/reconsideration 
requests). All submissions shall remain on the monthly report until a final outcome/decision has 
been reported to CMS. If this day falls on a weekend or a holiday, the report must be submitted 
the following business day. 
 
10.6.19  Other Medicare Contractor Duties 
(Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
(The contractor also shall review section 10.3 of this chapter regarding the topics in this section 
10.6.19.  In the event of a conflict, those instructions take precedence over those in this section 
10.6.19.)   
 
The contractor shall adhere to all instructions in this chapter and other CMS provider enrollment 
directives (e.g., technical direction letters).  The contractor shall also assign the appropriate  number of staff to the Medicare enrollment function to ensure that all such instructions and 
directives - including application processing timeframes and accuracy standards - are complied 
with and met.  
 
A.  Training 
 
The contractor shall provide (1) training to new employees, and (2) refresher training (as 
necessary) to existing employees to ensure that each employee processes enrollment applications 
in a timely, consistent, and accurate manner. Training shall include, at a minimum: 
 
  An overview of the Medicare program 
 
  A review of all applicable regulations, manual instructions, and other CMS guidance 
 
  A review of the contractors enrollment processes and procedures 
 
  Training regarding PECOS. 
 
For new employees, the contractor shall also:  
 
  Provide side-by-side training with an experienced provider enrollment analyst  
 
  Test the new employee to ensure that he or she understands Medicare enrollment policy 
and contractor processing procedures, including the use of PECOS 
 
  Conduct end-of-line quality reviews for 6 months after training or until the analyst 
demonstrates a clear understanding of Medicare enrollment policy, contractor procedures, 
and the proper use of PECOS. 
 
For existing employees, the contractor shall perform periodic quality reviews and refresher 
trainings. 
 
B.  PECOS 
 
The contractor shall: 
 
  Process all enrollment actions (e.g., initials, changes, revalidations, revocations, appeals, 
denials) through PECOS 
 
  Deactivate or revoke the provider or suppliers Medicare billing privileges in the Multi-
Carrier System or the Fiscal Intermediary Shared System only if the provider or supplier 
is not in PECOS; if the provider does not exist in MCS or FISS, the contractor shall 
contact its PEOG BFL prior to taking action.  
 
  Close or delete any aged logging and tracking (L & T) records older than 120 days for 
which there is no associated enrollment application 
    Participate in user acceptance testing for each PECOS release 
 
  Attend scheduled PECOS training when requested 
 
  Report PECOS validation and production processing problems through the designated 
tracking system for each system release 
 
  Develop (and update as needed) a written training guide for new and current employees 
on the proper processing of Form CMS-855 and Form CMS-20134 applications, opt-out 
affidavits, and the appropriate entry of data into PECOS. 
 
C.  Customer Service 
 
1.   Responding to Provider Enrollment Inquiries 
 
The contractors customer service unit may handle provider enrollment inquiries that do not 
involve complex enrollment issues.  Examples of inquiries that can be processed by customer 
service units include: 
 
  Application status checks (e.g., Has the contractor finished processing my application?)  
(The contractor may wish to establish electronic mechanisms by which providers can 
obtain updates on the status of their enrollment applications via the contractors web site 
or automated voice response (AVR). 
 
  Furnishing information on where to access Form CMS-855 or Form CMS-20134 
applications (and other general enrollment information) online 
 
  Explaining to providers/suppliers which Form CMS-855 or CMS-20134 applications 
should be completed. 
 
2. Contractors Responsiveness to Inquiries 
 
Excluding matters pertaining to application processing (e.g., development for missing data) and 
appeals (e.g., appeal of revocation), the contractor is encouraged to respond to all enrollment-
related provider/supplier correspondence (e.g., e-mails, letters, telephone calls) within 30 
business days of receipt. 
 
D.  Contractor Outreach to Providers 
 
The contractor is strongly encouraged to establish e-mail list serves with the provider 
community to disseminate important information thereto, such as contractor address changes, 
new CMS enrollment policies or internal contractor procedures, reminders about existing 
policies, etc.  By being proactive in distributing information to its providers and suppliers on a 
regular basis (e.g., weekly, bi-weekly), the contractor can reduce the number of policy inquiries 
it receives and help facilitate the submission of complete and accurate Form CMS-855 and Form 
CMS-20134 applications. 
  E.  Encouraging Use of Internet-based PECOS 
 
When a prospective provider or supplier contacts the contractor to obtain a paper enrollment 
Form CMS-855 or Form CMS-20134, the contractor shall encourage the provider or supplier to 
submit the application using Internet-based PECOS.  The contractor shall also notify the provider 
or supplier of: 
 
  The CMS Web site at which information on Internet-based PECOS can be found and at 
which the paper applications can be accessed (https://www.cms.gov/Medicare/Provider-
Enrollment-and-
Certification/MedicareProviderSupEnroll/index?redirect=/MedicareProviderSupEnroll/). 
  The contractors address so that the applicant knows where to return the paper 
application. 
  Any supporting documentation required for the applicant's provider/supplier type.  
  Other required forms as described in sections above. Notification can be given in any 
manner the contractor chooses. 
 
F.  Adherence to Responsibilities Based Upon Jurisdiction - Audit and Claims Contractors 
 
1.  Background 
 
For purposes of enrollment via the Form CMS-855A, there are generally two categories of 
contractors: audit contractors and claims contractors.  The audit contractor enrolls the provider, 
conducts audits, etc.  The claims contractor pays the providers claims.  In most cases, the 
providers audit contractor and claims contractor will be the same.  On occasion, though, they 
will differ.  This can happen, for instance, with provider-based entities, whereby the parent 
providers contractor (audit contractor) will process the providers enrollment application and a 
different contractor will pay the providers claims (claims contractor). 
 
Should the audit and claims contractors differ, the audit contractor shall process all changes of 
information, including all Form CMS-588 changes.  The audit contractor shall notify the 
applicant during the initial enrollment process that all future changes of information must be sent 
to the audit contractor, not the claims contractor.  If the provider inadvertently sends a change 
request to the claims contractor, the latter shall return the application per the instructions in this 
chapter. 
 
2.  Process 
 
If the audit contractor approves the Form CMS-855A transaction in question (e.g., initial 
enrollment), it shall: 
 
(i)  Send an e-mail to the claims contractor identifying the specific Form CMS-855A transaction 
involved and confirming that the information has been updated in PECOS.  Pertinent identifying 
information, such as the provider name, CCN, and NPI, shall be included in the e-mail 
notification.  The audit contractor need not include any supporting documentation in the e-mail 
because PECOS will contain any documents (e.g., approval letters from the state).  
  (ii) As applicable, fax, mail, or email an encrypted copy of the submitted Form CMS-588 to the 
appropriate claims contractor. 
 
Upon receipt of the e-mail notification, the claims contractor shall access PECOS, review the 
enrollment record, and, as needed, update its records accordingly. 
   
The audit contractor shall ensure that all original copies of Form CMS-855A paperwork and 
supporting documentation (including all Form CMS-588s), approval letters from the state, and 
other written documents related to the application are uploaded in PECOS. 
 
If the providers audit contractor and claims contractor are different, the audit contractor shall e-
mail or fax a copy of all SOG Location approval/denial notices/letters it receives to the claims 
contractor.  This is to ensure that the claims contractor is fully aware of the SOG Locations 
action, as some may only send copies of the approval letters to the audit contractor.  If the audit 
contractor chooses, it can simply contact the claims contractor by phone or e-mail and ask if the 
latter received the tie-in notice. 
 
It is imperative that audit and claims contractors effectively communicate and coordinate with 
each other in all payment-related and program integrity matters involving the provider. 
 
G.  Online Presence  Web Sites 
 
The contractor must provide a link to CMS provider/supplier enrollment Web site located at 
https://www.cms.gov/medicare/provider-enrollment-and-
certification/medicareprovidersupenroll/index.html?redirect=/medicareprovidersupenroll/ .  The 
link shall: (1) be available on the contractors existing provider outreach Web site (which should 
be an established sub-domain of the contractors current commercial Web site), and (2) comply 
with the guidelines stated in the Provider/Supplier Information and Education Web site section 
(Activity Code 14101) under the Provider Communications (PCOM) Budget and Performance 
Requirements (BPRs).  Bulletins, newsletters, seminars/workshops and other information 
concerning provider enrollment issues shall also be made available on the existing provider 
outreach Web site.  All contractor web sites must comply with section 508 of the Rehabilitation 
Act of 1973 in accordance with, 36 CFR 1194 and with CMS Contractor Website Standards 
and Guidelines posted on CMSs web site. 
 
The CMS Provider/Supplier Enrollment Web site gives users access to provider/supplier 
enrollment forms, specific requirements for provider/supplier types, manual instructions, 
frequently asked questions (FAQs), contact information, hot topics, and other pertinent 
provider/supplier information.  The contractor shall not duplicate content already provided at the 
CMS provider/supplier enrollment website and shall not reproduce the forms or establish the 
contractors own links to forms.  It shall, however, have a link on its website that goes directly to 
the forms section of the CMS provider/supplier enrollment site. 
 
On a quarterly basis (specifically, no later than the 15th day of January, April, July, and October), 
each contractor shall review and provide updates regarding its contact information shown at 
URL: https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/MedicareProviderSupEnroll/Downloads/contact_list.pdf.  If the contractor services 
several states with a universal address and telephone number, the contractor shall report that  information.  In situations where no updates are needed, a response from the contractor is still 
required (i.e., the contact information is accurate).  In addition, only such information that 
pertains to provider enrollment activity for the contractors jurisdiction is to be reported.  All 
updates shall be sent directly via e-mail to the contractors PEOG BFL. 
 
H.  Document Uploading and Retention 
 
1.  Introduction 
 
To ensure that proper internal controls are maintained and that important information is recorded 
in case of potential litigation, the contractor shall maintain documentation as outlined in this 
section 10.6.19(H) and, as applicable, section 10.3. CMS cannot stress enough how crucial it is 
for contractors to document their actions as carefully and thoroughly as possible. 
 
The requirements in this section 10.6.19(H) are in addition to, and not in lieu of, all other 
documentation or document maintenance requirements that CMS has mandated. 
 
The contractor shall maintain and store all documents relating to the enrollment of a provider 
into Medicare.  These documents include, but are not limited to, Medicare enrollment 
applications and all supporting documents, attachments, correspondence, and correspondence 
tracking documentation, and appeals submitted in conjunction with an initial enrollment, 
reassignment, change of enrollment, revalidation, etc. 
 
Supporting documentation includes, but is not limited to: 
 
  Copies of federal, state and/or local (city/county) professional licenses, certifications 
and/or registrations; 
 
   Copies of federal, state, and/or local (city/county) business licenses, certifications and/or 
registrations; 
 
   Copies of professional school degrees or certificates or evidence of qualifying course 
work; 
 
   Copies of CLIA certificates and FDA mammography certificates;  
 
  Copies of any entry found on the MED report that leads to a provider or suppliers 
revocation, and; 
 
  Copies of Centers for Disease Control and Prevention (CDC) Diabetes Prevention 
Recognition Program (DPRP) recognition letters or certificates indicating full or MDPP 
preliminary recognition.  
 
See section 10.6.19(I) below for additional document uploading requirements.   
 
2.  Document Disposal 
  The contractor shall dispose of the aforementioned records as described below: 
 
i. Provider/Supplier and Durable Medical Equipment Supplier Application 
 
a.  Rejected applications as a result of provider failing to provide additional 
information 
 
Disposition: Destroy when 7 years old. 
 
b.  Approved applications of provider/supplier 
 
Disposition: Destroy 15 years after the provider/supplier's enrollment has ended. 
 
c.  Denied applications of provider/supplier 
 
Disposition: Destroy 15 years after the date of denial. 
 
d.  Approved application of provider/supplier, but the billing number was 
subsequently revoked 
 
Disposition: Destroy 15 years after the billing number is revoked. 
 
e.  Voluntary deactivation of billing number 
 
Disposition:  Destroy 15 years after deactivation. 
 
f.  Provider/Supplier dies 
 
Disposition: Destroy 7 years after date of death. 
 
  ii. Electronic Mail and Word Processing System Copies 
 
a. Copies that have no further administrative value after the recordkeeping copy is 
made.  These include copies maintained by individuals in personal files, personal 
electronic mail directories, or other personal directories on hard disk or network 
drives, and copies on shared network drives that are used only to produce the 
recordkeeping copy. 
 
Disposition: Delete within 180 days after the recordkeeping copy has been produced. 
 
b. Copies used for dissemination, revision or updating that are maintained in addition 
to the recordkeeping copy. 
 
Disposition: Delete when dissemination, revision, or updating is complete. 
 
I.  Keeping Record of Activities 
  As with document retention as described in subsection (H) above, it is important that the 
contractor maintains records of its written and telephonic communications.  The contractor shall 
thus adhere to the instructions in this subsection (I).  
 
1.  Written Communications 
 
(For purposes of this section 10.6.19(I)(1), written correspondence includes mailed, faxed, and 
e-mailed correspondence.  Note that this is different from supporting documentation 
accompanying an enrollment application, the requirements for which are addressed in subsection 
(H) above.) 
 
Except as stated in this subsection (I)(1), the contractor shall: 
 
  Retain copies of all written correspondence pertaining to the provider, regardless of 
whether the correspondence was initiated by the contractor, the provider, CMS, state 
officials, etc. 
 
  Document when it sends written correspondence to providers.  For instance, if the 
contractor crafts an approval letter to the supplier dated March 1 but sends it out on 
March 3, the contractor shall note this in PECOS.  
 
  Document all referrals to CMS, the UPIC, or the OIG 
 
In cases where the written correspondence is sent directly via or to PECOS (e.g., PCV), the 
contractor need not separately document this; PECOS will retain this information (date, time, 
etc.).  For all other written correspondence not sent via or to PECOS, the contractor (1) shall 
upload a copy of the correspondence into PECOS (e.g., fax, a printed copy of the e-mail) and (2) 
shall note in PECOS: 
 
  The type of correspondence (e.g., approval letter)  
  The form of correspondence (e.g., fax, e-mail) 
  The date and time the correspondence was sent 
  The party to whom the correspondence was sent (e.g. provider name, contact person) 
 
2.  Telephonic or Face-to-Face Contact  
 
(Telephonic or face-to-face contact is hereafter referred to as oral communication.) 
 
The contractor shall document any and all actual or attempted oral communication with the 
provider, any representative thereof, or any other person or entity regarding a provider. This 
includes, but is not limited to, the following situations: 
 
  Telephoning a provider about its application.  (Even if the provider official was 
unavailable and a voice mail message was left, this must be documented.) 
 
  Requesting information from the state or another contractor concerning the applicant or 
enrollee   
  Contacting the UPIC for an update concerning a particular case 
 
  Phone calls from the provider 
 
  Conducting a meeting at the contractors headquarters/offices with officials from a 
hospital concerning problems with its application 
 
  Telephoning PEOG, the state agency, or the SOG Location and receiving instructions 
therefrom about a problem the contractor is having with an applicant or an existing 
provider 
 
  Telephoning the providers billing department with a question about the provider. 
 
When documenting oral communications, the contractor shall indicate (1) the time and date of 
the call or contact, (2) who initiated the contact, (3) who was spoken with, and (4) what the 
conversation pertained to.  Concerning the last requirement, the contractor need not write down 
every word that was said during the conversation.  Rather, the documentation should merely be 
adequate to reflect the contents of the conversation.  
 
The documentation requirements in this subsection (I)(2) only apply to enrolled providers and to 
providers that have already submitted an enrollment application.  In other words, these 
documentation requirements go into effect only after the provider submits an initial application.  
To illustrate, if a hospital contacts the contractor requesting information concerning how it 
should enroll in the Medicare program, this need not be documented because the hospital has not 
yet submitted an enrollment application. 
 
All oral communications addressed in this subsection (I)(2) shall be documented in PECOS. 
 
If an application is returned, the contractor shall document this.  The manner of documentation 
lies within the contractors discretion. 
 
J.  Documenting Verification of Data Elements 
 
Once the contractor has completed its review of the Form CMS-855 and Form CMS-20134 
applications (e.g., approved/denied application, approved change request) as well as opt-out 
affidavits, it shall document that it has: (1) verified all data elements on the application, and (2) 
reviewed all applicable names on the above- mentioned forms against the OIG/LEIE and the 
System for Access Management (SAM).  It can be drafted in any manner the contractor chooses 
so long as it certifies that the above-mentioned activities were completed.   
 
For each person or entity that appeared on the OIG/LEIE or SAM, the contractor shall document 
any positive findings via a screen printout and upload it into PECOS.  In all other situations, the 
contractor is not encouraged to document their reviews via screen printouts.  Simply using the 
verification statement described above is sufficient.  Although the contractor has the discretion to 
use screen prints if it so chooses, the aforementioned verification statement is still required. 
  K.  Release of Information  
 
On October 13, 2006, CMS published System of Records Notice for PECOS in the Federal 
Register.  Consistent with this notice, once the provider has submitted an enrollment application 
(as well as after it has been enrolled), the contractor shall not release  either orally or in writing 
- provider-specific data to any outside person or entity unless specified otherwise in this chapter.  
(Provider-specific data includes, but are not limited to, owners/managers, adverse legal history, 
practice locations, group affiliations, effective dates, etc.)  Examples of outside persons or 
entities include, but are not restricted to, national or state medical associations or societies, 
clearinghouses, billing agents, provider associations, or any person within the providers 
organization other than the providers authorized official(s), delegated official(s), or contact 
persons.  The only exceptions to this policy are: 
 
  A routine use found in the aforementioned System of Records applies. 
 
  The provider (or, in the case of an organizational provider, an authorized or delegated 
official): (1) furnishes a signed written letter on the providers letterhead stating that the 
release of the provider data is authorized; and (2) the contractor has no reason to question 
the authenticity of the persons signature.  The letter can be mailed, faxed, or e-mailed to 
the contractor.  The contractor shall upload the letter in PECOS. 
 
  The release of the data is specifically authorized in some other CMS instruction or 
directive. 
 
(These provisions also apply in cases where the provider requests a copy of any Form CMS-855 
or CMS-20134 paperwork the contractor has on file that the provider does not already have 
access to in PECOS.  For instance, if the provider already uses PECOS for application 
submissions, the contractor can simply refer the provider to PECOS if the document in question 
is in PECOS.  If the provider does not use PECOS, the contractor shall not require the provider 
to do so in order to access the document(s) but shall follow the above instructions; the latter shall 
also be followed if the provider uses PECOS but the requested document is not in PECOS.) 
 
It is recommended that the contractor notify the provider of the broad parameters of the 
aforementioned policy as early in the enrollment process as possible. 
 
The following information shall be made available over-the-phone to a caller who is able to provide a 
provider/suppliers name, PTAN, TIN/SSN, and NPI number; the caller need not be listed on the 
provider/suppliers enrollment record as a contact person: 
 
  Revalidation status (i.e., whether or not a provider/supplier has been revalidated) 
 
  Revalidation due date 
 
  Revalidation approval date  
 
  The specific information related to a revalidation development request  
    The date a provider/supplier was deactivated due to non-response to a revalidation or non-
response to a development request. 
 
In addition: 
 
  When sending emails, the contractor shall not transmit sensitive data, such as SSNs or 
EINs, without first encrypting the email.  
 
  The contractor may not send PECOS screen printouts to the provider. 
 
  With the exception of Form CMS-855S applications, if any contact person listed on the 
providers enrollment record requests a copy of a providers Medicare approval letter or 
revalidation notice and the contact person does not have access to PECOS, the contractor 
shall send to the contact person via email, fax or mail.  (This excludes certification 
Letters from the state agency, for the contractor does not generate these approvals.)  If the 
contact person has access to PECOS, the contractor can simply refer him/her to PECOS.  
If the contact person does not use PECOS, the contractor shall not require the contact 
person to do so in order to access the document(s) but shall follow the above instructions; 
the latter shall also be followed if the contact person uses PECOS but the requested 
document is not in PECOS.) 
 
L.  Security 
 
The contractor shall ensure that the highest level of security is maintained for all systems and its 
physical and operational processes in accordance with the CMS/Business Partners Systems 
Security Manual (BPSSM) and the Program Integrity Manual. 
 
Applications shall never be removed from the controlled area to be worked on at home or in a 
non-secure location.  Also, provider enrollment staff must control and monitor all applications 
accessed by other contractor personnel. 
 
All contractor staff shall be trained on security procedures as well as relevant aspects of the 
Privacy Act and the Freedom of Information Act.  This applies to all management, users, system 
owners/managers, system maintainers, system developers, operators and administrators - 
including contractors and third parties - of CMS information systems, facilities, communication 
networks, and information. 
 
Note that these instructions are in addition to, and not in lieu of, all other CMS instructions 
regarding security. 
 
M.  Establishment of Relationships 
 
To the maximum extent possible, and to help ensure it becomes aware of recent felony 
convictions of practitioners and owners of health care organizations, the contractor shall 
establish relationships with appropriate state government entities  such as, but not limited to, 
Medicaid fraud units, state licensing boards, and criminal divisions to facilitate the flow of  felony information from the state to the contractor.  For instance, the contractor can request that 
the state inform it of any new felony convictions of health care practitioners. 
 
N.  Monitoring Information from State Licensing Boards 
 
To help ensure that only qualified physicians and non-physician practitioners are enrolled in 
Medicare, the contractor shall undertake the activities described below.  (For purposes of this 
section, the term practitioner includes both physicians and non-physician practitioners.  In 
addition, the instructions in this section, apply only to these practitioners.) 
 
No later than the 15th day of each month, the contractor shall review state licensing board 
information for each state within its jurisdiction to determine whether any of its currently 
enrolled practitioners have, within the previous 60 days: 
 
  Had his/her medical license revoked, suspended, or inactivated (due to retirement, death, or 
voluntary surrender of license); 
 
  Otherwise lost his/her medical license or have had his/her license expire. 
 
For those practitioners who no longer have a valid medical license, the contractor shall take the 
necessary steps pursuant to this chapter. 
 
The mechanism by which the contractor performs these monthly licensure reviews lies within its 
discretion, though the most cost-effective method shall be used. 
 
O.  Regarding Potential Identity Theft or Other Fraudulent Activity  
   
If --when conducting the verification activities described in this chapter -- the contractor believes 
that a case of identity theft or other fraudulent activity likely exists,  the contractor shall notify its 
PEOG BFL immediately; the BFL will instruct the contractor as to what, if any, action  shall be 
taken  (For example, a physician indicates that she is not establishing a new practice location or 
changing her EFT information, and that the application submitted in his/her name is false.) 
 
10.6.20  Screening:  On-site Inspections and Site Verifications  
(Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
The contractor shall review section 10.3 of this chapter for special instructions regarding site 
visits.  In the event of a conflict, those instructions take precedence over those in this section 
10.6.20.   
 
A.  DMEPOS Suppliers and IDTFs 
 
The scope of site visits of DMEPOS suppliers and IDTFs shall continue to be conducted in 
accordance with existing CMS instructions and guidance. 
 
(For purposes of this section 10.6.20, the term contractor refers to the Medicare Administrative 
Contractor; the term SVC refers to the site visit contractor.)     
B.  Provider and Supplier Types Other Than DMEPOS Suppliers and IDTFs 
 
For provider/supplier types other than DMEPOS suppliers and IDTFs  that must undergo a site 
visit pursuant to this section 10.6.20 and  424.518, the SVC will perform such visits consistent 
with the procedures in this section 10.6.20.  This includes all of the following:   
 
(1) Documenting the date and time of the visit, and including the name of the individual 
attempting the visit.  
 
(2) Photographing the provider/suppliers business for inclusion in the provider/suppliers 
file.  All photographs will be date/time stamped. 
 
(3) Fully documenting observations made at the facility, which could include facts such as 
(a) the facility was vacant and free of all furniture, (b) a notice of eviction or similar 
documentation is posted at the facility, and (c) the space is now occupied by another 
company.  
 
(4) Writing a report of the findings regarding each site verification.  
 
(5) Including a signed site visit report stating the facts and verifying the completion 
of the site verification.  
 
In terms of the extent of the visit, the SVC will determine whether the following criteria are met: 
(i) the facility is open; (ii) personnel are at the facility; (iii) customers are at the facility (if 
applicable to that provider or supplier type); and (iv) the facility appears to be operational.  This 
will require the site visitor(s) to enter the provider/suppliers practice location/site rather than 
simply conducting an external review.  If any of the four elements ((i) through (iv)) listed above 
are not met, the contractor will, as applicable - and using the procedures outlined in this chapter 
and in existing CMS instructions - deny the providers enrollment application pursuant to  
424.530(a)(5)(i) or (ii) or revoke the providers Medicare billing privileges under  
424.535(a)(5)(i) or (ii). 
 
C.  Operational Status 
 
When conducting a site verification to determine whether a practice location is operational, the 
SVC shall make every effort to limit its verification to an external review of the location.  If the 
SVC cannot determine whether the location is operational based on this external review, it shall 
conduct an unobtrusive site verification by limiting its encounter with provider or supplier 
personnel or medical patients. 
 
The contractor must review and evaluate the site visit results received from the SVC prior to 
making a final determination.  If it is determined (during the review and evaluation process) that 
the location is non-operational based on the site visit results but there is reason to proceed with 
the enrollment, the contractor shall provide the appropriate justification in the comment section 
of the Validation Checklist in PECOS.  (For example, a second site visit determined the location 
to be operational; the provider only renders services in patients homes; etc.).  
  If the contractor is unsure of how to proceed based on its evaluation of the site visit results, it 
shall contact its PEOG BFL and copy its contracting officer's representative (COR). 
 
D.  Timing 
 
Site verifications should be done Monday through Friday (excluding holidays) during their 
posted business hours.  If there are no hours posted, the site verification should occur between 9 
a.m. and 5 p.m.  If, during the first attempt, there are obvious signs that the facility is no longer 
operational, no second attempt is required.  If, on the first attempt, the facility is closed but there 
are no obvious indications that the facility is non-operational, a second attempt on a different day 
during the posted hours of operation should be made. 
 
E.  Documentation 
 
As indicated previously, when conducting site verifications to determine whether a practice 
location is operational, the SVC shall: 
 
(i)  Document the date and time of the attempted visit and include the name of the individual 
attempting the visit. 
 
(ii)  As appropriate, photograph the provider/suppliers business for inclusion in the 
provider/suppliers file on an as-needed basis.  All photographs should be date/time stamped. 
 
(iii)  Fully document all observations made at the facility (e.g., the facility was vacant and free of 
all furniture, a notice of eviction or similar documentation was posted at the facility, the space is 
now occupied by another company, etc.).   
 
(iv)  Write a report of its findings regarding each site verification. 
 
F.  Determination  
 
(In the event an instruction in this subsection F is inconsistent with guidance in section 10.6.6, 
10.4.7 et seq., or 10.4.8, the latter three sections of instructions shall take precedence.) 
 
If a provider/supplier is determined not to be operational or in compliance with the regulatory 
requirements for its provider/supplier type, the contractor shall revoke the provider/suppliers 
Medicare billing privileges - unless the provider/supplier has submitted a change of information 
request that notified the contractor of a change in practice location.  Within 7 calendar days of 
CMS or the contractor determining that the provider/supplier is not operational, the contractor 
shall update PECOS or the applicable claims processing system (if the provider/supplier does not 
have an enrollment record in PECOS) to revoke Medicare billing privileges and issue a 
revocation notice to the provider/supplier.  The contractor shall afford the provider/supplier 
applicable appeal rights in the revocation notification letter. 
 
For non-operational status revocations, the contractor shall use either 42 CFR  424.535(a)(5)(i) 
or 42 CFR  424.535(a)(5)(ii) as the legal basis for revocation. Consistent with 42 CFR  
424.535(g), the date of revocation is the date on which CMS or the contractor determines that the  provider/supplier is no longer operational.  The contractor shall establish a 2-year reenrollment 
bar for providers/suppliers that are not operational.  
 
For regulatory non-compliance revocations, the contractor shall use 42 CFR  424.535(a)(1) as 
the legal basis for revocation.  Consistent with 42 CFR  424.535(g), the date of revocation is the 
date on which CMS or the contractor determines that the provider/supplier is no longer in 
compliance with regulatory provisions for its provider/supplier type.  The contractor shall 
establish a 2-year enrollment bar for providers/suppliers that are not in compliance with 
provisions for their provider/supplier type. 
 
G.  Multiple Site Visits 
 
Notwithstanding any other instruction to the contrary in this chapter, the contractor shall not 
order a site visit if the specific location to be visited has already undergone a successful site visit 
within the last 12 months and the applicable provider/supplier is in an approved status.   
Consider the following illustrations: 
Example 1 - A single-site home health agency (HHA) undergoes a revalidation site visit on 
February 1.  The HHA submits a change of information request on July 1 to add a branch 
location.  The contractor shall order this site visit because the visit will occur at a location (i.e., 
the branch location) different from the main location (i.e., the location that underwent the 
February 1 revalidation visit). 
Example 2 - A DMEPOS supplier undergoes a revalidation site visit on April 1.  It submits an 
initial Form CMS-855S application on May 1 to enroll a second location.  The new location shall 
undergo a site visit because: (1) it is different from the first (revalidated) location; and (2) it 
is/will be separately enrolled from the first location. 
Example 3 - A physical therapy (PT) group has three locations  X, Y, and Z.  As part of a 
revalidation, the contractor elects to order a site visit of Location Y rather than X or Z.  The visit 
was performed on June 1.  On October 4, the group submits a Form CMS-855B to report a 
change of ownership, thus requiring a site visit under this chapter.  However, the contractor shall 
not order a visit for Location Y because this site has been visited within the past 12 
months.  Location X or Location Z must instead be visited. 
Example 4 - An IDTF undergoes an initial enrollment site visit on July 1.  On September 24, it 
submits a Form CMS-855B application to change its practice location; this mandates a site visit 
under this chapter.  The site visit shall be performed even though the initial visit took place 
within the past 12 months.  This is because the second visit will be of the new location, whereas 
the first visit was of the old location.  
H.  Certified Providers/Suppliers  Address Validation Error  
Notwithstanding any other instruction to the contrary in this chapter, the contractor need not 
order a site visit for a certified provider/supplier prior to making a recommendation to the state if 
an address validation error is received in PECOS.  The contractor shall override the error  message and notate in the referral package that the address was unverifiable.  This avoids 
multiple site visits being performed (that is, pre-enrollment, survey, and post enrollment). 
10.6.21  Miscellaneous Enrollment Topics  
(Rev. 12100; Issued: 06-29-23; Effective: 07-31-23; Implementation: 07-31-23) 
 
This section 10.6.21 addresses additional provider enrollment policies.  Except as otherwise 
stated, the instructions in this section supersede any other instructions to the contrary in this 
chapter.  It is anticipated that the provisions in this section 10.6.21 will eventually be moved to 
those sections of this chapter most applicable to their respective subject matter.  For 
organizational reasons, section 10.6.21 is merely a placeholder section of chapter 10. 
 
A.  Group and Reassignment Reactivation 
 
If a group practice submits a reactivation application after being deactivated for non-response to 
a revalidation request, the contractor shall reactivate the groups reassignments when the groups 
reactivation application has been approved; Form CMS-855I and/or CMS-855R applications for 
the reassignments are not required.  The effective dates assigned to the reassigned providers shall 
align with the groups effective date per existing reactivation instructions. 
This section 10.6.21(A) only applies to deactivations based on a non-response to a revalidation 
request. 
 
B.  Specialty Changes  
 
When a Form CMS-855 enrollment application is submitted to report a change to a physicians 
or non-physician practitioners primary or secondary specialty, the contractor shall not contact 
the physician, non-physician practitioner, or contact person directly to confirm either the change 
itself or the individuals intent to change his/her specialty. 
 
C.  Reassignments Related to Revoked or Deactivated Reassignee 
 
The contractor shall end-date in PECOS all reassignment associations and the associated 
Provider Transaction Access Numbers (PTANs) when revoking or deactivating an individual or 
organization (reassignee) that is receiving reassigned benefits from an individual practitioner.  
The end-date shall be the same as the effective date of the revocation or deactivation; this will 
ensure the appropriate end-date in the Multi-Carrier System (MCS) and prevent improper use of 
those PTANs.  However, the contractor shall not deactivate the individual practitioners 
(reassignors) enrollment record even if (1) the reassigned PTAN is the only PTAN on the 
individuals enrollment record and/or (2) no other active locations exist (private practice 
locations or reassignments); the contractor shall allow the practitioners/reassignors enrollment 
record to remain in an approved status.   
 
When sending a deactivation, revocation, or voluntary withdrawal letter to the deactivated or 
revoked non-certified Part B supplier, said letter shall include the following language: Please 
notify all physician assistants and/or group members who reassign benefits to your organization 
that, in accordance with 42 CFR 424.540(a)(2), their Medicare enrollment status may be 
deactivated if they fail to update their enrollment record within 90 calendar days.  D.  Interstate License Compacts 
A new trend in medicine has arisen involving interstate license compacts.  While physician 
compacts streamline the licensure process for physicians who want to practice in multiple states, 
a separate license from each state in which the physician intends to practice is still issued (if all 
requirements are met). CMS will continue to rely on the license issued by the state medical board 
to help confirm compliance with federal requirements.  
In a similar vein, certain non-physician practitioner (NPP) compacts allow the NPP to work in a 
compact member state (other than their home state) without going through the normal process for 
licensure in the remote state. NPPs working under the authorization of such a compact must meet 
both the licensure requirements outlined in the primary state of residence and those established 
by the compact laws adopted by the legislatures of the interstate compact states.   
At present, there are interstate compacts involving physicians, physical therapists, occupational 
therapists, speech language pathologists, and psychologists (though none for nurse practitioners).  
More are possible. 
Licenses obtained through an interstate license compact for the above supplier types shall be 
treated as valid, full licenses for the purposes of meeting federal requirements.  The contractor 
shall thus accept Form CMS-855 applications from applicants reporting a license obtained via an 
interstate license compact.  In addition, the contractor shall attempt to verify the interstate license 
obtained through the compact using the state licensing board website(s) or compact website (if 
one exists); if neither technique can confirm the interstate license, the contractor shall request 
documentation from the supplier that validates said data.   
 
E.  Provisions in CMS-1770-F   
 
The CMS Calendar Year 2023 Physician Fee Schedule Final Rule (CMS-1770-F) included a 
number of revisions to our provider enrollment regulations.  This subsection 10.6.21(E) 
addresses these matters.  Effective January 1, 2023, the contractor shall apply and execute the 
policies in this subsection 10.6.21(E) notwithstanding any other instruction to the contrary in this 
chapter.     
 
1.  Managing Organizations, Officers, and Directors 
 
a.  Definitions 
 
CMS-1770-F finalized definitions of managing organization, officer, and director in 42 CFR  
424.502.  These definitions are consistent with those commonly understood in the provider 
enrollment arena and are as follows: 
 
  Managing organization - An entity that exercises operational or managerial control over, or 
who directly or indirectly conducts, the day-to-day operations of the provider or supplier, 
either under contract or through some other arrangement.   
  Officer - An officer of a corporation, regardless of whether the provider or supplier is a non-
profit entity.    Director - A director of a corporation, regardless of whether the provider or supplier is a non-
profit entity.  This includes any member of the corporations governing body irrespective of 
the precise title of either the board or the member; said body could be a board of directors, 
board of trustees, or similar body. 
 
Officers and directors can also include persons who serve in a voluntary or ceremonial capacity.  
CMS re-emphasizes, however, that officers and directors apply only to corporations.  
 
Managing organizations, officers, and directors have long been reported in Section 5 or 6 (as 
applicable) of the Form CMS-855 and on the Form CMS-20134.  The contractor shall continue 
to follow existing instructions in this chapter for: (1) ensuring that these parties and all required 
data pertaining thereto are disclosed, such as EINs/SSNs and any adverse legal history; and (2) 
performing all required verifications (e.g., reviewing against the OIG excluded parties list).     
  
b.  Expansion of  424.530(a)(2)/(3) and  424.535(a)(2)/(3) 
 
Managing organizations, officers, and directors have been added to the scope of the 
denial/revocation reasons at  424.530(a)(2), 424.530(a)(3), 424.535(a)(2), and 424.535(a)(3).  
This means that a felony conviction within the past 10 years, an OIG exclusion, or a SAM 
debarment against an officer, director, or managing organization can serve as the basis for the 
provider/suppliers denial/revocation.  The contractor shall continue to follow existing 
instructions in this chapter for handling potential denial and revocation situations with the 
understanding that officers, directors, and managing organizations now fall within the 
aforementioned denial and revocation reasons.  Thus, for example, if an officer of the provider 
has a current OIG exclusion, the contractor shall handle the matter in the same fashion it would if 
a supervising physician were excluded. 
 
Note that CMS-1770-F also formally incorporated into  424.530(a)(2)/(3) and  
424.535(a)(2)/(3) the policy that the individuals and entities listed within these regulatory 
provisions include W-2 employees and contracted individuals and organizations of the 
provider/supplier. 
 
c.  Expansion of  424.530(c) and  424.535(e)  
 
As mentioned in sections 10.4.2.3(B) and 10.6.18(C)(7) of this chapter,  424.530(c) and  
424.535(e) state that if a denial or revocation, respectively, was due to a prior adverse action 
(such as a sanction, exclusion, or felony) against a provider/suppliers owner, managing 
employee, authorized or delegated official, medical director, supervising physician, or other 
health care or administrative or management services personnel furnishing services payable by a 
federal health care program, the denial or revocation may be reversed if the provider/supplier 
terminates (and submits proof that it has terminated) its business relationship with that party 
within 30 days of the denial/revocation notification.  CMS-1770-F added officers, directors, and 
managing organizations to  424.530(c) and 424.535(e).  
 
2.  Clarification of  424.535(a)(12) 
  As stated in  424.535(a)(12) and in section 10.4.7.3(L) of this chapter, CMS may revoke a 
provider or supplier that is terminated, revoked, or otherwise barred from participation in a state 
Medicaid program or any other federal health care program.  Under  424.535(a)(12)(ii), CMS 
cannot revoke unless and until the provider or supplier has exhausted all applicable appeal 
rights.  However, CMS-1770 added the following to the end of this quoted language in  
424.535(a)(12)(ii): or the timeframe for filing an appeal has expired without the provider or 
supplier filing an appeal.  This merely incorporated into regulation CMS existing policy that  
424.535(a)(12) can be applied if the provider or supplier fails to file an appeal within the 
prescribed timeframe. 
 
3.  Expansion of Providers and Suppliers Undergoing High-Risk Screening 
 
CMS-1770-F also expanded the number and types of providers and suppliers that are subject to 
high-risk level screening under  424.518.  This generally involves, but is not limited to: (1) 
moving skilled nursing facilities (SNFs) from the limited screening category to the high 
screening category; and (2) including certain changes in ownership as among the types of 
enrollment transactions subject to the high screening category under  424.518.  These 
regulatory changes and the associated contractor instructions for effectuating them are described 
in (a) through (c) below. 
 
a.  Changes in Ownership  
 
i.  General Policy 
 
As stated in  424.518 and as described in section 10.6.15 of this chapter, the following three 
application types are subject to  424.518s screening requirements: (1) initial applications; (2) 
revalidations; and (3) applications to add a new practice location.  CMS-1770-F added the 
following two transaction types to the purview of  424.518:  
 
(i)  Change of ownership applications pursuant to 42 CFR  489.18 
(ii) Applications to report any new owner (regardless of ownership percentage, though consistent 
with the definition of owner in section 10.1.1 of this chapter) pursuant to a change of 
information or other enrollment transaction under title 42.   
 
The foregoing means that an application under (i) or (ii) must be processed at the high screening 
level if it is submitted by: 
 
  An enrolled OTP that has not been fully and continuously certified by SAMHSA since 
October 24, 2018  
  A DMEPOS supplier 
  An MDPP supplier 
  An HHA 
  A SNF (described further below) 
 
(For purposes of this subsection (E)(3)(a), these five provider/supplier types will be collectively 
referred to as the affected providers.)   
  Categories (i) and (ii) above would include, for instance: 
 
  A SNF CMS-855A CHOW, acquisition, merger, and consolidation application (as those 
terms are described on the CMS-855A and in section 10.6.1.1 of this chapter). 
 
  An HHA CHOW under 42 CFR  489.18.  (See section 10.2.1.6.1 of this chapter for 
information on these types of CHOWs.)  Note that a change in majority ownership under 42 
CFR  424.550(b) that requires a new enrollment would not fall under (i) or (ii) above 
because it would generate an initial enrollment, though, for this latter reason, it would still be 
processed at the high screening level (as all HHA initials are).)   
 
  A DMEPOS supplier reporting a 15 percent new owner.   
 
In sum, any change of/in ownership that meets all the following criteria would fall under (i) and 
(ii) above: 
 
  Does not involve the triggering of an initial enrollment (e.g., an HHA change in majority 
ownership and no exception applies, thus warranting a new enrollment); and  
  The change reports either: 
 
  For partnerships: A new partner (general or limited) that owns any percentage (even 1 
o
percent) of the affected provider; or 
  Excluding partnerships: A new direct or indirect owner of at least 5 percent of the 
o
affected provider. 
 
Changes of ownership involving providers/suppliers other than the five aforementioned affected 
provider categories (e.g., ambulance suppliers, CORFs) shall continue to be processed consistent 
with existing instructions.   
 
ii.  Processing Instructions 
 
Upon receipt of an application described in subsection (E)(3)(a)(i) above, the contractor shall 
process it consistent with the instructions in this chapter and, in particular, with section 10.6.15.  
This includes requesting fingerprints from any new direct or indirect owner of 5 percent or more 
of the provider, though the contractor need not also solicit them from the provider/suppliers 
existing owners; only the new owner(s) need be fingerprinted.   
 
The contractor shall also order a site visit of the affected provider consistent with existing 
instructions.  In terms of the timing of the HHA or SNF site visit, however, the contractor shall 
also adhere to the following:  
 
  No State/SOG Location Approval Required  If the ownership change does not require state 
or SOG Location approval under existing CMS instructions (see sections 10.6.1.1, 10.6.1.2, 
10.6.22, and 10.6.22.1 of this chapter for more information), the site visit shall be ordered 
and performed prior to the contractors final decision regarding the application. 
  State/SOG Location Approval Required - If the ownership change requires state or SOG 
Location approval under existing CMS instructions (see sections 10.6.1.1, 10.6.1.2, 10.6.22,  and 10.6.22.1), the site visit shall be ordered and performed no later than 5 business days 
after the contractor receives notice of approval from the state or SOG Location but before the 
contractor switches the provider/suppliers enrollment record to an Approved status.   
 
All clock stoppages permitted under this chapter (e.g., fingerprinting per section 10.5(C)(1)) 
apply to the situations described in this subsection (E)(3)(a).  In addition, since a site visit and 
fingerprinting are required, the contractor shall adhere to the timeliness standards in section 
10.5(A)(1)(a) for paper applications and those in section 10.5(A)(3)(a) for web-based 
applications. 
 
b.  SNFs 
 
As already mentioned, SNFs are now in the high screening category under  424.518(c).  
Accordingly, SNF initial applications require a site visit as well as the fingerprinting of the 
SNFs 5 percent or greater owners.  In executing this policy, the contractor shall follow existing 
instructions in this chapter regarding the collection and processing of fingerprints, including 
those in subsection (E)(3)(a) above for SNF ownership changes.  As for site visits, the contractor 
shall follow the instructions in section 10.2.1.14 for initial and revalidation applications and 
subsection (E)(3)(a) above for change in ownership applications. 
 
c.  Bump-Ups 
 
Effective January 1, 2023 (and pursuant to CMS-1770-F), any screening level adjustment under 
 424.518(c)(3) also applies to all other enrolled and prospective providers and suppliers that 
have the same legal business name and tax identification number as the provider or supplier for 
which the screening level under  424.518(c)(3) of this section was originally raised.  See section 
10.6.15(A)(4) of this chapter for more information. 
 
F.  Special Form CMS-855S Instructions 
 
1.  Addresses  
 
If an address (e.g., correspondence address, practice location) on the Form CMS-855S lacks a 
city, state, or zip + four, the contractor can verify the missing data in any manner it chooses. In 
addition, the contractor can obtain the zip + four from either the U.S. Postal Service or the 
Delivery Point Validation in PECOS. 
 
2.  Insurance 
 
With respect to the comprehensive liability insurance supplier standard in 42 CFR  
424.57(a)(10), the contractor shall: (1) verify with the insurance agent that the insurance policy is 
active and current; and (2) ensure that the contractor (i.e., the NPE contractor) is listed as the 
policy holder on the certificate.  The contractor may contact the insurance agent via any manner 
it chooses; however, verification shall be documented consistent with section 10.6.19 of this 
chapter (e.g., documenting telephonic communications).   
  G.  Transitioned Certified Providers and Suppliers  E-Mails to PEOG for Final 
Application Review and/or Approval 
 
As described in this chapter, the contractor must refer various matters involving transitioned 
certified provider/supplier enrollment applications to PEOG for final application review and 
approval (e.g., system updates, assignment of CCN, etc.)  When making such referrals---and 
notwithstanding any other instruction to the contrary in this chapter---the e-mail subject line shall 
include the following: SUBJECT LINE: S&C: Facility Type; Application Type; Facility Name; 
National Provider Identifier; CCN; Application Receipt Date (MMDDYY*) (*Date the 
Contractor Received the Application from the Provider/Supplier).  (Note, however, that this data 
need not be duplicated in the e-mails body.)  This instruction, to reiterate, only applies to e-
mails to PEOG involving: (1) transitioned certified providers/suppliers; and (2) instances where 
the contractor is explicitly required per this chapter to send the matter PEOG for final review, 
approval, and/or denial of an application (e.g., initial application, CHOW, certain COIs) and to 
wait for PEOGs determination.  (See, for example, section 10.6.1.2(A)(3)(a) of this chapter.)  
 
H.  Contacting State or SOG Location for Updates 
 
1. Transitioned Certified Providers/Suppliers - In situations where the contractor recommends 
approval to the state (initial applications, CHOWs, certain changes of information, etc.), the 
contractor---if it has not received the states recommendation within 120 days after the contractor 
sent its recommendation---may contact the state to ascertain whether said recommendation is 
forthcoming.  The contractor may contact the state every 30 days thereafter to determine the 
recommendations status.   
 
2. Non-Transitioned Certified Providers/Suppliers  If, as described in subsection (H)(1) 
above, the contractor recommends approval to the state, the contractor may contact the state for 
an update on the recommendations status beginning 120 days after the recommendation was 
sent and every 30 days thereafter.  If the state informs the contractor (via any means) that the 
application has been forwarded to the SOG Location, the contractor may contact the SOG 
Location for a status update every 30 days beginning on the date the contractor received this 
notice from the state.   
 
I.   Survey and Certification Documents  All Certified Providers and Certified Suppliers 
 
1.  Documents from the State/AO   
 
As applicable to the provider/supplier type in question, the state or accrediting organization (AO) 
must provide the signed CMS-1561 (or other/similar contract) and copy of the HHS-690 to the 
contractor with its approval recommendation.  (Note that the contractor can accept a CMS-1561 
or HHS-690 from either the state or AO.) 
If the state/AO neither furnished said documents nor otherwise indicated that they were 
uploaded into the Automated Survey Process Environment (ASPEN)/Internet Quality 
Improvement and Evaluation System (IQIES), the contractor shall contact the state/AO via any 
means for the applicable document(s).  If the state/AO responds within 10 days of the 
contractors request by either (a) sending the document(s) to the contractor or (b) stating that it  has uploaded the document(s) into ASPEN/IQIES, the contractor can continue processing the 
application consistent with applicable instructions.  (If the state/AO indicated (b) above, the 
contractor shall note this in its referral to PEOG.)  If the state/AO does neither (a) nor (b) within 
this 10-day period, the contractor shall: (1) proceed with sending the referral to PEOG consistent 
with existing instructions; and (2) include evidence of the state/AOs lack of responsiveness 
(e.g., e-mail evidence of the contractors request). 
2.  AO Documents to PEOG 
As applicable to the situation and provider/supplier type, the contractor shall include the AO 
deeming letter in referrals to PEOG that are required under this chapter (e.g., initial approvals). 
10.6.21.1  Additional Miscellaneous Enrollment Topics  
(Rev. 11682; Issued: 11-04-2022; Effective: 12-05-2022; Implementation:12-05-2022) 
 
(The instructions in this section 10.6.21.1 take precedence over all other contrary instructions in 
this chapter, including, but not limited to, the existing guidance in sections 10.3.1 et al.  The 
policies in this section will eventually be incorporated into the sections of this chapter that are 
applicable to the subject matter.) 
 
Type of Practice Location 
For Form CMS-855A, CMS-855B, and CMS-855I applications, the contractor may collect the 
practice location type in Section 4 of the application via telephone or---if the practice location 
type is otherwise apparent---may forgo development altogether. 
 
10.6.22 - Non-Transitioned Certified Provider/Supplier Changes of 
Ownership 
(Rev. 11859; Issued: 02-16-23; Effective: 03-17-23; Implementation: 03-17-23) 
 
(Until further notice, the contractor shall continue to follow these instructions for CHOWs 
involving those certified provider and certified supplier types that have not transitioned 
as described in section 10.6.1.1 of this chapter.)  
 
All references to the SOG Location (formerly the RO) in this section 10.6.22 refer to the 
applicable CMS Regional Offices Survey & Operations Group (SOG) Location.  Also, and 
except as otherwise indicated, all references to provider include certified suppliers (e.g., 
ambulatory surgical centers, portable x-ray suppliers). 
 
Changes of ownership (CHOWs) are officially defined in and governed by 42 CFR  489.18 and 
Publication 100-07, chapter 3, sections 3210 through 3210.5(C).  The SOG Location  not the 
contractor  makes the determination as to whether a CHOW has occurred (unless this function 
has been delegated). 
 
Except as otherwise specified, the term CHOW - as used in this section 10.6.22 - includes 
CHOWs, acquisitions/mergers, and consolidations. 
  Though the Change of Ownership (CHOW) Information section of the Form CMS-855A 
separates the applicable transactions into CHOWs, acquisition/mergers and consolidations for 
ease of disclosing and reporting, they fall within the general CHOW category under 42 CFR  
489.18 (e.g., an acquisition/merger is a type of CHOW under  489.18). 
 
A.  Definitions for CHOWs  
 
For purposes of provider enrollment only, there are three main categories of CHOWs captured 
on the Form CMS-855A application:  
 
1.  Standard CHOW  
 
This occurs when a providers CMS Certification Number (CCN) and provider agreement are 
transferred to another entity as a result of the latters purchase of the provider.  To illustrate, 
suppose Entity A is enrolled in Medicare, but Entity B is not.  B acquires A.  Assuming all 
regulatory requirements are met, As provider agreement and CCN number will transfer to B. 
 
This is the most frequently encountered change of ownership scenario.  As explained in this 
section 10.6.22, even though it is technically an acquisition (i.e., B bought/acquired A) under  
489.18, this situation falls under the CHOW category  as opposed to the 
Acquisition/Merger category  on the Form CMS-855A. 
 
2.  Acquisition/Merger  
 
In general, this occurs when two or more Medicare-enrolled entities combine, leaving only one 
remaining CCN number and provider agreement.  For instance, Entity A and Entity B are both 
enrolled in Medicare, each with its own CCN number and provider agreement.  The two entities 
decide to merge.  Entity Bs CCN number and provider agreement will be eliminated (leaving 
only Entity As CCN number and provider agreement). 
 
If the acquisition results in an existing provider having new owners but keeping its existing 
provider number, the applicant should check the CHOW box in the Basic Information section of 
the Form CMS-855A. 
 
Unlike the new owner in a CHOW or consolidation, the new owner in an acquisition/merger 
need not complete the entire Form CMS-855A.  This is because the new owner is already 
enrolled in Medicare.  As such, the provider being acquired should be reported as a practice 
location in the Practice Location Information section of the new owners Form CMS-855A. 
 
3.  Consolidations 
 
This occurs when the merger of two or more Medicare-enrolled entities results in the creation of 
a brand new entity. To illustrate, if Entities A and B decide to combine and, in the process, create 
a new entity (Entity C), the CCN numbers and provider agreements of both A and B will be 
eliminated.  Entity C will have its own CCN number and provider agreement. 
  Note the difference between acquisitions/mergers and consolidations.  In an acquisition/merger, 
when A and B combine there is one surviving entity.  In a consolidation, when A and B combine 
there are no surviving entities.  Rather, a new entity is created  Entity C. 
 
Under 42 CFR  489.18(a)(4), the lease of all or part of a provider facility constitutes a change of 
ownership of the leased portion.  If only part of the provider is leased, the original provider 
agreement remains in effect only with respect to the un-leased portion.  (See Pub. 100-07, 
chapter 3, section 3210.1D (4) for more information.) 
 
Note that a provider may undergo a financial or administrative change that it considers to be a 
CHOW, but does not meet the regulatory definition identified in 489.18. 
 
B.  Examining Whether a CHOW May Have Occurred  
 
As stressed previously, the SOG Location  not the contractor  determines whether a CHOW 
has occurred (unless this function has been delegated).  However, in processing the application, 
the contractor shall perform all necessary background research regarding whether: (1) a CHOW 
may have occurred, and/or (2) the new owner is accepting assignment of the Medicare assets and 
liabilities of the old owner.  Such research may include reviewing the sales agreement or lease 
agreement, contacting the provider(s) to request clarification of the sales agreement, etc.  (A 
CHOW determination by the SOG Location is usually not required prior to the contractor 
making its recommendation.) 
 
While a CHOW is usually accompanied by a tax identification number (TIN) change, this is not 
always the case.  There may be isolated instances where the TIN remains the same.  Conversely, 
there may be cases where a provider is changing its TIN but not its ownership.  In short, while a 
change of TIN (or lack thereof) is evidence that a CHOW may or may not have occurred, it is not 
the most important factor; rather, the change in the providers ownership arrangement is.  Hence, 
the contractor should review the sales/lease agreement closely, as this will help indicate whether 
a CHOW may or may not have occurred. 
 
In addition: 
 
(a) If the provider claims that the transaction in question is a stock transfer and not a CHOW, the 
contractor reserves the right to request any information from the provider to verify this (e.g., 
copy of the stock transfer agreement). 
 
If  after performing the necessary research  the contractor remains unsure as to whether a 
CHOW has occurred and/or whether the new owner is accepting assignment, the contractor may 
refer the matter to the SOG Location for guidance.  Such referrals to the SOG Location should 
only be made if the contractor is truly uncertain as to whether a CHOW and/or acceptance of 
assignment may have taken place and should not be made as a matter of course. A SOG Location 
CHOW determination is usually not required prior to the contractor making its recommendation. 
 
(b) There may be instances where the contractor enters a particular transaction into PECOS as a 
CHOW, but it turns out that the transaction was not a CHOW (e.g., was a stock transfer; was an 
initial enrollment because the new owner refused to accept the Medicare liabilities).  If the  contractor cannot change the transaction type in PECOS, it can leave the record in a CHOW 
status; however, it should note in the providers file that the transaction was not a CHOW. 
 
C.  Processing CHOW Applications 
 
Unless stated otherwise in this chapter, the contractor shall ensure that all applicable sections of 
the Form CMS-855A for both the old and new owners are completed in accordance with the 
instructions on the Form CMS-855A. 
 
1.  Previous Owner(s) 
 
The previous owners Form CMS-855A CHOW application does not require a recommendation 
for approval.  Any recommendations will be based on the CHOW application received from the 
new owner. 
 
If the previous owner's Form CMS-855A is available at the time of review, the contractor shall 
examine the information therein against the new owners Form CMS-855A to ensure consistency 
(e.g., same names).  If the previous owner's Form CMS-855A has not been received, the 
contractor shall contact the previous owner and request it.  However, the contractor may begin 
processing the new owners application without waiting for the arrival of the previous owners 
application.  It may also make its recommendation to the state agency without having received 
the previous owners Form CMS-855A.  The contractor, of course, shall not make a 
recommendation for approval unless the new owner has checked on the form that it will assume 
the provider agreement and the terms of the sales agreement indicate as such. 
 
If a certification statement is not on file for the previous owner, the contractor shall request that 
the Individual Ownership and/or Managing Control section be completed for the individual who 
is signing the certification statement. 
 
Note that a previous owners Form CMS-855A CHOW application is essentially the equivalent 
of a Form CMS-855 voluntary termination submission, as the seller is voluntarily leaving the 
Medicare program.  As such, the contractor shall not require the seller to submit a separate Form 
CMS-855 voluntary termination along with its Form CMS-855A CHOW application. 
 
2.  New Owner(s) 
 
If a Form CMS-855A is not received from the new owner within 14 calendar days of receipt of 
the previous owners Form CMS-855A, the contractor shall contact the new owner.  If, within 30 
calendar days after the contractor contacted it, the new owner fails to (1) submit a Form CMS-
855A and (2) indicate that it accepts assignment of the provider agreement, the contractor shall 
send an e-mail to its PEOG BFL notifying him/her of the situation. PEOG will determine 
whether the providers billing privileges should be deactivated under  424.540(a)(2) or  
424.550(b) or revoked under  424.535(a)(1) or (a)(9).  PEOG will notify the contractor of its 
decision. 
 
3.  Order of Processing 
  To the maximum extent practicable, Form CMS-855A applications from the previous and new 
owners in a CHOW should be processed as they come in.  The contractor should not wait for 
applications from both the previous and new owner to arrive before processing them.  However, 
unless the instructions in this chapter indicate otherwise, the contractor should attempt to send 
the previous and new owners applications to the state simultaneously, rather than as soon as 
they are processed.  For instance, suppose the previous owner submits an application on March 
1.  The contractor should begin processing the application immediately, without waiting for the 
arrival of the new owners application.  Yet it should avoid sending the previous owners 
application to the state until the new owners application is processed.  (For acquisition/mergers 
and consolidations, the contractor may send the applications to the SOG Location separately, 
since one number is going away.) 
 
4.  Sales and Lease Agreements 
 
The contractor shall abide by the following: 
 
(i)  Verification of Terms - The contractor shall determine whether: (1) the sales/lease agreement 
includes the signatures of the buyer and seller and the information contained within is consistent 
with that reported on the new owner's Form CMS-855A (e.g., same names, effective date), and 
(2) the terms of the contract indicate that the new owner will assume the provider agreement.  In 
many cases, the sales/lease agreement will not specifically refer to the Medicare provider 
agreement.  Clearly, if the box in the Change of Ownership (CHOW) Information section is 
checked "Yes" and the sales/lease agreement either confirms that the new owner will assume the 
agreement or is relatively silent on the matter, the contractor can proceed as normal.  Conversely, 
if the agreement indicates that the assets and liabilities will not be accepted, the contractor should 
deny the application. 
 
(Note that-- 
 
  A bill of sale/lease agreement/sales transfer agreement is a sales/lease business document and 
should not be confused with a patient transfer agreement. 
  The agreement must contain the signatures of both parties to the transaction.  If it does not, 
the contractor shall develop for an agreement containing both signatures.) 
 
(ii)  Form of Sales/Lease Agreement - There may be instances where the parties in a CHOW did 
not sign a sales or lease agreement in the conventional sense of the term; the parties, for 
example, may have documented their agreement via a bill of sale.  The contractor may accept 
this documentation in lieu of a sales/lease agreement so long as the document furnishes clear 
verification of the terms of the transaction and the information is consistent with that contained 
in the Form CMS-855A as discussed above. 
 
(iii)  Submission of Final Sales/Lease Agreement - The contractor shall not forward a copy of the 
application to the state until it has received and reviewed the final sales/lease agreement.  It need 
not revalidate the information on the Form CMS-855A, even if the data therein may be 
somewhat outdated by the time the final agreement is received. 
  If a final sales/lease agreement is not submitted within 30 days after the contractors receipt of 
the new owners application, the contractor shall reject the application.  Though the contractor 
must wait until the 30th day to reject the application, the contractor may do so regardless of how 
many times it contacted the new owner or what types of responses (short of the actual receipt of 
the agreement) were obtained. 
 
Unless specified otherwise in this chapter, both the previous and new owners must submit 
separate Form CMS-855A applications, as well as copies of the interim and final sales/lease 
agreements. 
 
5.  CHOWs Involving Subtypes 
 
On occasion, a CHOW may occur in conjunction with a change in the facilitys provider 
subtype.  This frequently happens when a hospital undergoes a CHOW and changes from a 
general hospital to another type of hospital, such as a psychiatric hospital.  Although a change in 
hospital type is considered a change of information (COI), it is not necessary for the provider to 
submit separate applications  one for the COI and one for the CHOW.  Instead, all information 
(including the change in hospital type) should be reported on the CHOW application; the entire 
application should then be processed as a CHOW.  However, if the facility is changing from one 
main provider type to another (e.g., hospital converting to a skilled nursing facility) and also 
undergoing a CHOW, the provider must submit its application as an initial enrollment. 
 
NOTE:  For Medicare purposes, a critical access hospital (CAH) is a separately-recognized 
provider type.  Thus, a general hospital that undergoes a CHOW while converting to a CAH 
must submit its Form CMS-855A as an initial enrollment, not as a CHOW. 
 
6.  Unreported CHOW 
 
If the contractor learns via any means (including receipt of a tie-in notice or other SOG Location 
or state notice) that an enrolled provider (1) has been purchased by another entity or has 
purchased another Medicare enrolled provider, the contractor shall immediately request Form 
CMS-855A applications from both the previous and new owners.  If the new owner fails to 
submit a Form CMS-855A within the latter of (1) the date of acquisition or (2) 30 days after the 
request, the contractor shall stop payments to the provider.  Payments may be resumed upon 
receipt of the completed Form CMS-855A. 
 
7.  Relocation of Entity 
 
A new owner may propose to relocate the provider concurrent with the CHOW.  If the relocation 
is to a site in a different geographic area serving different clients than previously served and 
employing different personnel to serve those clients, the contractor shall notify the SOG 
Location immediately.  Unless the SOG Location dictates otherwise, the provider shall - per 
CMS Publication 100-07, chapter 3, section 3210.1(B)(5) - treat the transaction as an initial 
enrollment (and the provider as a new applicant), rather than as an address change of the existing 
provider. 
 
8.  Transitioning to Provider-Based Status 
  Consistent with existing CMS policy, a provider undergoing a CHOW pursuant to 42 CFR 
 489.18 may be assigned to a new contractor jurisdiction only if the provider is 
transitioning from freestanding to provider-based status.  In such cases, the contractor for 
the new jurisdiction (the new contractor) shall process both the buyers and sellers Form 
CMS-855A applications.  Should the old/previous (or current) contractor receive the 
buyers and/or sellers Form CMS-855A application, it shall: (a) forward the application to 
the new contractor within 5 business days of receipt, and (b) notify the new contractor 
within that same timeframe that the application was sent. 
 
9.  Intervening Change of Ownership (CHOW) 
 
(This section does not apply to home health agencies.) 
 
In situations where (1) the provider submits a Form CMS-855A initial application or CHOW 
application and (2) a Form CMS-855A CHOW application is subsequently submitted but before 
the contractor has received the tie-in notice from the SOG Location, the contractor shall abide by 
the following: 
 
Situation 1  The provider submitted an initial application followed by a CHOW application, and 
a recommendation for approval has not yet been made with respect to the initial application  
The contractor shall return both applications and require the provider to re-submit an initial 
application with the new owners information. 
 
Situation 2 - The provider submitted a CHOW application followed by another CHOW 
application, and a recommendation for approval has not been made for the first application - The 
contractor shall process both applications  preferably in the order in which they were received  
and shall, if recommendations for approval are warranted, refer both applications to the 
state/SOG Location in the same package.  The accompanying notice/letter to the state/SOG 
Location shall explain the situation. 
 
Situation 3 - The provider submitted an initial application followed by a CHOW application, and 
a recommendation for approval of the initial application has been made  The contractor shall: 
 
(i)  Return the CHOW application. 
 
(ii)  Notify the state/SOG Location via letter (sent via mail or e-mail) that there has been a 
change of ownership (the new owner should be identified) and that the contractor will be 
requiring the provider to resubmit a new initial application containing the new owners 
information. 
 
(iii)  Request via letter that the provider submit a new initial Form CMS-855A application 
containing the new owners information within 30 days of the date of the letter.  If the provider 
fails to do so, the contractor shall return the initial application and notify the provider and the 
state/SOG Location of this via letter.  If the provider submits the application, the contractor shall 
process it as normal and, if a recommendation for approval is made, send the revised application 
package to the state/SOG Location with an explanation of the situation; the initially submitted 
application becomes moot. If the newly submitted application is denied, however, the initially 
submitted application is denied as well; the contractor shall notify the provider and the state/SOG  Location accordingly. 
 
Situation 4 - The provider submitted a CHOW application followed by another CHOW 
application, and a recommendation for approval has been made for the first application - The 
contractor shall: 
 
(i) Notify the state/SOG Location via e-mailed letter that there has been a change of ownership 
(the new owner should be identified) and that the contractor will be requiring the provider to 
resubmit a new initial application containing the new owners information. 
 
(ii) Process the new CHOW application as normal. If a recommendation for approval is made, 
the contractor shall send the revised CHOW package to the state/SOG Location with an 
explanation of the situation; the first CHOW application becomes moot.  If the newly submitted 
CHOW application is denied, the first application is denied as well; the contractor shall notify 
the provider and the state/SOG Location accordingly. 
 
10.  CHOWs and Address Changes 
 
A new owner may propose to relocate the supplier concurrent with a CHOW.  If the relocation is 
to a site in a different geographic area serving different clients than previously served and 
employing different personnel to serve those clients, the contractor shall notify the SOG 
Location immediately.  Unless the SOG Location dictates otherwise, the supplier shall - per Pub. 
100-07, chapter 3, section 3210.1(B)(5) - treat the transaction as an initial enrollment (and the 
supplier as a new applicant), rather than as an address change of the existing supplier. 
 
D.  Form CMS-855A - Entry into PECOS 
 
If the new owner will or will not be accepting assignment as well as the assets and liabilities of 
the old owner, the contractor shall enter the CHOW information into the new enrollment record 
that shall be created for the CHOW buyer.  If the SOG Location approves the CHOW and sends 
the tie-in/approval notice to the contractor, the suppliers CCN will be maintained in the new 
owners enrollment record once the record is switched to an approved status. 
 
If the CHOW is for a Part B certified supplier, a new enrollment record must be created if a new 
TIN is created in the CHOW.  
 
E.  Form CMS-855A - Electronic Funds Transfer (EFT) Payments and CHOWs  
 
In a CHOW, the contractor shall continue to pay the old owner until it receives the tie-
in/approval notice from the SOG Location.  Hence, any application from the old or new owner to 
change the EFT account or special payment address to that of the new owner shall be rejected.  It 
is the responsibility of the old and new owners to work out any payment arrangements between 
themselves while the contractor and SOG Location are processing the CHOW.   It is advisable 
that the contractor notify the new owner of this while the application is being processed. 
 
In a CHOW, the existing provider agreement is automatically assigned to the buyer/transferee. If 
the buyer/transferee does not explicitly reject automatic assignment before the transfer date, the 
provider agreement is automatically assigned, along with the CCN, effective on the transfer date.  The assigned agreement is subject to all applicable statutes and regulations and to the terms and 
conditions under which it was originally issued. Among other things, this means that the 
contractor will continue to adjust payments to the provider to account for prior overpayments and 
underpayments, even if they relate to services provided before the sale/transfer. If the buyer 
rejects assignment of the provider agreement, the buyer must file an initial application to 
participate in the Medicare program. In this situation, Medicare will never pay the applicant for 
services the prospective provides before the date on which the provider qualifies for Medicare 
participation as an initial applicant.  
 
Depending on the terms of the sale, the buyer/transferee may obtain a new NPI or maintain the 
existing NPI. After CHOW processing is complete, the seller/transferor will no longer be 
allowed to bill for services (i.e., services furnished after CHOW processing is complete) and 
only the buyer is permitted to submit claims using the existing CCN. It is ultimately the 
responsibility of the old and new owners to work out between themselves any payment 
arrangements for claims for services furnished during the CHOW processing period. 
 
F.  Form CMS-855A CHOW: Pre-Approval Changes of Information  
 
1.  CHOW: Regarding Seller 
 
If  prior to the issuance of the tie-in notice  the contractor receives from the seller a Form 
CMS-855 request to change any of the providers enrollment data, the contractor shall reject the 
change request if the information in question involves changing the providers: 
 
i.  EFT or special payment address information to that of the buyer  
 
ii.  Practice location or base of operations to that of the buyer 
 
iii.  Ownership or managing control to that of the buyer  
 
iv.  Legal business name, TIN, or doing business as name to that of the buyer 
 
All other pre-tie-in notice Form CMS-855 change requests from the seller can be processed 
normally. 
 
2.  CHOW: Regarding Buyer 
 
If  prior to the issuance of the tie-in notice  the contractor receives from the buyer a Form 
CMS-855 request to change any of the providers existing enrollment information, the contractor 
shall reject the change request.  Until the tie-in notice is issued, the seller remains the owner of 
record.  Hence, the buyer has no standing to submit Form CMS-855 changes on behalf of the 
provider. 
 
10.6.22.1 - Non-Transitioned Certified Provider/Supplier Changes of 
Information 
(Rev. 11859; Issued: 02-16-23; Effective: 03-17-23; Implementation: 03-17-23) 
  (Until further notice, the contractor shall continue to follow these instructions for changes 
of information involving all certified provider and certified supplier types that have not 
transitioned.)    
 
All references to the SOG Location (formerly the RO) in this section 10.6.22.1 refer to the 
applicable CMS Regional Offices Survey & Operations Group (SOG) Location.  Also, and 
except as otherwise indicated, all references to provider include certified suppliers (e.g., 
ambulatory surgical centers, portable x-ray suppliers). 
 
Any instructions in this section 10.6.22.1 concerning the voluntary termination of a sub-unit, or 
other practice location that does not involve the termination of the entire enrollment and/or 
provider agreement take precedence over those in section 10.6.1.3.  For instance, suppose a 
certified providers Form CMS-855A enrollment has three practice locations and/or sub-units.  
The provider is voluntarily terminating one of them.  Here, the contractor shall use the 
instructions in section 10.6.22.1 (or, for transitioned providers/suppliers, section 10.6.1.2) when 
processing this transaction.  Now assume that a provider is of a type that must individually and 
separately enroll each location.  The provider has three separately enrolled locations with three 
separate provider agreements.  The provider seeks to terminate one of these locations.  Since this 
will involve the termination of an individual/entire enrollment and corresponding provider 
agreement, the instructions in section 10.6.1.3 apply. 
 
A.  Form CMS-855A - Referrals to State/SOG Location 
 
1.  Transactions 
 
The following is a list of Form CMS-855A transactions that generally require a recommendation 
and referral to the state/SOG Location: 
 
  Addition of hospice satellite 
 
  Change in type of Prospective Payment System (PPS)-exempt unit 
 
  Conversion of a hospital from one type to another (e.g., acute care to psychiatric) 
 
  Addition of hospital physician/practitioner group practice location when a survey of the new 
site may be required.  (If the contractor is uncertain as to whether the state will perform a 
survey, it may (1) contact the state for guidance or (2) make the referral based on the 
contractors experience with these types of changes and with the practices of the state in 
question.  Note that a survey often may be required if the location is shifting outside of the 
existing geographic area.) 
 
  Excluding hospital physician/practitioner group practice locations, change and/or relocation 
of a practice location regardless of whether a survey of the new site may be required.   
 
  RHC change of address 
 
  Stock transfer (except as stated below in subsection (A)(2) below)   
In these situations, the Provider Enrollment, Chain and Ownership System (PECOS) record 
should not be switched to approved until the contractor receives notice from the SOG Location 
that the latter has authorized the transaction.  However, if the contractor knows that the particular 
state/SOG Location in question typically does not review, approve, or deny this type of 
transaction, the contractor need not send the transaction to the state/SOG Location for approval 
and shall instead follow the instructions in section 10.6.22.1(B) below. 
 
2.  Stock Transfers  
 
If the transaction is a stock transfer, the contractor need not send the transaction to the state/SOG 
Location for approval (and shall instead follow the instructions in section 10.6.22.1(B) below) if 
the following three conditions are met:  
 
(i) The contractor is confident that the transaction is merely a transfer of stock and not a CHOW,  
 
(ii) The SOG Location in question (based on the contractors past experience with this SOG 
Location) does not treat stock transfers as potential CHOWs, and 
 
(iii) The contractor knows that the particular state/SOG Location in question does not review, 
approve, or deny this type of transaction. 
 
If any of these three conditions are not met, the contractor shall send the transaction to the 
state/SOG Location for approval. 
 
3.  Additional Instructions  
 
SOG Location approval for the transactions listed above in section 10.6.22.1(A)(1) may be 
furnished to the contractor via tie-in notice, letter, e-mail, fax, or even telephone; the contractor 
may accept any of these formats. 
 
If the SOG Location (after receiving the transaction from the contractor for review) notifies the 
contractor that it does not normally review/approve/deny such transactions, the contractor may 
finalize the transaction (e.g., switch the PECOS record to approved). 
 
B.  Form CMS-855A - Post-Approval SOG Location Contact Required 
 
Form CMS-855A changes that do not mandate a recommendation to the state/SOG Location but 
do require post-approval correspondence with the SOG Location include: 
 
  Deletions/voluntary terminations of practice locations or hospital subunits 
 
  Legal business name, tax identification number, or doing business as name changes that do 
not involve a CHOW 
 
  Except as described in section 10.6.22.1(A)(1), address changes that do not require a survey 
of the new location   
  The transactions (excluding stock transfers) described in section 10.6.22.1(A)(1) for which 
the contractor knows that the state/SOG Location does not issue approvals/denials 
 
  Stock transfers for which all three conditions mentioned in section 10.6.22.1(A)(2) are met 
 
  Voluntary terminations of PTANs (except as otherwise stated in this section 10.6.22.1 and in 
section 10.6.1.3 of this chapter)  
 
For these transactions, the contractor shall: (1) notify the provider via letter, fax, e-mail, or 
telephone that the change has been made, and (2) switch the PECOS record to approved.  The 
contractor shall also notify the state and SOG Location of the changed information (via any 
mechanism it chooses, including copying the state/SOG Location on the notification letter or e-
mail) no later than 10 calendar days after it has completed processing the transaction.  Such 
notice to the State/SOG Location shall specify the type of information that is changing. 
 
C.  Form CMS-855A - All Other Changes of Information 
 
For all Form CMS-855A change requests not identified in section 10.6.22.1(A) or (B), the 
contractor shall notify the provider via letter, fax, e-mail, or telephone that the change has been 
made and shall switch the PECOS record to approved.  The state and SOG Location need not 
be notified of the change.  
 
D.  Form CMS-855A Revalidations, Form CMS-855A Reactivations and Complete Form 
CMS-855A Applications 
 
In situations where the provider submits a: (1) Form CMS-855A reactivation, (2) Form CMS-
855A revalidation, or (3) full Form CMS-855A as part of a change of information (i.e., the 
provider has no enrollment record in PECOS), the contractor shall make a recommendation to 
the state/SOG Location and switch the PECOS record to approval recommended only if the 
application contains new/changed data falling within one of the categories in 10.6.22.1(A)(1).  
For instance, if a revalidation application reveals a new hospital psychiatric unit that was never 
reported to CMS via the Form CMS-855A, the contractor shall make a recommendation to the 
state/SOG Location and await the SOG Locations approval before switching the record to 
approved.   In this situation, the contractor should forward the application to the state with a 
note explaining that the only matter the state/SOG Location needs to consider is the new hospital 
unit. 
 
If the application contains new/changed data falling within one of the categories in section 
10.6.22.1(B), the contractor can switch the PECOS record to approved.  It shall also notify the 
state and SOG Location of the changed information (via any mechanism it chooses, including 
copying the state/SOG Location on the notification letter or e-mail) no later than 10 calendar 
days after it has completed processing the transaction.  
 
10.6.23  Special Instructions for Electronic Funds Transfer (EFT) Accounts 
and Special Payment Addresses  
(Rev. 11682; Issued: 11-04-2022; Effective: 12-05-2022; Implementation:12-05-2022)   
 (The instructions in this section 10.6.23 take precedence over all other contrary instructions in 
this chapter, including, but not limited to, the existing guidance in sections 10.3.1.1.4, 10.3.1.2.4, 
and 10.3.1.3.4.  The policies in this section will eventually be incorporated into the sections of 
this chapter that are applicable to the subject matter.) 
 
A.  Enrolled Providers/Suppliers 
 
1.  General Policy 
 
A provider/supplier may only have one EFT account and one special payment address (SPA) per 
enrollment.  As a general rule, multiple EFT accounts or SPAs within an existing enrollment will 
remain in effect only until the provider/supplier submits any update to its EFT information or 
SPA data, respectively, for any of these accounts or addresses.  At that time, the EFT account or 
SPA for which the provider/supplier submitted the update will become the lone EFT account or 
SPA (as applicable) for that enrollment.    
 
For purposes of this requirement: 
 
(i) The term enrollment means a single enrollment in a single state involving a single 
provider/supplier type.  The particular PTAN arrangement under the enrollment (e.g., a group 
practice has three practice locations under its Form CMS-855B enrollment, each with a separate 
PTAN) is irrelevant for purposes of this requirement; again, the requirement is based on the 
enrollment, not the PTAN.    
 
(ii) Any submitted change to any of the provider/suppliers EFT or SPA data for any EFT 
account or SPA within an enrollment --- even a change that the provider/supplier did not cause 
(e.g., a government-generated zip code change) and even if it is for only one of the enrollments 
EFT accounts or SPAs --- triggers the aforementioned requirement.  The materiality of the 
change does not matter.  However, the changed data must have actually been submitted via the 
appropriate CMS form to invoke the requirement; using the example in the previous sentence, 
this zip code change would not trigger the requirement unless and until the provider/supplier 
reports it via a CMS form.    
 
(iii) If the provider/supplier reports the changed EFT or SPA data as part of a revalidation, 
reactivation, or other enrollment transaction other than a change of information (COI), the 
requirement is invoked to the same extent as with a COI.    
 
(iv) The requirement applies only to the precise enrollment (e.g., Enrollment A) for which the 
change was submitted.  It is inapplicable to the provider/suppliers other enrollments 
(Enrollments B and C), even if B and C have: 
 
  Multiple EFT accounts or SPAs that match those for which the provider/supplier reported 
a change to its Enrollment A EFT or SPA data; and/or  
  The same LBN or TIN as Enrollment A.   
  (v) A change in EFT data does not invoke the need to consolidate the provider/suppliers SPAs 
if the provider/supplier has multiple SPAs; likewise, a change in SPA data does not require the 
consolidation of the provider/suppliers multiple EFT accounts.  (For purposes of this section 
10.6.23, the term consolidate simply means reducing the provider/suppliers multiple EFT 
accounts or SPAs to one.)  
 
(vi) Even if the multiple EFT accounts are with the same banking institution, the aforementioned 
consolidation requirement applies.   
 
(vii) Any EFT and/or SPA consolidation under this section 10.6.23 applies to all PTANs under 
the single enrollment. 
 
(viii) The consolidation requirement applies irrespective of whether the EFT or SPA change that 
the provider/supplier submitted is approved, denied, rejected, or returned. 
 
(ix) The term multiple EFT accounts or SPAs only applies to active EFT accounts/SPAs. 
 
(x) Except as otherwise noted, any consolidation described in this section 10.6.23 becomes 
effective on the date of the applicable approval, denial, rejection, or return letter (see subsection 
(A)(2)(i) below).   
 
Consider the following: 
 
EXAMPLE  Provider X is enrolled as a group practice and a HIT supplier (i.e., two separate 
enrollments) in State Y.  Currently: 
 
  The group practice enrollment has two EFT accounts (one with Smith Bank and one with 
Jones Bank) and two SPAs (1 James Street and 200 Johnson Street) 
  The HIT supplier enrollment has the same two EFT accounts and SPAs as the group 
practice 
 
Provider X submits a change to its Smith Bank account information for the group practice 
enrollment.  In this scenario: (1) the Smith Bank account becomes the lone EFT account for 
the group practice; (2) the group practices Jones Bank account becomes inactive in PECOS 
effective on the date of the notice to the provider/supplier that the originally submitted EFT 
or SPA change was approved, denied, etc. (see subsection (A)(2)(i) below); (3) the Smith 
Bank and Jones Bank accounts for the HIT supplier enrollment are unaffected; and (4) the 
SPAs for Provider Xs two enrollments are unaffected.  
 
2.  Operational Procedures 
 
If the contractor receives an EFT or SPA change and determines that the provider/supplier has 
multiple EFT accounts or SPAs (as applicable and consistent with the guidelines described in 
subsection (A) above) for that enrollment, the contractor shall follow the procedures described 
below.  (The example in subsection (A) will be used as a format.) 
  Step 1  The contractor shall process the EFT data change for the group practices Smith Bank 
account as normal. 
 
Step 2  Upon final completion of its processing of the change, the contractor shall: 
 
i.  Send the appropriate approval, denial, etc., letter to the provider/supplier consistent with the 
instructions in this chapter.  The contractor shall, however, add the following language to the 
letter: 
 
Under CMS policy, a Medicare provider or supplier may only have one [EFT account or 
special payment address, as applicable] per enrollment.  Consistent therewith, [Contractor 
name] has designated the [EFT account or special payment address, as applicable] for which 
you reported changed [EFT or special payment address] information as the sole [EFT 
account or special payment address] for this enrollment.  This designation is effective as of 
the date of this letter.  All payments previously sent to your other [EFT account(s) or special 
payment address(es)] under this enrollment will now be made to the sole designated [EFT 
account or special payment address] described above.  If you wish to change this sole 
designated [EFT account or special payment address], you must submit the applicable [Form 
CMS-588, Form CMS-855, or Form CMS-20134, as applicable] to do so. 
 
Note that the sole designation described above applies only to the enrollment for which you 
submitted the requested change to your [EFT or special payment address] data.  It is 
inapplicable to any other enrollments you have. 
 
The contractor may: (1) notwithstanding any other instruction to the contrary in section 10.7 et 
seq. of this chapter, alter the forgoing language to conform to the provider/suppliers particular 
factual situation (prior CMS approval is unnecessary); and (2) insert said language in any part of 
the letter it chooses.   
 
ii.  End-date the other EFT account(s) or SPA(s) (as applicable) effective the date of the letter 
described in subsection (A)(2)(i) above.  The contractor shall make all payments under the 
enrollment to the sole account/SPA beginning the day after the date of the letter.  
 
iii.  Apply the PTAN(s) associated with the deleted EFT account/SPA to the sole EFT 
account/SPA.   
 
iv.  Complete all other normal steps required under this chapter for finalizing the transaction in 
question.  
 
B.  Providers/Suppliers Initially Enrolling or Undergoing a CHOW Consistent with 
Principles of 42 CFR  489.18   
 
The aforementioned policy that a provider/supplier may only have one EFT account and one 
SPA per enrollment also applies to: (1) providers/suppliers submitting an initial enrollment 
application; and (2) new owners in a certified provider/supplier CHOW (i.e., a CHOW consistent 
with the principles of  489.18).  The contractor shall apply this policy to such applications.  If, 
therefore, the provider/supplier/new owner submits the application with more than one EFT 
account or SPA, the contractor shall develop for a single EFT account or SPA (as applicable)  consistent with the instructions in this chapter.  If the provider/supplier/new owner fails to 
comply within 30 days, the contractor shall reject the application pursuant to 42 CFR  
424.525(a)(1).   
 
10.7  Model Letters  
(Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
The contractor shall use the following letters when rejecting, returning, approving or denying an 
application, or when revoking an entitys Medicare billing privileges.  Any exceptions to this 
guidance shall be approved by the contractors CMS Provider Enrollment & Oversight Group 
Business Function Lead (PEOG BFL), unless specified otherwise.  The contractor shall 
document approval received by its PEOG BFL for QASP purposes.   
 
As stated in section 10.3, PECOS will automatically generate and send some of the letters 
described in this section 10.7 et seq.  If any modifications or additions to a certain PECOS-
generated letter are required pursuant to the instructions in this section 10.7 et seq. or elsewhere 
in this chapter, the contractor shall, of course, ensure that such edits are made before the letter is 
sent.  This includes situations where a particular party is typically copied on a letter but the 
circumstances of the transaction do not require the party to be copied. 
 
In the event of a conflict between the instructions in section 10.3 and section 10.7, et al, the 
instructions in section 10.3 take precedence.   
 
A.  Issuing Letters - Model Letter Guidance 
 
All letters sent by contractors to providers and suppliers shall contain and/or adhere to the 
formats/requirements addressed in sections 10.7(A) and (B).  Note, however, the following: 
 
(i) For certified provider/supplier types and transactions that have formally transitioned as 
described in section 10.7.5.1, the requirements (e.g., data elements) of the model letters in 
section 10.7.5.1 take precedence over any contrary instruction in section 10.7.  For example, if 
section 10.7 requires a data element that a specific letter in section 10.7.5.1 pertaining to the 
same enrollment transaction/situation does not, the section 10.7.5.1 letter requirements supersede 
the former.  Likewise, if section 10.7 requires the removal/addition of language that is/is not in 
the applicable section 10.7.5.1 letter, the latter controls. 
 
(ii) For certified provider/supplier types and transactions that have not transitioned (and except 
as otherwise stated in section 10.7 (e.g., subsection (A)(2)(n)), the contractor shall continue to 
follow the existing instructions in section 10.7 and utilize the letters in section 10.7.5.   
 
1.   General Guidance 
 
(a) The CMS logo (2012 version) displayed per previous CMS instructions. 
 
(b) The contractors logo shall be displayed however the contractor deems appropriate.  There 
are no restrictions on font, size, or location.  The only restriction is that the contractors logo 
must not conflict with the CMS logo.   
(c) Excluding items in the header or footer, all text shall be written in Times New Roman 12-
point font (with the exception of name and address information per USPS requirements). 
 
(d) All dates in letters, except otherwise specified, shall be in the following format: 
month/dd/YYYY (e.g., January 26, 2012). 
 
(e) Letters shall contain fill-in sections as well as static, or boilerplate sections.  The fill-in 
sections are delineated by words in brackets in italic font in the model letters. 
 
(f) The static sections shall be left as-is unless there is specific guidance for removing a section 
(e.g., removing a CAP section for certain denial and revocation reasons; removing state survey 
language for certain provider/supplier types that do not require a survey).  If there is no guidance 
for removing a static section, the contractor must obtain approval from its PEOG BFL to modify 
or remove such a section. 
 
2.   Approval Letters 
 
(a) Part A/B certified provider and supplier paper/web COI and revalidation approval 
recommended letters shall detail the recommended changes (e.g. practice location changed to 
123 Main Street, Baltimore MD 21244).  
 
(b) For COI and revalidation applications that do not require a tie-in or recommendation but 
require notification to the SOG Location as a cc, the contractor shall add the additional fields 
applicable to the letter (e.g., cc the state/SOG Location).  The contractor should itemize the 
changes if it is beneficial to the SOG Location.    
 
(c) Part A/B and DME provider and supplier paper/web COI and revalidation letters shall only 
list the section title (at the sub-section level) from the paper/web Form CMS-855 and Form 
CMS-20134 application (e.g., Correspondence Mailing Address, Final Adverse Legal Actions, 
Remittance Notices/Special Payments Mailing Address, etc.).   
 
(d) If, as part of a revalidation, the provider/supplier only partially revalidates (i.e., a provider 
has multiple PTANs, and one PTAN is revalidated with the others end-dated), the contractor 
shall notate the reassignments that were terminated due to non-response and the effective date of 
termination (i.e., the revalidation due date or the development due date). 
 
(e) If the provider is submitting a change as part of a voluntary termination application (e.g. 
special payment address, EFT, authorized official), the contractor shall enter the applicable fields 
into the Medicare Enrollment information table. 
 
(f) Approval letters may include a generic provider enrollment signature and contact information 
(e.g. customer service line).  However, all development letters shall include a provider 
enrollment analysts name and phone number for provider/supplier contacts. 
 
(g) Participation status shall only be included in initial and reactivation letters for Part B sole 
proprietors, Part B sole owners, any Part B organizations and DME suppliers.  Change of  information approval letters shall only include the participation status if it was changed as part of 
the application submission. 
 
(h) The contractor shall add lines to the enrollment information tables on any reactivation letter if 
the provider/supplier has reactivated following non-response to a revalidation and enrollment 
information was changed on the application.   
 
(i) The contractor shall enter an effective date on all change of information approval letters if a 
new PTAN is issued based on the changes (e.g., a new location is added to a new payment 
locality). 
 
(j) The contractor shall add appeal rights to all change of information and revalidation approval 
letters if a new PTAN is issued based on the changes (e.g., a new location is added to a new 
payment locality; a new reassignment is created). 
 
(k) If the provider/supplier is revalidating multiple reassignments to different groups, the 
contractor shall add additional lines to the grid to identify the separate groups and PTANs.  
 
(l) If the provider/supplier revalidates both reassignments and one or more sole proprietorship 
locations, the contractor shall indicate on the appropriate letter that the approval covers the 
reassignments and sole proprietorship locations.  
 
(m) In the Part B non-certified supplier letters, the contractor shall populate 42 CFR 424.205 
for MDPP suppliers or  424.516 for all other providers/suppliers with the following paragraph: 
Submit updates and changes to your enrollment information within the timeframes specified 
at [42 CFR  424.516 or 42 CFR 424.205].  For more information on the reporting 
requirements, go to Medicare Learning Network Article SE1617.  
 
(n) For all pre-transition and post-transition seller CHOWs (both HHA and non-HHA), the 
contractor shall use the M. Approval  Seller CHOW (Part A/B Certified Org) letter in section 
10.7.5.1 when voluntarily terminating the sellers enrollment in a 42 CFR  489.18 CHOW 
(which includes mergers, acquisitions, and consolidations).  The contractor shall use the effective 
date of the CHOW as the Effective Date of Enrollment Termination in the letter. 
 
(o) The contractor shall remove the following language when issuing the Approval  Voluntary 
Termination (Part B Non-Certified Org or Part B Sole Owner) letter in section 10.7.6(V) for a 
Part B non-certified supplier: Reassignments and any physician assistant employment 
arrangements are also deactivated, unless other active reassignments/employment arrangements 
exist on the enrollment. 
 
3.  Denial/Revocation Letters 
 
(a) The contractor shall populate the fill-in sections with the appropriate information, such as 
primary regulatory citation, specific denial and revocation reasons, names/addresses, etc. 
 
(b) The fill-in sections shall be indented 12 inch from the normal text of the letter. 
  (c) All specific or explanatory reasons shall appear in bold type and shall match the federal 
registry heading.  This applies to headings.  For example, if the revocation letter contains the 
following specific explanatory language, the heading should be in bold type and the explanation 
should be in normal type as shown in the excerpt below:  
 
42 CFR  424.535(a)(8)(i)  Abuse of Billing Privileges  
 
Data analysis conducted on claims billed by [Dr. Ambassador], for dates of service [Month XX, 
XXXX], to [Month XX, XXXX], revealed that [Dr. Ambassador] billed for services provided to 
[XX] Medicare beneficiaries who were deceased on the purported date of service.  
 
(d) There may be more than one primary reason listed. 
 
(e) This subsection (A)(3)(e) applies to certified provider and certified supplier denial or 
revocation letters that meet both of the following requirements: 
 
  The provider enrollment denial or revocation also requires the denial or termination of the 
corresponding provider or supplier agreement (e.g., Form CMS-1561, Form CMS-370, etc.) 
  The SOG Location is responsible for handling the reconsideration/appeal of the 
provider/supplier agreement denial or termination. 
 
If these requirements are met -- and notwithstanding any instruction to the contrary in this 
chapter -- the contractor shall insert the following language into the provider enrollment denial or 
revocation letter (preferably at the conclusion of the letters discussion/outline of appeal rights): 
 
Note that the provider enrollment appeal rights addressed in this letter are unrelated to any 
appeal rights concerning the [denial or termination, as applicable] of your [provider or supplier, 
as applicable] agreement.  The two processes are separate and distinct, and a successful appeal of 
your enrollment [denial or revocation, as applicable] does not automatically restore your 
[provider or supplier] agreement.  Any such restoration of the latter is handled by the Survey 
Operations Group Location and not by CMS Provider Enrollment & Oversight Group. 
 
4.  Voluntary Terminations 
 
If a provider/supplier (certified or non-certified) is voluntarily terminating their enrollment, the 
contractor shall use the applicable voluntary termination letter.     
 
5.  No PEOG Approval 
 
The following letter revisions do not require prior PEOG BFL approval.  (Notwithstanding the 
language in subsection 10.7(A)(i), this includes the letters in section 10.7.5.1 et seq.) 
 
(a) If the contractor cannot format the enrollment information table as provided in these model 
letters, the contractor may provide the information in a similar non-table format.  
  (b) Placing a reference n umber or numbers between the provider/supplier address and the 
salutation.  (For Internet-based PECOS applications, the contractor can include its document 
control number and the Web Tracking ID in this field.) 
 
(c) The contractor shall enter N/A or leave blank a data element in an enrollment information 
table if said field is inapplicable (e.g., doing business as (DBA), effective date for changes).  
 
(d) The contractor shall include the applicable PTAN and NPI for the application submission on 
the letter.  If multiple PTANs or NPIs apply, the contractor should: (1) enter multiple in the 
PTAN and NPI fields; (2) copy and add additional PTAN/NPI rows to the enrollment 
information tables; or (3) attach a list of any and all PTAN and NPI combinations that apply in 
the letter.  
(e) For individual revalidations in which multiple PTANs may be revalidating from multiple 
reassignments or individual associations, the contractor may also list the groups LBN and 
PTAN effective date in connection with the appropriate individual NPI-PTAN combinations. 
The contractor has flexibility in relaying these fields when multiplicities exist, ensuring they 
meet the templates reporting requirements. 
(f) Appropriate documents attached to specific letters as needed. 
 
(g) Placing language in any letter regarding self-service functions, such as the Provider Contact 
Center Interactive Voice Response (IVR) system and Electronic Data Interchange (EDI) 
enrollment process. 
 
B.  Sending Letters 
 
The contractor shall note the following: 
 
1.  Except as stated otherwise in this chapter (e.g., certain applications from already-transitioned 
certified provider/supplier types), the contractor shall issue approval letters within 5 business 
days of approving the application in PECOS.    
 
2.  For all applications other than the Form CMS-855S, the contractor shall send 
development/approval letters, etc., to the contact person if one is listed. Otherwise, the contractor 
may send the letter to the provider/supplier at the e-mail, mailing address, or fax provided in the 
correspondence address or special payments address sections.   
 
3.  The contractor may insert an attention field with the contacts name as part of the mailing 
address, but the letter should still be addressed to the provider/supplier.  As applicable, the 
contractor shall continue to send letters to the DMEPOS suppliers correspondence address until 
their automated process can be updated to include the contact person as a recipient of the letters. 
 
4.  If the provider/supplier submits two Form CMS-855Rs concurrently, two separate approval 
letters shall be issued (one for each group reassignments).   
 
5.  For initial, change of information, revalidation, and voluntary termination applications 
submitted by sole owners, the contractor should issue one approval letter.  However, the  Medicare enrollment information table shall distinctly list the individual and sole owner 
information.   
 
6.  If, as part of revalidation, a physician assistant is adding and terminating an employment 
relationship, one letter shall be issued (approving the revalidation). However, the termination and 
additional employment relationship shall be noted in the approval letter.   
 
7.  The contractor shall issue all denial and revocation letters via certified mail.   
 
8.  Notwithstanding any other instruction to the contrary in this chapter, the contractor shall copy 
via email the applicable accrediting organization (AO) (along with, as currently required, the 
state agency) on a recommendation for approval letter or final provider/supplier notification 
letter (e.g., final approval, denial, etc.) letter if: (1) the provider/supplier lists the AO on the Form 
CMS-855 or ADR application; (2) PEOG notifies the contractor of the AO's involvement; or (3) 
the contractor otherwise becomes aware of the provider/suppliers AO affiliation.   
 
10.7.1  Acknowledgement Letters  
(Rev. 11637; Issued: 10-07-22; Effective: 12-09-22; Implementation: 12-09-22) 
 
A.  Acknowledgement Letter Guidance 
 
Sending an acknowledgement letter is optional for enrollment applications. Acknowledgement 
letters are required for accepted CAP, Reconsideration Request. See sections 10.7.10, 10.7.11, 
and 10.7.13 of this chapter. 
 
B.  Model Acknowledgement Letter 
 
1.  Acknowledgement Example  Application Receipt 
 
[month] [day], [year] 
 
[Provider/Supplier Name] 
[Address] 
[City] ST [Zip] 
 
Reference ID: (Case #, Control Number, etc.) 
 
Dear [Provider/Supplier Name]:  
 
Your Medicare enrollment application(s) was received on [date] and [is/are] currently being 
reviewed. You will receive a letter within 30 calendar days if we need any additional 
information.  
 
Additional provider/supplier identification information: NPI, DBA Name, etc. 
  Please retain this letter in case you must submit additional information to support your 
application. If you have any questions, please contact our office at [phone number] between the 
hours of [x:00 AM/PM] and [x:00 AM/PM] 
 
Sincerely,  
 
 
[Name] 
[Title] 
[Company] 
 
10.7.2  Development Letters 
(Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 
 
A.  Development Letter Guidance  
 
In the following sentence: 
 
Please submit the requested revisions and/or supporting documentation preferably within [xx] 
calendar days of the postmarked date of this letter to the address listed below: 
 
The value in xx may be from 7 to 30. 
 
Note: Items such as checklists and documents may be attached to the letter. 
 
B. Model Development Letters 
 
Example 
 
[month] [day], [year] 
 
[Provider/Supplier Name] 
[Address] 
[City] ST [Zip] 
 
Reference # (PTAN #, Enrollment #, Case #, etc.) 
 
 
Dear [Provider/Supplier Name]:  
 
We have received your Medicare enrollment application(s). We may reject your application(s) if 
you do not furnish complete information within 30 calendar days from the postmarked date of 
this letter pursuant to 42 CFR 424.525.  In order to complete processing your application(s), 
please make the following revisions and/or supply the requested supporting documentation:  
 
[Specify revisions and/or supporting documentation needed] 
  [If the application was submitted via paper, use the following language: 
 
Please submit the requested revisions and/or supporting documentation within [xx] days of the 
postmarked date of this letter to the address listed below:  
 
[Name of MAC] 
[Address] 
[City], ST [Zip] 
 
Finally, please attach a copy of this letter with your revised application(s).] 
 
[If the application was submitted via PECOS, use the following language: 
 
Please submit the requested revisions and/or supporting documentation via PECOS within [xx] 
days of the date on this letter.].  
  
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM. 
 
Sincerely, 
 
 
[Name] 
[Title] 
[Company] 
 
10.7.3  Approval Letters  
(Rev. 10182; Issued: 06-15-2020; Effective: 09-16-2020; Implementation: 09-16-2020) 
 
Contractors shall use the formatting instructions found in Section 10.7 of this chapter to 
complete and issue approval letters for all provider and supplier types. 
 
10.7.4  DME Approval Letter Templates 
(Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
A. Approval  Change of Information (DME) 
 
[Month, Day, Year] 
 
[Provider/Supplier Name] 
[Address] 
[City, State, Zip] 
 
Reference # (Application Tracking Number) 
 
Dear [Provider/Supplier],    
[Insert Contractor] approved your Change of Information (COI) application.  
 
 
 
 
Medicare Enrollment Information 
 
Supplier Legal Business Name (LBN)   
Doing Business As (DBA)   
Physical Location Address    
Supplier Type   
National Provider Identifier (NPI)       
Provider Transaction Access Number (PTAN)   
PTAN Effective Date     
Changed Information  Include detailed changes or section titles, as 
applicable.  
 
 
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.  
 
Filing claims electronically? Contact the Common Electronic Data Exchange (CEDI) Contractor 
at www.ngscedi.com or (866) 311-9184.   
 
Subscribe to receive timely listserv messages regarding Medicare billing policies at: 
 
  Jurisdiction A  Noridian Healthcare Solutions, med.noridianmedicare.com/web/jadme  
  Jurisdiction B  CGS, www.cgsmedicare.com 
  Jurisdiction C  CGS, www.cgsmedicare.com 
  Jurisdiction D  Noridian Healthcare Solutions, med.noridianmedicare.com/web/jddme  
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified at 
42 CFR  424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617. 
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov. 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information]. 
 
Sincerely, 
 
[Name] 
[Title]  [Company] 
 
B.  Approval  Initial (DME) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)    
  
Dear [Provider/Supplier],   
 
[Insert Contractor] approved your initial enrollment application.   
 
Medicare Enrollment Information  
 
Supplier Legal Business Name (LBN)     
Doing Business As (DBA)     
Physical Address Location     
Supplier Type     
National Provider Identifier (NPI)     
Provider Transaction Access Number (PTAN)    
PTAN Effective Date     
Participation Status     
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
 
Filing claims electronically? Contact the Common Electronic Data Exchange (CEDI) Contractor 
at www.ngscedi.com or (866) 311-9184.    
 
Subscribe to receive timely listserv messages regarding Medicare billing policies at:  
  
  Jurisdiction A  Noridian Healthcare Solutions, med.noridianmedicare.com/web/jadme   
  Jurisdiction B  CGS, www.cgsmedicare.com  
  Jurisdiction C  CGS, www.cgsmedicare.com  
  Jurisdiction D  Noridian Healthcare Solutions, med.noridianmedicare.com/web/jddme   
  
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
  
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
  Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
 
  If the authorized representative is an attorney, the attorneys statement that he or she has 
o
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her 
behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
  (Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
 
[Name of MAC]      [Centers for Medicare & Medicaid Services]  
[Address]                    or  [Center for Program Integrity]   
[City], ST [Zip]      [Provider Enrollment & Oversight Group] 
            [ATTN: Division of Provider Enrollment Appeals] 
            [7500 Security Blvd.]  
            [Mailstop: AR-19-51]  
            [Baltimore, MD 21244-1850] 
 
Or emailed to: 
 
[Insert MAC email address]       or   [ProviderEnrollmentAppeals@cms.hhs.gov] 
   
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
C.  Approval  Reactivation (DME) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],   
 
[Insert Contractor] approved your reactivation application.   
 
Medicare Enrollment Information 
 
Supplier Legal Business Name (LBN)     
Doing Business As (DBA)     
Physical Address Location     
Supplier Type    
National Provider Identifier (NPI)     
Provider Transaction Access Number (PTAN)     
PTAN Effective Date     
Participation Status       Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
 
To file claims electronically, please contact the Common Electronic Data Exchange (CEDI) 
Contractor at www.ngscedi.com or (866) 311-9184.    
 
Subscribe to receive timely listserv messages regarding Medicare billing policies at:  
  
  Jurisdiction A  Noridian Healthcare Solutions, med.noridianmedicare.com/web/jadme   
  Jurisdiction B  CGS, www.cgsmedicare.com  
  Jurisdiction C  CGS, www.cgsmedicare.com  
  Jurisdiction D  Noridian Healthcare Solutions, med.noridianmedicare.com/web/jddme   
  
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov..  
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
 
  If the authorized representative is an attorney, the attorneys statement that he or she has 
o
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier  submitting a signed statement authorizing that individual from the group to act on his/her 
behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
(Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
 
[Name of MAC]      [Centers for Medicare & Medicaid Services]  
[Address]                    or  [Center for Program Integrity]   
[City], ST [Zip]      [Provider Enrollment & Oversight Group] 
            [ATTN: Division of Provider Enrollment Appeals] 
            [7500 Security Blvd.]  
            [Mailstop: AR-19-51]  
            [Baltimore, MD 21244-1850] 
 
Or emailed to: 
 
[Insert MAC email address]    or   [ProviderEnrollmentAppeals@cms.hhs.gov] 
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
D. Approval  Revalidation (DME) 
 
[Month, Day, Year]  
   [Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],   
 
[Insert Contractor] approved your revalidation application.  
 
Medicare Enrollment Information 
 
Supplier Legal Business Name (LBN)     
Doing Business As (DBA)     
Physical Address Location     
Supplier Type     
National Provider Identifier (NPI)     
Provider Transaction Access Number (PTAN)     
PTAN Effective Date     
Changed Information  Include detailed changes or section 
t itles, as applicable.  
 
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
 
To file claims electronically, please contact the Common Electronic Data Exchange (CEDI) 
Contractor at www.ngscedi.com or (866) 311-9184.    
 
Subscribe to receive timely listserv messages regarding Medicare billing policies at:  
  
  Jurisdiction A  Noridian Healthcare Solutions, med.noridianmedicare.com/web/jadme   
  Jurisdiction B  CGS, www.cgsmedicare.com  
  Jurisdiction C  CGS, www.cgsmedicare.com  
  Jurisdiction D  Noridian Healthcare Solutions, med.noridianmedicare.com/web/jddme   
  
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.  
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
  You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
 
  If the authorized representative is an attorney, the attorneys statement that he or she has 
o
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her 
behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
(Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
 
[Name of MAC]      [Centers for Medicare & Medicaid Services]  
[Address]                    or  [Center for Program Integrity]    [City], ST [Zip]      [Provider Enrollment & Oversight Group] 
            [ATTN: Division of Provider Enrollment Appeals] 
            [7500 Security Blvd.]  
            [Mailstop: AR-19-51]  
            [Baltimore, MD 21244-1850] 
 
Or emailed to: 
 
[Insert MAC email address]       or   [ProviderEnrollmentAppeals@cms.hhs.gov] 
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
E. Approval  Voluntary Termination (DME) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],   
 
[Insert Contractor] completed your application to voluntarily disenroll from the Medicare 
program.   
 
Medicare Enrollment Information 
 
Supplier Legal Business Name (LBN)     
Doing Business As (DBA)     
Physical Address Location     
Supplier Type     
National Provider Identifier (NPI)     
Provider Transaction Access Number (PTAN)     
Effective Date of Termination and Deactivation     
  
Medicare will not reimburse you for any claims with dates of service on or after your effective 
date of termination.   
  With this voluntary termination, your billing privileges are also being deactivated effective on 
the aforementioned date of the termination pursuant to 42 C.F.R.  424.540(a)(7). 
 
REBUTTAL RIGHTS: 
 
If you believe that this deactivation determination is not correct, you may rebut the deactivation 
as indicated in 42 C.F.R.  424.545(b). The rebuttal must be received by this office in writing 
within 15 calendar days of the date of this letter. The rebuttal must state the issues or findings of 
fact with which you disagree and the reasons for disagreement. You may submit additional 
information with the rebuttal that you believe may have a bearing on the decision. You must 
submit all information that you would like to be considered in conjunction with the rebuttal. This 
includes any application(s) to update your enrollment, if necessary. You may only submit one 
rebuttal in response to this deactivation of your Medicare enrollment.  
 
The rebuttal must be signed and dated by the individual provider/supplier, the authorized or 
delegated official, or a legal representative. Please be advised that authorized or delegated 
officials for groups cannot sign and submit a rebuttal on behalf of a reassigned provider/supplier 
without the provider/supplier submitting a signed statement authorizing that individual from the 
group to act on his/her/their behalf. 
 
If the provider/supplier wishes to appoint a legal representative that is not an attorney to sign the 
rebuttal, the provider/supplier must include with the rebuttal a written notice authorizing the 
legal representative to act on the provider/suppliers behalf. The notice should be signed by the 
provider/supplier.  
 
If the provider/supplier has an attorney sign the rebuttal, the rebuttal must include a statement 
from the attorney that he/she/they have the authority to represent the provider/supplier.  
 
If you wish to receive communication regarding your rebuttal via email, please include a valid 
email address in your rebuttal submission.  
 
The rebuttal should be sent to the following:  
[Contractor Rebuttal Receipt Address]  
[Contractor Rebuttal Receipt Email Address]  
[Contractor Rebuttal Receipt Fax Number]  
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM ET/CT/MT/PT] and [x:00 AM/PM ET/CT/MT/PT].  
 
Sincerely,  
 
 
 
[Name]  
[Title]  
[Company] 
  10.7.5  Part A/B Certified Provider and Supplier Approval Letter Templates 
(Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
A. Approval  Change of Information (Part A/B Certified Org, No Recommendation 
Required)  
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)    
  
Dear [Provider/Supplier],  
 
[Insert Contractor] has approved your Change of Information (COI) application.    
 
Medicare Enrollment Information 
 
Legal Business Name (LBN)     
Doing Business As (DBA)      
Provider/Supplier Type     
National Provider Identifier (NPI)     
Provider Transaction Access Number (PTAN)     
Changed Information  Include detailed changes or section 
t itles, as applicable.  
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.  
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.  
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]   [Company]  
 
[CC: SOG Location and State]  
 
B.  Approval - Post Tie-In Change of Information (Part A/B Certified) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor] has processed the Medicare Tie in Notice approving your change of 
information application.   
 
 
Medicare Enrollment Information 
 
Legal Business Name (LBN)     
Doing Business As (DBA)     
Provider/Supplier Type     
National Provider Identifier (NPI)     
Provider Transaction Access Number (PTAN)     
Changed Information  Include detailed changes or section 
titles, as applicable.  
 
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.  
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.  
 
Submit updates and changes to your enrollment information within the timeframes specified at 
42 CFR 424.516. For more information on the reporting requirements, go to Medicare Learning 
Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,    
[Name]  
[Title]  
[Company]  
 
C.  Approval - Post Tie-In Change of Ownership (Part A/B Certified) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor] has processed the Medicare Tie in Notice approving your change of 
ownership application.  
 
Medicare Enrollment Information 
 
Legal Business Name (LBN)    
Doing Business As (DBA)     
Provider/Supplier Type     
National Provider Identifier (NPI)     
Provider Transaction Access Number (PTAN)     
PTAN Effective Date     
CHOW Effective Date   
Medicare Year-End Cost Report Date (Part A CHOWs  
only) 
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.     
 
Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number].  
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.  
 
Submit updates and changes to your enrollment information within the timeframes specified at 
42 CFR 424.516. For more information on the reporting requirements, go to Medicare Learning 
Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.    
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
 
  If the authorized representative is an attorney, the attorneys statement that he or she has 
o
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her 
behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
Centers for Medicare & Medicaid Services  
Center for Program Integrity  Provider Enrollment & Oversight Group 
ATTN: Division of Provider Enrollment Appeals 
7500 Security Blvd. 
Mailstop: AR-19-51  
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
ProviderEnrollmentAppeals@cms.hhs.gov 
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
D.  Approval - Post Tie-In/Initial (Part A/B Certified)  
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor] has processed the Medicare Tie in Notice approving your initial 
enrollment application.   
 
Medicare Enrollment Information 
 
Legal Business Name (LBN)    
Doing Business As (DBA)     
Provider/Supplier Type     
National Provider Identifier (NPI)     
Provider Transaction Access Number (PTAN)     
PTAN Effective Date     
Medicare Year-End Cost Report Date (Part A   
only) 
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
  Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number].   
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified at 
42 CFR 424.516. For more information on the reporting requirements, go to Medicare Learning 
Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
 
  If the authorized representative is an attorney, the attorneys statement that he or she has 
o
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her 
behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for  reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
Centers for Medicare & Medicaid Services  
Center for Program Integrity 
Provider Enrollment & Oversight Group 
ATTN: Division of Provider Enrollment Appeals 
7500 Security Blvd.  
Mailstop: AR-19-51  
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
ProviderEnrollmentAppeals@cms.hhs.gov 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely, 
  
[Name]  
[Title]  
[Company] 
 
E. Approval Recommended - Initial (Part A/B Certified)  
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)  
 
Dear [Provider/Supplier],  
 
[Insert Contractor] assessed your initial Medicare enrollment application and forwarded it 
to the Centers for Medicare & Medicaid Services (CMS) [City] Regional Office for a final 
review.   
  A survey may be conducted by a State Survey Agency or deemed accrediting organization 
approved by CMS to ensure compliance. 
 
We will contact you when we have a decision.   
 
 
 
Medicare Enrollment Information 
 
Legal Business Name (LBN)     
Doing Business As (DBA)     
Provider/Supplier Type     
National Provider Identifier (NPI)     
Medicare Year-End Cost Report Date (Part A   
only) 
  
For questions concerning the application, contact [Insert State] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
[CC: SOG Location and State] 
 
 
F.  Approval Recommended  Change of Information or Change of Ownership (Part A/B 
Certified) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)  
 
Dear [Provider/Supplier],  
 
[Insert Contractor] assessed your [Change of Information or Change of Ownership] Medicare 
enrollment application and forwarded it to the Centers for Medicare & Medicaid Services (CMS) 
[City] Regional Office for a final review.   
 
A survey may be conducted by a State Survey Agency or deemed accrediting organization 
approved by CMS to ensure compliance.    
  We will contact you when we have a decision. 
 
Medicare Enrollment Information 
 
Legal Business Name (LBN)     
Doing Business As (DBA)     
Provider/Supplier Type     
National Provider Identifier (NPI)     
Provider Transaction Access Number (PTAN)   
Medicare Year-End Cost Report Date (Part A   
only) 
Recommended Changes (applicable to COI  Existing     
a nd CHOW, remove if doesnt apply)   New     
Effective Date   
  
For questions concerning the recommended application, contact [Insert State] at [contact 
information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
[CC: SOG Location and State]  
 
G.  Approval  Revalidation (Part A/B Certified Org)  
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor] has [approved your revalidation application/assessed your revalidation 
application and forwarded it to the Centers for Medicare & Medicaid Services (CMS) [City] 
Regional Office for a final review].   
 
Medicare Enrollment Information 
 
Legal Business Name (LBN)     
Doing Business As (DBA)     
Provider/Supplier Type      Provider/Supplier National Provider Identifier    
(NPI)  
Provider Transaction Access Number (PTAN)     
PTAN Effective Date     
Changed Information  Include detailed changes or section 
titles, as applicable.  
 
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
 
  If the authorized representative is an attorney, the attorneys statement that he or she has 
o
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her 
behalf.   
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
Centers for Medicare & Medicaid Services  
Center for Program Integrity 
Provider Enrollment & Oversight Group 
ATTN: Division of Provider Enrollment Appeals 
7500 Security Blvd  
Mailstop: AR-19-51  
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
ProviderEnrollmentAppeals@cms.hhs.gov 
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
H. Approval  Voluntary Termination (Part A/B Certified Org)  
 
[Month, Day, Year]  
   
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
  
Reference # (Application Tracking Number)       
Dear [Provider/Supplier],  
 
[Insert Contractor] completed your application to voluntarily disenroll from the Medicare 
program.   
 
Medicare Enrollment Information 
 
Legal Business Name (LBN)     
Doing Business As (DBA)     
Provider/Supplier Type     
National Provider Identifier (NPI)     
Provider Transaction Access Number (PTAN)     
Effective Date of Termination and    
Deactivation  
  
Medicare will not reimburse you for any claims with dates of service on or after your effective 
date of termination.  With this voluntary termination, your billing privileges are also being 
deactivated effective on the aforementioned date of the termination pursuant to 42 C.F.R.  
424.540(a)(7). 
 
REBUTTAL RIGHTS: 
 
If you believe that this deactivation determination is not correct, you may rebut the deactivation 
as indicated in 42 C.F.R.  424.545(b). The rebuttal must be received by this office in writing 
within 15 calendar days of the date of this letter. The rebuttal must state the issues or findings of 
fact with which you disagree and the reasons for disagreement. You may submit additional 
information with the rebuttal that you believe may have a bearing on the decision. You must 
submit all information that you would like to be considered in conjunction with the rebuttal. This 
includes any application(s) to update your enrollment, if necessary. You may only submit one 
rebuttal in response to this deactivation of your Medicare enrollment.  
 
The rebuttal must be signed and dated by the individual provider/supplier, the authorized or 
delegated official, or a legal representative. Please be advised that authorized or delegated 
officials for groups cannot sign and submit a rebuttal on behalf of a reassigned provider/supplier 
without the provider/supplier submitting a signed statement authorizing that individual from the 
group to act on his/her/their behalf. 
 
If the provider/supplier wishes to appoint a legal representative that is not an attorney to sign the 
rebuttal, the provider/supplier must include with the rebuttal a written notice authorizing the 
legal representative to act on the provider/suppliers behalf. The notice should be signed by the 
provider/supplier.  
 
If the provider/supplier has an attorney sign the rebuttal, the rebuttal must include a statement 
from the attorney that he/she/they have the authority to represent the provider/supplier.  
  If you wish to receive communication regarding your rebuttal via email, please include a valid 
email address in your rebuttal submission.  
 
The rebuttal should be sent to the following:  
[Contractor Rebuttal Receipt Address]  
[Contractor Rebuttal Receipt Email Address]  
[Contractor Rebuttal Receipt Fax Number]  
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM ET/CT/MT/PT] and [x:00 AM/PM ET/CT/MT/PT].  
 
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
[CC: SOG Location and State for Certified Providers/Suppliers]  
 
I. Approval  Reactivation (Part A/B Certified Org) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],   
 
[Insert Contractor] approved your reactivation enrollment application.   
 
Medicare Enrollment Information 
 
Legal Business Name (LBN)     
Provider/Supplier Type     
National Provider Identifier (NPI)     
Provider Transaction Access Number (PTAN)     
PTAN Effective Date     
Participation Status     
  
Include if applicable: [While your PTAN(s) and effective date(s) remain the same, you will have 
a gap in billing privileges from [deactivation date] through [reactivation date] for failing to fully 
revalidate during a previous revalidation cycle. You will not be reimbursed for services provided  to Medicare beneficiaries during this time period since you were not in compliance with 
Medicare requirements.]  
 
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
 
Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number].   
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
 
  If the authorized representative is an attorney, the attorneys statement that he or she has 
o
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her 
behalf. 
 
Providers and suppliers may:   
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
Centers for Medicare & Medicaid Services  
Center for Program Integrity 
Provider Enrollment & Oversight Group 
ATTN: Division of Provider Enrollment Appeals 
7500 Security Blvd.  
Mailstop: AR-19-51  
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
ProviderEnrollmentAppeals@cms.hhs.gov 
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
10.7.5.1  Part A/B Certified Provider and Supplier Letter Templates  Post-
Transition 
(Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
The model letters in this section 10.7.5.1 pertain to certain enrollment transactions involving 
certified providers and certified suppliers.  Except as otherwise stated, the contractor shall begin 
utilizing these letters (instead of those in section 10.7.5) upon completion of the transition of the 
applicable CMS Survey & Operations Group (SOG) function to the contractor and the CMS 
Provider Enrollment & Oversight Group (PEOG).  In other words, once a provider specialty, 
provider agreement, or provider enrollment transaction type (for example, voluntary 
terminations) has been transitioned, the contractor shall commence using the section 10.7.5.1  letter(s) pertaining to said transaction.  CMS will notify contractors once a particular transition 
has occurred.  
 
For certified provider/supplier transactions (and transaction outcomes) not specifically addressed 
in this section 10.7.5.1, the contractor shall continue to use the existing model letters in section 
10.7 et seq. (even after the aforementioned transition).    
 
In addition: 
 
(i) Most of the documents in this section 10.7.5.1 identify parties that must receive a copy of the 
letter in question.  If an inconsistency exists between said copied parties and those listed 
elsewhere in this chapter concerning a particular letter, the parties identified in this section 
10.7.5.1 take precedence.  To illustrate, suppose another section of this chapter requires X, Y, 
and Z to be copied on a certain letter while section 10.7.5.1 only requires X to be copied.  The 
contractor in this situation need only copy X.    
 
(ii) The contractor need only copy an accrediting organization (AO) on a particular letter if the 
provider/supplier has an AO for the identified provider/supplier specialty.  The contractor can 
typically ascertain this by checking PECOS (for currently enrolled providers/suppliers) or 
reviewing the application (for initial enrollments) to see if an AO is disclosed.  Also, PEOG will 
often identify an AO (if one exists) in cases where it must review the transaction before notifying 
the contractor of its final approval (e.g., CHOWs, certain changes of information, voluntary 
termination).   
 
(iii) See section 10.7.5.1(P) below for the applicable e-mail addresses of the SOG Locations.  
The contractor shall insert the relevant e-mail address into any letter in section 10.7.5.1 that 
addresses the provider/suppliers right to a reconsideration of a provider agreement 
determination.   
 
(iv) Any data element boxes that the contractor cannot complete because the information is 
unavailable or inapplicable (e.g., CMS Certification Number (CCN) in certain instances) can be: 
(1) left blank; (2) denoted with N/A, Not applicable, or any similar term; or (3) removed 
altogether. 
 
(v) The Provider Transaction Access Number (PTAN) box should contain the CCN for all 
provider/supplier types other than ASCs and PXRSs; the PTAN for the latter two supplier types 
will be that which the contractor assigns or has assigned.   
 
(vi) The Primary Practice Location Address box shall include the suite number if one was/is 
listed on the application. 
 
(vii) For the Denial letter in section 15.7.5.1(H), the contractor shall indicate (in any manner it 
chooses) whether the denial pertains to the buyers or the sellers application if a prospective 
CHOW was involved. 
  (viii) In cases where provider/supplier data has changed and the contractor must list detailed 
information or application section titles (as applicable), the contractor has the discretion to list 
either (i.e., the info or the section titles).  
 
A. Approval  Change of Information (Part A/B Certified Org; No Recommendation to 
State Was Required)  
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)    
  
Dear [Provider/Supplier],  
 
[Insert Contractor name [and Contractor number]] has approved your Change of Information 
(COI) application.    
 
Medicare Enrollment Information 
Legal Business Name (LBN)   
Doing Business As Name    
Primary Practice Location Address   
Provider/Supplier Type    
National Provider Identifier (NPI)     
Provider Transaction Access Number    
(PTAN)  
Changed Information  Include detailed changes or application 
section titles, as applicable.  
 
                       Provider/Supplier Agreement-Specific Information 
CMS Certification Number (CCN)    
CCN Effective Date   
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.  
 
Enroll, make changes, or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.  
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR  424.516.  For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations, at [insert contractors web address] or https://www.cms.gov.    
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
CC: State Agency [& Accrediting Organization (AO), if applicable]  
 
B.  Approval - State Agency Approved Change of Information (Part A/B Certified; 
Recommendation to State Was Required) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor name [and Contractor number]] has received a response from the Medicare 
State Agency. Your change of information application is now approved.   
 
Medicare Enrollment Information 
   Legal Business Name (LBN)    
Doing Business As Name    
Primary Practice Location Address    
Provider/Supplier Type    
National Provider Identifier (NPI)     
Provider Transaction Access Number     
(PTAN)  
Changed Information  Include detailed changes or application 
section titles, as applicable 
 
Provider/Supplier Agreement Specific Information 
CMS Certification Number (CCN)    
CCN Effective Date   
 
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.  
 
Enroll, make changes, or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.    
Submit updates and changes to your enrollment information within the timeframes specified at 
42 CFR  424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
CC: State Agency [& AO, if applicable]  
 
C.  Approval - State Agency Approved Change of Ownership (Part A/B Certified 
Excluding FQHCs) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor name [and Contractor number]] has received a response from the State 
Agency. Your change of ownership application is now approved. The corresponding executed 
[insert provider/supplier agreement type] is enclosed/attached.  Your enrollment and 
[provider/supplier agreement-specific] information is outlined below: 
 
Medicare Enrollment Information 
Legal Business Name (LBN)    
Doing Business As Name    
Primary Practice Location Address    
Provider/Supplier Type    
National Provider Identifier (NPI)     
Provider Transaction Access Number    
(PTAN)  
 
Provider/Supplier Agreement Specific Information 
CMS Certification Number (CCN)    
CCN Effective Date (use effective date     of sellers CCN) 
CHOW Effective Date   
 
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.     
 
Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number].  
 
Enroll, make changes, or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.  
 
Submit updates and changes to your enrollment information within the timeframes specified at 
42 CFR  424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations, at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or she has 
o
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her 
behalf. 
 
Providers and suppliers may:   
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 CFR Part 
498. 
 
The reconsideration request should be sent to:  
 
Centers for Medicare & Medicaid Services  
Center for Program Integrity 
Provider Enrollment & Oversight Group 
ATTN: Division of Provider Enrollment Appeals  
7500 Security Blvd. 
Mailstop: AR-19-51  
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
ProviderEnrollmentAppeals@cms.hhs.gov 
 
And  
 
If you are also requesting a reconsideration of the provider/supplier agreement determination, 
you must submit a separate Reconsideration Request.  Your requests must be e-mailed to: 
[Insert: Name and e-mail address of CMS Location Office] 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
CC:  State Agency [and AO, if applicable] 
 
Attachments: [Include any attachments that the contractor must send to the provider/supplier, the 
state agency, and/or the AO per the instructions in this chapter 10.]    
  D.  Approval - State Agency Approved Initial (Part A/B Certified)  
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor name [and Contractor number]] received a response from the Medicare State 
Agency.  Your initial enrollment application and [provider/supplier agreement] is 
approved.  Your executed [insert provider/supplier agreement name] is enclosed/attached.  The 
effective date is the date you met all federal requirements.  
 
Medicare Enrollment and Provider/Supplier Specific Participation Agreement Information 
 
Medicare Enrollment Information 
Legal Business Name (LBN)    
Doing Business As Name    
Primary Practice Location Address    
Provider/Supplier Type    
National Provider Identifier (NPI)     
Provider Transaction Access Number    
(PTAN)  
Enrollment Effective Date   
 
Provider/Supplier Agreement Specific Information 
 CMS Certification Number (CCN)    
 CCN Effective Date   
Medicare Year-End Cost Report Date    
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
 
Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number].   
 
Enroll, make changes, or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified at 
42 CFR  424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
  Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations, at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
 
  If the authorized representative is an attorney, the attorneys statement that he or she has 
o
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her 
behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 CFR Part 
498. 
 
The reconsideration request should be sent to:  
  Centers for Medicare & Medicaid Services  
Center for Program Integrity 
Provider Enrollment & Oversight Group 
ATTN: Division of Provider Enrollment Appeals 
7500 Security Blvd.  
Mailstop: AR-19-51  
Baltimore, MD 21244-1850 
 
Or emailed to: ProviderEnrollmentAppeals@cms.hhs.gov 
 
And  
 
If you are also requesting a provider/supplier agreement reconsideration, you must submit a 
separate Reconsideration Request.  Your requests must be e-mailed to:    
 
[Insert: Name and e-mail address of CMS Location Office] 
 
Your e-mail must include the following in the subject line: Subject:  Medicare 
Provider/Supplier Agreement Reconsideration Request 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely, 
  
[Name]  
[Title]  
[Company] 
 
CC:  State Agency [and AO, if applicable] 
 
Attachments: [Include any attachments that the contractor must send to the provider/supplier, the 
state agency, and/or the AO per the instructions in this chapter 10.]    
 
E.  Approval Recommended - Initial (Part A/B Certified)  
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)  
 
Dear [Provider/Supplier],  
 
[Insert Contractor name [and Contractor number]] assessed your initial Medicare enrollment 
application and your request for participation in the Medicare program as a [insert 
provider/supplier type] provider/supplier. A recommendation for approval has been forwarded to  the [enter name of State Agency], which will review this application for further compliance. 
A survey may be conducted by a State Survey Agency or deemed accrediting organization 
approved by CMS.  
 
We will contact you when we have a decision.   
 
Medicare Enrollment Information 
Legal Business Name (LBN)    
Doing Business As Name    
Primary Practice Location Address    
Provider/Supplier Type    
National Provider Identifier (NPI)     
Medicare Year-End Cost Report Date   Date that the provider/supplier requested    
(delete if not applicable) 
 
For questions concerning the application, contact [Insert State] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
CC:  State Agency [and AO, if applicable] 
 
F.  Approval Recommended  Change of Information, Change of Ownership, Revalidation, 
or Reactivation Containing Changed New/Changed Data that the State Must Review (if 
applicable) (Part A/B Certified)  
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)  
 
Dear [Provider/Supplier],  
 
[Insert Contractor name [and Contractor number]] assessed your [change of information, change 
of ownership, revalidation, or reactivation] Medicare enrollment application.  A recommendation 
of approval has been sent to [name of State Agency], which will conduct a review for further 
compliance.  
 
A survey may be conducted by a State Survey Agency or deemed accrediting organization 
approved by CMS to ensure compliance.    
  We will contact you when we have a decision. 
    
Medicare Enrollment Information 
Legal Business Name (LBN)     
Doing Business As Name      
Primary Practice Location Address    
Provider/Supplier Type    
National Provider Identifier (NPI)     
Provider Transaction Access Number (PTAN)   
 
Provider/Supplier Agreement Information 
CMS Certification Number (CCN)   
Requested Changes (applicable to COI, CHOW, or  Existing    Seller 
Revalidation; remove if inapplicable)   New    Buyer 
  Effective Date    
 
For questions concerning the recommended application, contact [Insert State Agency name] at 
[contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
CC: State Agency [and AO, if applicable] 
 
G.  Approval Revalidation (Part A/B Certified Org)  
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor name [and add Contractor number]] has approved your revalidation 
application [include if the application was sent to the state: and forwarded it to the State 
Agency.  The State Agency review has also been completed]. Your Medicare enrollment 
information is provided below.   
 
Medicare Enrollment Information 
  Legal Business Name (LBN)     
Doing Business As Name      
Primary Practice Location Address    
Provider/Supplier Type    
National Provider Identifier (NPI)     
Provider Transaction Access Number    
(PTAN)  
PTAN Effective Date     
Changed Information  Include detailed changes or application 
section titles, as applicable. 
  
Provider/Supplier Agreement Information 
CMS Certification Number (CCN)   
Requested Changes (applicable to COI, CHOW, or  Existing    Seller 
Revalidation; remove if inapplicable)   New    Buyer 
  Effective Date    
 
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR  424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations, at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
    If the authorized representative is an attorney, the attorneys statement that he or she has 
o
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her 
behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 CFR Part 
498. 
 
The reconsideration request should be sent to:  
 
Centers for Medicare & Medicaid Services  
Center for Program Integrity 
Provider Enrollment & Oversight Group 
ATTN: Division of Provider Enrollment Appeals 
7500 Security Blvd  
Mailstop: AR-19-51  
Baltimore, MD 21244-1850 
 
Or emailed to:  
 
ProviderEnrollmentAppeals@cms.hhs.gov 
 
And  
 
If you are also requesting a provider/supplier agreement reconsideration, you must submit a 
separate Reconsideration Request.  Your requests must be e-mailed to:    
 
[Insert: Name and e-mail address of CMS Location Office] 
  Your e-mail must include the following in the subject line: Subject:  Medicare 
Provider/Supplier Agreement Reconsideration Request 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
CC: State Agency [and AO, if applicable] 
 
H.  Denial Letter  Post-1539 (Or Other Similar Notice) Received from State Agency for 
the following application typesInitials, COIs, CHOWs, revalidations, and reactivations  
(This letter only applies in cases where: 
 
(1) A recommendation to the state was required per the instructions in this chapter (e.g., the 
particular revalidation application contained information/changes requiring state review), and  
(2) The state sends notification to the contractor (e.g., via the 1539 or other notice) that the 
application should be denied and/or, if applicable, the provider/supplier agreement should be 
terminated.   
 
As explained in this chapter, certain changes of information and revalidation applications can 
result in an enrollment revocation and provider agreement termination, though most do not.  
Accordingly, the contractor shall insert the applicable review result language (e.g., see bracketed 
options below) in the first paragraph of the letter.) 
 
[Month, Day, Year] 
[Provider/Supplier Name]  
[Address] 
[City, State, Zip] 
 
Reference # (Application Tracking Number)  
 
Dear [Provider/Supplier], 
 
[The [insert name of State Agency] completed its evaluation of your [initial application] or 
[change of information] or [change of ownership] or [revalidation] or [reactivation].  [Insert the 
following language based on the situation involved and the specific result of the states review: 
 
[INITIAL ENROLLMENT: Your participation in the Medicare Program and your enrollment in 
the Medicare Program is [denied] for the following reasons]: 
 
[NO REVOCATION AND/OR PROVIDER AGREEMENT TERMINATION INVOLVED: 
Your application for [insert] is denied for the following reasons]: 
  [REVOCATION AND/OR PROVIDER AGREEMENT TERMINATION RESULTING FROM 
THE APPLICATION SUBMISSION.  As a result of the states review, your provider/supplier 
agreement for participation in the Medicare program is terminated and your enrollment in the 
Medicare program is revoked for the following reason(s]: 
 
[INSERT DENIAL OR TERMINATION REASON GIVEN BY THE STATE AGENCY] 
 
Information about your provider/supplier agreement and your Medicare enrollment are outlined 
in the text box below.   
 
 
Medicare Administrative Contractor Name &  
 
Contractor Number  
 
   
 
Medicare Enrollment Determination 
 
Status  DENIED [OR REVOKED] 
 
Legal Business Name (LBN)   
 
Doing Business As Name    
 
  Primary Practice Location Address      
  National Provider Identifier (NPI)   
  Provider Transaction Access Number   
(PTAN) 
 
     
  Provider/Supplier Agreement Determination 
  Provider/Supplier Agreement   DENIED [OR TERMINATED] 
  CMS Certification Number (CCN)          
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below. 
  State the issues or findings of fact with which you disagree and the reasons for disagreement. 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the  appointment of its representative with the submission of the reconsideration 
request.   
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
RECONSIDERATIONS REQUESTMAILING ADDRESSES: 
 
Requests for Reconsideration: Medicare Provider Enrollment:  The reconsideration request 
regarding your Medicare enrollment may be submitted electronically via e-mail to:  
ProviderEnrollmentAppeals@cms.hhs.gov or addressed as follows:   
 
Centers for Medicare & Medicaid Services 
Center for Program Integrity 
Provider Enrollment & Oversight Group  
ATTN: Division of Provider Enrollment Appeals  
7500 Security Blvd. 
Mailstop: AR-19-51  
Baltimore, MD 21244-1850 
 
And  
 
Requests for Reconsideration: Medicare Provider/Supplier Agreement:  For reconsideration 
of the Provider/Supplier Agreement determination, you must submit a separate Reconsideration 
Request.  Your requests must be e-mailed to:  
 
[Insert: Name and e-mail address of CMS Location Office] 
   
Your e-mail must include the following in the subject line: Subject:  Medicare 
Provider/Supplier Agreement Reconsideration Request  
  [If a failed survey was involved, the contractor shall include the following language here: Note 
that any survey deficiencies may only be addressed as part of the provider/supplier agreement 
reconsideration process.] 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information]. 
 
 
Sincerely, 
 
[Name]  
[Title]  
[Company] 
   
 
CC: State Agency [and AO, if applicable] 
 
I. Approval  Voluntary Termination (Part A/B Certified Org)  
 
[Month, Day, Year]  
   
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor name [and Contractor number]] has received notification from the State 
Agency that you are voluntarily terminating your provider/supplier agreement or [Insert 
Contractor name [and Contractor number]] has completed processing your application [or letter] 
to voluntarily disenroll from the Medicare program. Therefore, your provider agreement has 
been terminated and your enrollment in the Medicare program has been voluntarily terminated 
effective on the dates shown below.   
 
Medicare Enrollment and Provider Agreement Information 
 
Medicare Enrollment Termination and Deactivation of Billing Privileges 
Legal Business Name (LBN)     
Doing Business As Name      
Primary Practice Location Address    
Provider/Supplier Type    
National Provider Identifier (NPI)     
Provider Transaction Access Number    
(PTAN)  
Effective Date of Enrollment    
Termination and Deactivation    
Provider/Supplier Agreement Termination 
CMS Certification Number (CCN)   
Effective Date of CCN Termination   
Reason for Termination   
  
In accordance with 42 CFR  489.52, Medicare will not reimburse you for any claims with dates 
of service on or after your effective date of termination.  With this termination, your billing 
privileges are also being deactivated effective on the aforementioned date of the termination 
pursuant to 42 C.F.R.  424.540(a)(7). 
 
REBUTTAL RIGHTS: 
 
If you believe that this deactivation determination is not correct, you may rebut the deactivation 
as indicated in 42 C.F.R.  424.545(b). The rebuttal must be received by this office in writing 
within 15 calendar days of the date of this letter. The rebuttal must state the issues or findings of 
fact with which you disagree and the reasons for disagreement. You may submit additional 
information with the rebuttal that you believe may have a bearing on the decision. You must 
submit all information that you would like to be considered in conjunction with the rebuttal. This 
includes any application(s) to update your enrollment, if necessary. You may only submit one 
rebuttal in response to this deactivation of your Medicare enrollment.  
 
The rebuttal must be signed and dated by the individual provider/supplier, the authorized or 
delegated official, or a legal representative. Please be advised that authorized or delegated 
officials for groups cannot sign and submit a rebuttal on behalf of a reassigned provider/supplier 
without the provider/supplier submitting a signed statement authorizing that individual from the 
group to act on his/her/their behalf. 
 
If the provider/supplier wishes to appoint a legal representative that is not an attorney to sign the 
rebuttal, the provider/supplier must include with the rebuttal a written notice authorizing the 
legal representative to act on the provider/suppliers behalf. The notice should be signed by the 
provider/supplier.  
 
If the provider/supplier has an attorney sign the rebuttal, the rebuttal must include a statement 
from the attorney that he/she/they have the authority to represent the provider/supplier.  
 
If you wish to receive communication regarding your rebuttal via email, please include a valid 
email address in your rebuttal submission.  
 
The rebuttal should be sent to the following:  
[Contractor Rebuttal Receipt Address]  
[Contractor Rebuttal Receipt Email Address]  
[Contractor Rebuttal Receipt Fax Number]  
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM ET/CT/MT/PT] and [x:00 AM/PM ET/CT/MT/PT].  
   
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
CC: State Agency [and AO, if applicable] 
 
J. Approval  Reactivation (Part A/B Certified Org) 
 
(This letter should be used for reactivation approvals regardless of whether the application was 
referred to the state agency for review.)   
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],   
 
[Insert Contractor name [and add Contractor number]] has approved your reactivation enrollment 
application.   
 
Medicare Enrollment Information 
Legal Business Name (LBN)     
Doing Business As Name   
Primary Practice Location Address    
Provider/Supplier Type    
National Provider Identifier (NPI)     
Provider Transaction Access Number    
(PTAN)  
PTAN Effective Date     
  
Provider/Supplier Agreement Specific Information 
CMS Certification Number (CCN)    
 CCN Effective Date   
 
Include if applicable: [While your PTAN(s) and effective date(s) remain the same, you will have 
a gap in billing privileges from [deactivation date] through [reactivation date] for failing to fully 
revalidate during a previous revalidation cycle. You will not be reimbursed for services provided 
to Medicare beneficiaries during this time period since you were not in compliance with 
Medicare requirements.]  
  Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
 
Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number].   
 
Enroll, make changes, or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR  424.516.  For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations, at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
 
  If the authorized representative is an attorney, the attorneys statement that he or she has 
o
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her 
behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer  to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 CFR Part 
498. 
 
The reconsideration request should be sent to:  
 
Centers for Medicare & Medicaid Services  
Center for Program Integrity 
Provider Enrollment & Oversight Group 
ATTN: Division of Provider Enrollment Appeals 
7500 Security Blvd.  
Mailstop: AR-19-51  
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
ProviderEnrollmentAppeals@cms.hhs.gov 
 
And 
 
Requests for Reconsideration: Medicare Provider/Supplier Agreement:  For reconsideration 
of the Provider/Supplier Agreement determination, you must submit a separate Reconsideration 
Request.  Your requests must be e-mailed to:  
 
[Insert: Name and e-mail address of CMS Location Office] 
   
Your e-mail must include the following in the subject line: Subject:  Medicare 
Provider/Supplier Agreement Reconsideration Request 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
(Note:  No CC: to State Agency/AO required. Deactivations do not impact certified provider 
CCN participation status.) 
  K.   Voluntary Termination: Failure to Respond to Request for Information 
 
Month, Day, Year 
 
 
PROVIDER/SUPPLIER NAME 
ADDRESS 
CITY, STATE, ZIP 
 
 
Reference # Application ID 
 
Dear Provider Name (LBN), 
 
[Insert Contractor name [and Contractor number]] has received notification from the State 
Agency that you are no longer operational.  We have not received a response to the request sent 
on Month DD, YYYY to update your enrollment information.  Therefore, we have disenrolled 
you from the Medicare program.  Your [provider/supplier agreement] has also been terminated.   
 
Medicare Enrollment and Provider Agreement Information 
 
Medicare Enrollment Termination and Deactivation of Billing Privileges 
Information 
Legal Business Name (LBN)     
Doing Business As Name      
Primary Practice Location Address    
Provider/Supplier Type/Specialty     
National Provider Identifier (NPI)     
Provider Transaction Access Number    
(PTAN)  
Effective Date of Enrollment    
Deactivation 
 
Provider/Supplier Agreement Termination Information 
CMS Certification Number (CCN)   
Effective Date of CCN Termination   
 
In accordance with 42 CFR  489.52, Medicare will not reimburse you for any claims with dates 
of service on or after your effective date of termination.  With this termination, your billing 
privileges are also being deactivated effective on the aforementioned date of the termination 
pursuant to 42 C.F.R.  424.540(a)(7). 
 
 
REBUTTAL RIGHTS: 
 
If you believe that this deactivation determination is not correct, you may rebut the deactivation 
as indicated in 42 C.F.R.  424.545(b). The rebuttal must be received by this office in writing  within 15 calendar days of the date of this letter. The rebuttal must state the issues or findings of 
fact with which you disagree and the reasons for disagreement. You may submit additional 
information with the rebuttal that you believe may have a bearing on the decision. You must 
submit all information that you would like to be considered in conjunction with the rebuttal. This 
includes any application(s) to update your enrollment, if necessary. You may only submit one 
rebuttal in response to this deactivation of your Medicare enrollment.  
 
The rebuttal must be signed and dated by the individual provider/supplier, the authorized or 
delegated official, or a legal representative. Please be advised that authorized or delegated 
officials for groups cannot sign and submit a rebuttal on behalf of a reassigned provider/supplier 
without the provider/supplier submitting a signed statement authorizing that individual from the 
group to act on his/her/their behalf. 
 
If the provider/supplier wishes to appoint a legal representative that is not an attorney to sign the 
rebuttal, the provider/supplier must include with the rebuttal a written notice authorizing the 
legal representative to act on the provider/suppliers behalf. The notice should be signed by the 
provider/supplier.  
 
If the provider/supplier has an attorney sign the rebuttal, the rebuttal must include a statement 
from the attorney that he/she/they have the authority to represent the provider/supplier.  
 
If you wish to receive communication regarding your rebuttal via email, please include a valid 
email address in your rebuttal submission.  
 
The rebuttal should be sent to the following:  
[Contractor Rebuttal Receipt Address]  
[Contractor Rebuttal Receipt Email Address]  
[Contractor Rebuttal Receipt Fax Number]  
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM ET/CT/MT/PT] and [x:00 AM/PM ET/CT/MT/PT].  
 
 
Sincerely, 
 
[Name] 
[Title] 
[Company]  
 
 
CC:  State Agency [and AO, if applicable] 
 
 
L.  Voluntary Termination Cessation of Business  
[Month, Day, Year]  
 
  PROVIDER/SUPPLIER NAME 
ADDRESS  
CITY, STATE, ZIP 
 
Reference Number:        
 
Dear Provider/Supplier Name: 
 
[Insert Contractor name [and Contractor number]] was notified by State Agency Name that on 
MONTH DD, YYYY, the State Agency attempted to verify if your Type of Provider is 
operational. The State Agency has reported that your facility was closed, not operational, and/or 
ceased business at your address of record.  
 
Pursuant to 42 CFR  489.52(b)(3), CMS considers a cessation of business and providing 
services to the community to constitute a voluntary withdrawal from the Medicare program. 
 
If you believe that our determination is incorrect and your Type of Provider facility remains 
operational, you must notify the State Agency and copy this office within 10 days from your 
receipt of this notice that your facility is still operational and participating in the Medicare 
program. You must provide the State Agency and this office with information to clarify why 
your facility was not functional at the address of record at the time the State Agency performed 
the site survey.  
 
STATE AGENCY NAME 
ADDRESS  
CITY, STATE, ZIP 
 
We request that you complete and submit a CMS-855 or an application via the Internet-Based 
Provider Enrollment Chain and Ownership System (PECOS) for a change of information to 
indicate that your facility/practice location remains open and operational or to request a 
voluntary termination of your enrollment.  
 
If we do not hear from you, your Medicare enrollment and corresponding Provider Agreement 
will be terminated pursuant to 42 CFR  489.52(b)(3).  With this termination, your billing 
privileges will also be deactivated effective on the aforementioned date of the termination 
pursuant to 42 C.F.R.  424.540(a)(7). 
 
If you have any questions, please contact our office at: 
 
 
Sincerely, 
 
[Name] 
[Title] 
[Company]  
 
M. Approval  Seller CHOW (Part A/B Certified Org)  
  [Month, Day, Year]  
   
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor name [and Contractor number]] has received notification from the [use State 
Agency or CMS Survey & Operations Group Location, as appropriate] that the change of 
ownership involving [insert seller name] is now approved.  Therefore, you have been disenrolled 
from the Medicare program effective on the date shown below.   
 
Medicare Enrollment Termination Information 
 
Medicare Enrollment Termination 
Legal Business Name (LBN)     
Doing Business As Name      
Primary Practice Location Address    
Provider/Supplier Type    
National Provider Identifier (NPI)     
Provider Transaction Access Number    
(PTAN)  
Effective Date of Enrollment    
Termination  
  
Provider/Supplier Agreement Information 
CMS Certification Number (CCN)   
Effective Date of CCN Termination   
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
CC: State Agency [and AO, if applicable] 
 
N.  Federally Qualified Health Centers (FQHCs)  Initial Enrollment Approval Letter 
 
Notwithstanding any other instruction to the contrary in this chapter, the contractor shall use this 
letter (which was formerly in section 10.7.19 of this chapter) for all FQHC initial enrollment  approvals.  For all other FQHC transactions (e.g., revalidations), the contractor may use the 
applicable letters in either 10.7.5 or 10.7.5.1. 
 
[Month, Day, Year]  
  
[FQHC Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [FQHC],  
 
[Insert Contractor] has approved your enrollment as a federally qualified health center (FQHC).   
 
 
 
 
Medicare Enrollment Information 
 
Legal Business Name (LBN)    
Doing Business As (DBA)     
Physical Location Address    
National Provider Identifier (NPI)     
Provider Transaction Access Number    
(PTAN)/CMS Certification Number 
(CCN)   
PTAN/CCN Effective Date     
Medicare Year-End Cost Report Date    
 
Provider/Supplier Agreement Information 
CMS Certification Number (CCN)   
Effective Date of CCN    
 
Included with this letter is a copy of your Attestation Statement for Federal Qualified Health 
Center (Exhibit 177), which CMS has signed.   
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
 
Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number].   
 
Enroll, make changes to, or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
  Submit updates and changes to your enrollment information within the timeframes specified at 
42 CFR  424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that he or she has 
o
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her 
behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498.   
The reconsideration request should be sent to:  
 
Centers for Medicare & Medicaid Services  
Center for Program Integrity 
Provider Enrollment & Oversight Group 
ATTN: Division of Provider Enrollment Appeals 
7500 Security Blvd.  
Mailstop: AR-19-51  
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
ProviderEnrollmentAppeals@cms.hhs.gov 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely, 
  
[Name]  
[Title]  
[Company] 
 
O.  Approval  FQHC Change of Ownership  
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
Your change of ownership application is now approved. The corresponding executed 
Attestation Statement for Federal Qualified Health Center (Exhibit 177), which CMS has 
signed, is enclosed/attached.  Your enrollment and Exhibit 177 information is outlined below: 
 
Medicare Enrollment Information 
Legal Business Name (LBN)    
Doing Business As Name    
Primary Practice Location Address    
Provider/Supplier Type    
National Provider Identifier (NPI)     
Provider Transaction Access Number    
(PTAN)  
  Provider Agreement Specific Information 
CMS Certification Number (CCN)    
CCN Effective Date (use effective date    
of sellers CCN) 
CHOW Effective Date   
 
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.     
 
Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number].  
 
Enroll, make changes, or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.  
 
Submit updates and changes to your enrollment information within the timeframes specified at 
42 CFR  424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations, at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
  
  If the authorized representative is an attorney, the attorneys statement that he or she has 
o
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier  submitting a signed statement authorizing that individual from the group to act on his/her 
behalf. 
 
You may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 CFR Part 
498. 
 
The reconsideration request should be sent to:  
 
Centers for Medicare & Medicaid Services  
Center for Program Integrity 
Provider Enrollment & Oversight Group 
ATTN: Division of Provider Enrollment Appeals  
7500 Security Blvd. 
Mailstop: AR-19-51  
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
ProviderEnrollmentAppeals@cms.hhs.gov 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
CC:  State Agency [and AO, if applicable] 
 
Attachments: [Include any attachments that the contractor must send to the provider/supplier, the 
state agency, and/or the AO per the instructions in this chapter 10.]    
 
P.  36-Month Rule Voluntary Termination Letter 
  [Month, Day, Year]  
   
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [HHA Seller],  
 
[Insert Contractor name] has [Insert appropriate situation (e.g., reviewed [insert HHAs current 
name] change of ownership application; learned that [insert HHAs current name] may have 
undergone a change in majority ownership pursuant to 42 C.F.R.  424.550(b)(1); etc.].  After 
our review, [Insert Contractor name] has determined that [insert HHAs current name] has 
undergone a change in majority ownership under 42 C.F.R.  424.550(b)(1) and that none of the 
exceptions described in 42 C.F.R.  424.550(b)(2) apply to this situation.  Pursuant to 42 C.F.R. 
 424.550(b)(1), therefore, [insert HHAs current name] provider agreement 
and Medicare billing privileges do not convey to the new owner.  The prospective 
provider/owner of [insert HHAs current name] must instead: 
 
  Enroll in the Medicare program as a new (initial) home health agency under the provisions 
of 42 C.F.R  424.510; and 
  Obtain a state survey or an accreditation from an approved accreditation organization. 
 
Consistent with the foregoing, [insert HHAs current name] provider agreement [will be/has 
been] voluntarily terminated and its Medicare billing privileges [will be/have been] deactivated 
pursuant to 42 C.F.R  424.540(a)(8) effective [Insert date(s)].  
 
Medicare Enrollment and Provider Agreement Information 
 
Medicare Enrollment Deactivation 
Legal Business Name (LBN)     
Doing Business As Name      
Primary Practice Location Address    
Provider/Supplier Type    
National Provider Identifier (NPI)     
Provider Transaction Access Number    
(PTAN)  
Effective Date of Enrollment    
Deactivation  
 
Provider/Supplier Agreement Termination 
CMS Certification Number (CCN)   
Effective Date of CCN Termination   
Reason for Termination   
   In accordance with 42 CFR  489.52, Medicare will not reimburse you for any claims with dates 
of service on or after your effective date of termination.   
 
REBUTTAL RIGHTS: 
 
If you believe that this deactivation determination is not correct, you may rebut the deactivation 
as indicated in 42 C.F.R.  424.545(b). The rebuttal must be received by this office in writing 
within 15 calendar days of the date of this letter. The rebuttal must state the issues or findings of 
fact with which you disagree and the reasons for disagreement. You may submit additional 
information with the rebuttal that you believe may have a bearing on the decision. You must 
submit all information that you would like to be considered in conjunction with the rebuttal. This 
includes any application(s) to update your enrollment, if necessary. You may only submit one 
rebuttal in response to this deactivation of your Medicare enrollment.  
 
The rebuttal must be signed and dated by the individual provider/supplier, the authorized or 
delegated official, or a legal representative. Please be advised that authorized or delegated 
officials for groups cannot sign and submit a rebuttal on behalf of a reassigned provider/supplier 
without the provider/supplier submitting a signed statement authorizing that individual from the 
group to act on his/her/their behalf. 
 
If the provider/supplier wishes to appoint a legal representative that is not an attorney to sign the 
rebuttal, the provider/supplier must include with the rebuttal a written notice authorizing the 
legal representative to act on the provider/suppliers behalf. The notice should be signed by the 
provider/supplier.  
 
If the provider/supplier has an attorney sign the rebuttal, the rebuttal must include a statement 
from the attorney that he/she/they have the authority to represent the provider/supplier.  
 
If you wish to receive communication regarding your rebuttal via email, please include a valid 
email address in your rebuttal submission.  
 
The rebuttal should be sent to the following:  
[Contractor Rebuttal Receipt Address]  
[Contractor Rebuttal Receipt Email Address]  
[Contractor Rebuttal Receipt Fax Number]  
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM ET/CT/MT/PT] and [x:00 AM/PM ET/CT/MT/PT].  
 
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
CC: State Agency [and AO, if applicable] 
  Q.  Applicable SOG Location E-mail Boxes 
 
CMS Locations Corporate Email Addresses 
CMS LOCATION  BRANCH  EMAIL Address 
 
   
       BostonRO-
CMS Boston 
ACC & LTC  DSC@cms.hhs.gov 
Connecticut, Maine, Massachusetts, New 
Hampshire, Rhode Island, Vermont 
   
 
   
CMS Philadelphia  ACC & LTC         ROPHIDSC@cms.hhs.gov 
Delaware, District of Columbia, Maryland, 
Pennsylvania, Virginia, West Virginia 
   
 
   
CMS New York  ACC & LTC         RONYdsc@cms.hhs.gov 
New Jersey, New York, Puerto Rico, Virgin 
Islands 
   
 
   
CMS Atlanta  ACC & LTC         ROATLHSQ@cms.hhs.gov 
Alabama, Florida, Georgia, Kentucky,  
Mississippi, North Carolina, South Carolina, 
Tennessee 
   
 
   
CMS Chicago  ACC & LTC         ROCHISC@cms.hhs.gov 
Illinois, Indiana, Michigan, Minnesota, 
Ohio, Wisconsin 
   
 
   
CMS Kansas City  ACC & LTC         ROkcmSCB@cms.hhs.gov 
Iowa, Kansas, Missouri, Nebraska 
   
 
   
CMS Denver  ACC & LTC        DenverMAC@cms.hhs.gov 
Colorado, Montana, North 
Dakota, South Dakota, Utah, 
Wyoming 
   
 
   
CMS Dallas  ACC & LTC       RODALDSC@cms.hhs.gov 
Arkansas, Louisiana, New Mexico, 
Oklahoma, Texas 
   
 
   
CMS San Francisco  ACC & LTC       ROSFOSO@cms.hhs.gov  Arizona, California, Hawaii, Nevada, Pacific 
Territories 
   
 
   
    
CMS Seattle 
ACCB  CMS_RO10_CEB@cms.hhs.gov 
Alaska, Idaho, Oregon, Washington  LTC      Seattle_LTC@cms.hhs.gov 
     
 
10.7.5.1.1  Additional Certified Provider and Certified Supplier Letters  
(Rev. 11574; Issued: 08-25-22; Effective: 6-24-22; Implementation: 09-27-22) 
 
This section 10.7.5.1.1 contains additional letters that contractors shall use in certain special 
situations involving certified providers and suppliers.  They take precedence over all other letters 
in this chapter potentially pertaining to the situations described in this section 
 
A.  Denials Based on Survey Failure for Transitioned Certified Providers/suppliers 
 
(This letter does not apply to non-transitioned certified providers/suppliers.) 
 
 
[Month, Day, Year]  
   
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier]: 
 
We regret to inform you that (Provider/Supplier] does not meet the requirements for participation 
in the Medicare program (Title XVIII of the Social Security Act).  
 
In order to participate in the Health Insurance for the Aged and Disabled Program, a [list the 
provider/supplier type] must be in compliance with all applicable Conditions of [Participation or 
Coverage, as applicable] established by the Secretary of Health and Human Services.  Based on 
the [list date survey occurred] survey conducted by [list the state agency or accrediting 
organization name], CMS has determined that your facility does not qualify.  The deficiencies 
that the [list the state agency or accrediting organization name] found are listed on the Survey 
Report. Your facility is not in compliance with the following Conditions of [Participation or 
Coverage]:  
 
 [List regulatory cite (e.g., 42 CFR  418.56) and the specific provision in question (e.g.,: 
Interdisciplinary Group, Care Planning, and Coordination of Services] 
  You may take steps to correct the deficiencies and reapply to establish eligibility.  However, 
current survey funding levels (as appropriated by Congress) may not allow for a resurvey. CMS 
priority for use of the limited funds available are to ensure the health and safety of Medicare 
beneficiaries at currently participating facilities.  Contact [list the state survey agency or 
accrediting organization that performed the initial survey] for the status of initial surveys of non-
participating facilities.   
 
Please note that you may submit no more than two reapplications for certification in connection 
with one enrollment application, and no more than six months may elapse between the date of 
the first survey denial notification and the CMS Survey & Certification Groups receipt of the 
second reapplication for certification.  Applicants who reapply for certification must undergo and 
pass a subsequent survey. (Note that a reapplication for certification is different from the 
submission of a [Form CMS-855A or Form CMS-855B, as applicable to the provider/supplier 
type] Medicare enrollment application.  At this time, you need not submit a [Form CMS-855A or 
Form CMS-855B, as applicable] to request another survey per the previous paragraph.)   
 
If you believe that this decision is not correct, you may request that this decision be reconsidered.  
The request must be submitted in writing to [list applicable SOG Location] within 60 days of the 
date you receive this notice. You may submit with your request any additional information which 
you feel may have a bearing on this decision. If you have any questions, please contact [list 
appropriate SOG Location contact person] at   xxxxxx@cms.hhs.gov.   
 
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
CC: State Agency [and AO, if applicable] 
 
10.7.6  Part B Non-Certified Provider and Supplier Approval Letter 
Templates 
(Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
A.  Approval  Change of Information (Part B Sole Proprietor)  
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)   
   
Dear [Provider/Supplier],  
  [Insert Contractor] has approved your Change of Information (COI) application.   
 
Medicare Enrollment Information  
 
Individual Name      
Individual Specialty     
Individual National Provider Identifier (NPI)     
Individual Provider Transaction Access    
Number (PTAN)  
 
Changed Information 
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.  
 
You must include your NPI, as the billing and rendering provider, on all Medicare claim 
submissions.   
 
Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number].  
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
B. Approval  Change of Information (Part B Physician Assistant)  
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)       
Dear [Provider/Supplier],  
 
[Insert Contractor] has approved your Change of Information (COI) application.   
 
Medicare Enrollment Information  
 
Individual Name     
Individual Specialty    Physician Assistant 
Individual National Provider Identifier (NPI)     
Individual Provider Transaction Access    
Number (PTAN)  
Individual PTAN Effective Date   
Employer Legal Business Name (LBN)     
Employer National Provider Identifier (NPI)     
Employer Provider Transaction Access Number   
(PTAN)  
 
Changed Information 
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.  
 
You must include your NPI, as the rendering provider, on all Medicare claims submissions.   
 
Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number].  
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
C. Approval  Change of Information (Part B Org or Part B Sole Owner)  
  [Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor] has approved your Change of Information (COI) application.    
 
Medicare Enrollment Information  
 
Legal Business Name (LBN)     
Doing Business As (DBA)      
Provider/Supplier Type     
National Provider Identifier (NPI)     
Provider Transaction Access Number (PTAN)     
 
Changed Information 
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.  
 
Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number].  
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified 
at [42 CFR 424.516 or 42 CFR424.205]. For more information on the reporting 
requirements, go to Medicare Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
D. Approval  Change of Information (Part B Reassignment for Existing Physician or Non-
Physician Practitioner)   
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)      
  
Dear [Provider/Supplier],  
 
[Insert Contractor] has approved your Change of Information (COI) application.   
 
Medicare Enrollment Information  
 
Individual Name     
Individual Specialty     
Individual National Provider Identifier (NPI)     
Individual Provider Transaction Access    
Number (PTAN)  
Group Legal Business Name (LBN)     
Group NPI     
Group PTAN     
Reassignment Effective Date     
Changed Information   
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
 
You must include your NPI, as the rendering provider, on all Medicare claim submissions.   
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]   [Company] 
 
E. Approval  Change of Information (Part B Reassignment to CAH) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)  
       
Dear [Provider/Supplier],  
 
[Insert Contractor] has approved your Change of Information (COI) application.  
  
Medicare Enrollment Information 
 
Individual Name     
Individual Specialty     
Individual National Provider Identifier (NPI)     
Provider/Supplier Legal Business Name (LBN)    
Provider/Supplier Type   Critical Access Hospital (CAH)  
Provider/Supplier NPI     
Provider/Supplier PTAN   
Reassignment Effective Date     
Changed Information   
 
This action establishes a relationship between the above named individual and the Critical 
Access Hospital (CAH) facility, in PECOS, for enrollment purposes only.  This does not 
constitute approval of the election of this facility or individual for Method II Billing, as identified 
in Section 1834(g)(2) of the Act. 
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
  [Name]  
[Title]  
[Company] 
 
F. Approval  Initial/Reactivation Reassignment (Part B CAH) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)    
  
Dear [Provider/Supplier],  
 
[Insert Contractor] approved your [initial or reactivation] enrollment application.     
 
Medicare Enrollment Information 
 
Individual Name     
Individual Specialty     
Individual National Provider Identifier (NPI)     
Provider/Supplier Legal Business Name (LBN)    
Provider/Supplier Type   Critical Access Hospital (CAH)  
Provider/Supplier NPI     
Provider/Supplier PTAN   
Reassignment Effective Date     
  
This action establishes a relationship between the above named individual and the Critical 
Access Hospital (CAH) facility, in PECOS, for enrollment purposes only.  This does not 
constitute approval of the election of this facility or individual for Method II Billing, as identified 
in Section 1834(g)(2) of the Act. 
 
 Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.  
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
  You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during 
the administrative appeals process unless an ALJ allows additional information to be 
submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
[Name of MAC]        
[Address]     
[City], ST [Zip]       
  Or emailed to: 
 
[Insert MAC email address]     
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
G. Approval  Initial/Reactivation (Part B Order and Certify) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)    
 
Dear [Provider/Supplier],  
 
[Insert Contractor] approved your [initial or reactivation] enrollment application to solely order 
and certify items and services for Medicare beneficiaries.  You may not send billed services 
claims to [Insert Contractor].       
 
Medicare Enrollment Information  
 
Individual Name     
Individual Specialty     
Individual National Provider Identifier (NPI)     
Effective Date     
  
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.  
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
  You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during 
the administrative appeals process unless an ALJ allows additional information to be 
submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
 
[Name of MAC]        
[Address]          
[City], ST [Zip]                     
 
Or emailed to: 
 
[Insert MAC email address]     
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company] 
 
H. Approval  Change of Information (Part B Order and Certify) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor] has approved your Change of Information (COI) application.    
 
Medicare Enrollment Information  
 
Individual Name      
Individual Specialty     
Individual National Provider Identifier (NPI)     
 
Changed Information 
  
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
  Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
I. Approval  Initial/Reactivation (Part B Org) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],   
 
[Insert Contractor] approved your [initial or reactivation] enrollment application.   
 
Medicare Enrollment Information  
 
Legal Business Name (LBN)     
Provider/Supplier Type     
National Provider Identifier (NPI)     
Provider Transaction Access Number (PTAN)     
PTAN Effective Date     
Participation Status     
  
Include if applicable: [While your PTAN(s) and effective date(s) remain the same, you will have 
a gap in billing privileges from [deactivation date] through [reactivation date] for failing to fully 
revalidate during a previous revalidation cycle. You will not be reimbursed for services provided 
to Medicare beneficiaries during this time period since you were not in compliance with 
Medicare requirements.]  
 
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
 
Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number].   
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified 
at [42 CFR 424.516 or 42 CFR424.205]. For more information on the reporting 
requirements, go to Medicare Learning Network Article SE1617.    
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during 
the administrative appeals process unless an ALJ allows additional information to be 
submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
  The reconsideration request should be sent to:  
 
(Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
 
[Name of MAC]      [Centers for Medicare & Medicaid Services]  
[Address]        [Center for Program Integrity] 
[City], ST [Zip]  or    [Provider Enrollment & Oversight Group] 
           [ATTN: Division of Provider Enrollment Appeals] 
           [7500 Security Blvd.]  
           [Mailstop: AR-19-51]  
           [Baltimore, MD 21244-1850] 
 
Or emailed to: 
 
[Insert MAC email address]    or   [ProviderEnrollmentAppeals@cms.hhs.gov] 
    
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
J. Approval  Initial/Reactivation (Part B Physician Assistant) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],   
 
[Insert Contractor] approved your [initial or reactivation] enrollment application.   
 
Medicare Enrollment Information  
 
Individual Name     
Individual Specialty   Physician Assistant 
Individual National Provider Identifier (NPI)     
Individual Provider Transaction Access    
Number (PTAN)  
Individual PTAN Effective Date    Employer Legal Business Name (LBN)     
Employer National Provider Identifier (NPI)     
Employer Provider Transaction Access Number   
(PTAN)  
  
Include if applicable: [While your PTAN(s) and effective date(s) remain the same, you will have 
a gap in billing privileges from [deactivation date] through [reactivation date] for failing to fully 
revalidate during a previous revalidation cycle. You will not be reimbursed for services provided 
to Medicare beneficiaries during this time period since you were not in compliance with 
Medicare requirements.]  
 
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
 
Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number].   
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.  
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the  appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during 
the administrative appeals process unless an ALJ allows additional information to be 
submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
[Name of MAC]        
[Address]     
[City], ST [Zip]       
 
Or emailed to: 
 
[Insert MAC email address]     
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely, 
 
[Name]  
[Title]  
[Company] 
 
K. Approval  Initial/Reactivation (Part B Sole Owner)  
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]   [City, State, Zip]  
  
Reference # (Application Tracking Number)       
 
Dear [Provider/Supplier],   
 
[Insert Contractor] approved your [initial or reactivation] enrollment application. 
  
Medicare Enrollment Information  
 
Individual Name     
Individual Specialty     
Individual National Provider Identifier (NPI)     
Individual Provider Transaction Access    
Number (PTAN)  
Individual PTAN Effective Date     
Group Legal Business Name (LBN)     
Group Specialty     
Group NPI     
Group PTAN     
Group PTAN Effective Date     
Participation Status   
  
Include if applicable: [While your PTAN(s) and effective date(s) remain the same, you will have 
a gap in billing privileges from [deactivation date] through [reactivation date] for failing to fully 
revalidate during a previous revalidation cycle. You will not be reimbursed for services provided 
to Medicare beneficiaries during this time period since you were not in compliance with 
Medicare requirements.]  
 
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
 
You must include the individual providers NPI as the rendering provider and the organizational 
providers NPI as the billing provider on all Medicare claim submissions.   
 
Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number].   
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.    
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during 
the administrative appeals process unless an ALJ allows additional information to be 
submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
[Name of MAC]         [Address]        
[City], ST [Zip]       
 
Or emailed to: 
 
[Insert MAC email address]     
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
L. Approval  Initial/Reactivation (Part B Sole Proprietor) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)    
  
Dear [Provider/Supplier],  
 
[Insert Contractor] approved your [initial or reactivation] enrollment application.   
 
Medicare Enrollment Information  
 
Individual Name     
Individual Specialty     
Individual National Provider Identifier (NPI)     
Individual Provider Transaction Access    
Number (PTAN)  
PTAN Effective Date     
Participation Status     
  
Include if applicable: [While your PTAN(s) and effective date(s) remain the same, you will have 
a gap in billing privileges from [deactivation date] through [reactivation date] for failing to fully 
revalidate during a previous revalidation cycle. You will not be reimbursed for services provided 
to Medicare beneficiaries during this time period since you were not in compliance with 
Medicare requirements.]  
 
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.    
You must include your NPI, as the billing and rendering provider, on all Medicare claim 
submissions.   
 
Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number].   
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.  
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may: 
    Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during 
the administrative appeals process unless an ALJ allows additional information to be 
submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
[Name of MAC]        
[Address]        
[City], ST [Zip]       
 
Or emailed to: 
 
[Insert MAC email address]     
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
M. Approval  Initial/Reactivation with Reassignment (Part B Ind) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],   
 
[Insert Contractor] approved your [initial or reactivation] enrollment and reassignment 
application(s).   
  Medicare Enrollment Information  
 
Individual Name     
Individual Specialty     
Individual National Provider Identifier (NPI)     
Individual Provider Transaction Access    
Number (PTAN)  
Group Legal Business Name (LBN)     
Group NPI     
Group PTAN     
Reassignment Effective Date     
  
Include if applicable: [While your PTAN(s) and effective date(s) remain the same, you will have 
a gap in billing privileges from [deactivation date] through [reactivation date] for failing to fully 
revalidate during a previous revalidation cycle. You will not be reimbursed for services provided 
to Medicare beneficiaries during this time period since you were not in compliance with 
Medicare requirements.]  
 
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
You must include your NPI, as the billing and rendering provider, on all Medicare claim 
submissions.   
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.      Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during 
the administrative appeals process unless an ALJ allows additional information to be 
submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
[Name of MAC]        
[Address]        
[City], ST [Zip]       
 
Or emailed to: 
 
[Insert MAC email address]     
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]    
N. Approval  Revalidation (Part B Ind with Reassignment) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor] has approved your revalidation application.   
 
Medicare Enrollment Information  
 
Individual Name     
Individual Specialty     
Individual National Provider Identifier (NPI)     
Individual Provider Transaction Access    
Number (PTAN)  
Group Legal Business Name (LBN)     
Group NPI     
Group PTAN     
PTAN Effective Date     
Changed Information   
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.  
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.  
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.])   
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during 
the administrative appeals process unless an ALJ allows additional information to be 
submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
[Name of MAC]        
[Address]        
[City], ST [Zip]       
 
Or emailed to: 
 
[Insert MAC email address]     
   For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
O. Approval  Revalidation (Part B Sole Proprietor) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor] approved your revalidation enrollment application.   
 
Medicare Enrollment Information  
 
Individual Name     
Individual Specialty     
Individual National Provider Identifier (NPI)     
Individual Provider Transaction Access    
Number (PTAN)  
PTAN Effective Date     
Changed Information   
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.  
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.  
 
Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
 
Right to Submit a Reconsideration Request:   
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during 
the administrative appeals process unless an ALJ allows additional information to be 
submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
[Name of MAC]        
[Address]        
[City], ST [Zip]         
Or emailed to: 
 
[Insert MAC email address]     
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
P. Approval  Revalidation (Part B Physician Assistant) 
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor] has approved your revalidation application.   
 
Medicare Enrollment Information  
 
Individual Name     
Individual Specialty    Physician Assistant 
Individual National Provider Identifier (NPI)     
Individual Provider Transaction Access    
Number (PTAN)  
Individual PTAN Effective Date   
Employer Legal Business Name (LBN)     
Employer National Provider Identifier (NPI)     
Employer Provider Transaction Access Number   
(PTAN)  
Changed Information   
  
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.  
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.  
  Submit updates and changes to your enrollment information within the timeframes specified 
at 42 CFR 424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during 
the administrative appeals process unless an ALJ allows additional information to be 
submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
  If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
[Name of MAC]        
[Address]        
[City], ST [Zip]       
 
Or emailed to: 
 
[Insert MAC email address]     
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
Q. Approval  Revalidation (Part B Non-Certified Org or Part B Sole Owner)  
 
[Month, Day, Year]  
  
[Provider/Supplier Name]  
[Address]  
[City, State, Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor] has approved your revalidation application.   
 
Medicare Enrollment Information  
 
Legal Business Name (LBN)     
Doing Business As (DBA)     
Provider/Supplier Type     
Provider/Supplier National Provider Identifier    
(NPI)  
Provider Transaction Access Number (PTAN)     
PTAN Effective Date     
Changed Information   
   Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.   
 
Enroll, make changes or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified 
at [42 CFR 424.516 or 42 CFR424.205]. For more information on the reporting 
requirements, go to Medicare Learning Network Article SE1617.  
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations at [insert contractors web address] or https://www.cms.gov.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during  the administrative appeals process unless an ALJ allows additional information to be 
submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
(Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
 
[Name of MAC]      [Centers for Medicare & Medicaid Services]  
[Address]        [Center for Program Integrity] 
[City], ST [Zip]  or    [Provider Enrollment & Oversight Group] 
           [ATTN: Division of Provider Enrollment Appeals] 
           [7500 Security Blvd.]  
           [Mailstop: AR-19-51]  
           [Baltimore, MD 21244-1850] 
 
Or emailed to: 
 
[Insert MAC email address]    or   [ProviderEnrollmentAppeals@cms.hhs.gov] 
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
R. Approval  Voluntary Termination (Part B Sole Proprietor)  
 
[Month, Day, Year]  
   
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor] completed your application to disenroll from the Medicare program.     
Medicare Enrollment Information  
 
Individual Name     
Individual Specialty     
Individual National Provider Identifier (NPI)     
Individual Provider Transaction Access    
Number (PTAN)  
Effective Date of Termination     
  
Medicare will not reimburse you for any claims with dates of service on or after your effective 
date of termination.   
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
S. Approval  Voluntary Termination (Part B Physician Assistant)  
 
[Month, Day, Year]  
   
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor] completed your application to disenroll from the Medicare program.   
 
Medicare Enrollment Information  
 
Individual Name     
Individual Specialty    Physician Assistant 
Individual National Provider Identifier (NPI)     
Individual Provider Transaction Access    
Number (PTAN)  
Employer Name   
Employer National Provider Identifier (NPI)    
Employer Provider Transaction Access Number  
(PTAN)  
Effective Date of Termination        
Medicare will not reimburse you for any claims with dates of service on or after your effective 
date of termination.   
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
T. Approval  Termination of Reassignment (Part B Ind)  
 
[Month, Day, Year]  
   
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor] completed your application to disenroll from the Medicare program.   
 
Medicare Enrollment Information  
 
Individual Name     
Individual Specialty     
Individual National Provider Identifier (NPI)     
Individual Provider Transaction Access    
Number (PTAN)  
Group Name    
Group National Provider Identifier (NPI)    
Group Provider Transaction Access Number   
(PTAN)  
Effective Date of Termination     
  
Medicare will not reimburse you for any claims with dates of service on or after your effective 
date of termination.   
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]   [Title]  
[Company]  
 
U. Approval  Termination of Reassignment (Part B CAH)  
 
[Month, Day, Year]  
   
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],  
 
[Insert Contractor] completed your application to disenroll from the Medicare program.   
 
Medicare Enrollment Information  
 
Individual Name     
Individual Specialty     
Individual National Provider Identifier (NPI)     
Provider/Supplier Legal Business Name (LBN)    
Provider/Supplier Type   Critical Access Hospital (CAH)  
Provider/Supplier NPI   
Provider/Supplier PTAN   
Effective Date of Termination     
  
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
V. Approval  Voluntary Termination (Part B Non-Certified Org or Part B Sole Owner)  
 
[Month, Day, Year]  
   
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
  
Reference # (Application Tracking Number)     
 
Dear [Provider/Supplier],    
[Insert Contractor] completed your application to disenroll from the Medicare program.   
 
Medicare Enrollment Information  
Legal Business Name (LBN)     
Doing Business As (DBA)     
Provider/Supplier Type     
National Provider Identifier (NPI)     
Provider Transaction Access Number (PTAN)     
Effective Date of Termination     
  
Reassignments and any physician assistant employment arrangements are also deactivated. 
 
Medicare will not reimburse you for any claims with dates of service on or after your effective 
date of termination.   
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
10.7.7  Application Return and Rejection Model Letters 
(Rev. 11859; Issued: 02-16-23; Effective: 03-17-23; Implementation: 03-17-23) 
 
A. Returned Application Letter 
 
[month] [day], [year] 
 
[Provider/Supplier Name] 
[Address] 
[City] ST [Zip] 
 
Reference # (PTAN #, Enrollment #, Case #, etc.) 
 
Dear [Provider/Supplier Name]:  
 
Your Medicare enrollment application(s) was received on [date]. We are closing this request and 
returning your application(s) for the following reason(s):  
 
[List all reasons for return] 
 
If you would like to resubmit an application, you must complete a new Medicare enrollment 
application(s). Please address the above issues as well as sign and date the new certification 
statement page on your resubmitted application(s).    
Providers and suppliers can apply to enroll in the Medicare program using one of the following 
two methods:  
 
1. Internet-based Provider Enrollment, Chain and Organization System (PECOS). Go to: 
https://pecos.cms.hhs.gov/pecos/login.do. 
 
2. Paper application process:  Download and complete the Medicare enrollment 
application(s) at http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/MedicareProviderSupEnroll/EnrollmentApplications.html.  
 
Please return the completed application(s) to: 
 
[Name of MAC] 
[Address] 
[City], ST [Zip] 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM]. 
 
Sincerely,  
 
 
[Name] 
[Title] 
[Company] 
 
B. Model Rejection Letter  
 
[month] [day], [year] 
 
[Provider/Supplier Name] 
[Address] 
[City] ST [Zip] 
 
Reference # (PTAN #, Enrollment #, Case #, etc.) 
 
 
Dear [Provider/Supplier Name]: 
 
We received your Medicare enrollment application(s) on [Receipt Date]. We are rejecting your 
application(s) for the following reason(s):  
 
[List all reasons for rejection] 
 
If you would like to resubmit an application, you must complete a new Medicare enrollment 
application(s). Please address the above issues as well as sign and date the new certification 
statement page on your resubmitted application(s).   
In compliance with Federal regulations found at 42 CFR 424.525, providers and suppliers are 
required to submit complete application(s) and all supporting documentation within 30 calendar 
days from the postmark date of the contractor request for missing/incomplete information. 
 
Providers and suppliers can apply to enroll in the Medicare program using one of the following 
two methods:  
 
1. Internet-based Provider Enrollment, Chain and Organization System (PECOS). Go to: 
https://pecos.cms.hhs.gov/pecos/login.do. 
 
2. Paper application process:  Download and complete the Medicare enrollment 
application(s) at http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/MedicareProviderSupEnroll/EnrollmentApplications.html.  
 
Please return the completed application(s) to:  
 
[Name of MAC] 
[Address] 
[City], ST [Zip] 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM]. 
 
 
Sincerely,  
 
 
[Name] 
[Title] 
[Company] 
 
 
C. Rejection Letter for Locations That Do Not Meet the Distance Requirements 
 
[Provider/Supplier Name] 
[Address] 
[City] ST [Zip] 
 
Reference # (PTAN #, Enrollment #, Case #, etc.) 
 
 
Dear [Provider/Supplier Name]: 
 
We received your Medicare enrollment application(s) to add a new provider-based location to 
your Critical Access Hospital enrollment on [date]. We are rejecting your application because the 
[enter the office that made the decision] has found that your new location does not meet distance 
requirements found in 42 CFR  485.610(e)(2).    
Please refer to communications from the [enter the office that made the decision] for instructions 
for your next steps regarding the new provider-based location. 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM]  and [x:00 AM/PM]. 
 
 
Sincerely,  
 
 
[Name] 
[Title] 
[Company] 
 
10.7.8  Denial Model Letters  
(Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
A. Denial Letter Guidance 
 
The contractor must submit one or more of the denial citations as found in Section 10.4.2 et seq. 
of this chapter into the appropriate section on the Model Denial Letter.  Only the CFR citation 
and a short heading shall be cited for the primary denial reason.  
 
  The contractor may submit one or more denial reason, as appropriate. The denial 
reason(s) should state sufficient details so it is clear as to why the provider or supplier is 
being denied.  
 
  Specific Denial Reasons may contain one or more of the following items:  
 
  A specific regulatory (CFR) citation.  
o
 
  Dates (of actions, suspensions, convictions, receipt of documents, etc.)  
o
 
  Pertinent details of action(s)  
o
 
DMEPOS supplier-only language.  All denial letters for DMEPOS suppliers shall replace the 1st 
paragraph of the model denial letter with the following text:  
 
Your application to enroll in Medicare is denied. After reviewing your submitted 
application document(s), it was determined that per 42 CFR  405.800, 42 CFR  424.57, 
and 42 CFR  498.22, that you do not meet the conditions of enrollment or meet the 
requirements to qualify as a Medicare Durable Medical Equipment, Prosthetics, Orthotics, 
and Supplies (DMEPOS) provider or supplier for the following reason(s):  
  (Exclusions and sanctions  the following two sentences should be REMOVED for all denial 
letters that DO NOT involve an exclusion or sanction action:  
 
You may not appeal through this process the merits of any exclusion by another federal 
agency. Any further permissible administrative appeal involving the merits of such 
exclusion must be filed with the federal agency that took the action.)  
 
For IDTF, DMEPOS, and MDPP providers and suppliers, each regulatory citation needs to be 
listed along with the specific regulatory language. For IDTF, the standards are found in 42 CFR 
 410.33(g). For DMEPOS providers and suppliers, the standards are found in 42 CFR  
424.57(c)(1) through (30). For MDPP suppliers, the standards are found in 42 CFR  424.205(d).  
 
If a provider is being added to the CMS Preclusion List, the following should be inserted to the 
denial letter (should PEOG instruct the contractor to do so: 
 
The Centers for Medicare & Medicaid Services (CMS) has been made aware of [Provider 
Name]s [Date], felony conviction, as defined in 42 C.F.R.  1001.2, for [reason] in 
violation of [Code] in the Court Name]. After reviewing the specific facts and 
circumstances surrounding [Jane Doe]s felony conviction, CMS has determined that 
[Provider Name]s felony conviction is detrimental to the best interests of the Medicare 
program and its beneficiaries.   
 
Additionally, [Provider Name] will be placed on the CMS Preclusion List because 
[he/she] has been convicted of a felony, as described above, under Federal or State law, 
within the previous 10 years, that CMS deems detrimental to the best interests of the 
Medicare program. CMS may take this action regardless of whether you are or were 
enrolled in the Medicare program. This action is being taken pursuant to 42 C.F.R.  
422.2, 422.222, 423.100, and 423.120(c)(6). 
 
The effective date of your inclusion on the Preclusion List is dependent upon the 
submission or non-submission of a reconsideration request (see below). If you do submit 
a reconsideration request and your inclusion on the Preclusion List is upheld, you will be 
added to the Preclusion List on the date of the reconsideration decision. If you do not 
submit a reconsideration request, you will be included on the Preclusion List 65 days 
after the date of this letter. 
  
During the time period that your name will be included on the Preclusion List as listed 
above, any claims you submit for health care items or services furnished under a 
Medicare Advantage (MA) benefit may be denied. Additionally, any pharmacy claims 
submitted for Medicare Part D drugs that you prescribe may be rejected or denied. This 
means that your patients may not be able to receive coverage of their prescriptions using 
their Part D benefit at the pharmacy.  
  
The below appeal rights apply to both your denial and preclusion. If you choose to appeal, 
you must file an appeal to the denial and preclusion jointly.  
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination.   
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below. 
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement. 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, supplier, 
o
or authorized or delegated official must file written notice of the appointment of 
its representative with the submission of the reconsideration request. 
  Authorized  or  delegated  officials  for  groups  cannot  sign  and  submit  a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) 
to consider during a hearing, you must submit that information with your request for 
reconsideration.  This  is  your  only  opportunity  to  submit  information  during  the 
administrative appeals process unless an ALJ allows additional information to be submitted. 
 
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
If  a  reconsideration  is  not  requested,  CMS  deems  this  a  waiver  of  all  rights  to  further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to: 
 
Centers for Medicare & Medicaid Services 
Center for Program Integrity 
Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to:   
ProviderEnrollmentAppeals@cms.hhs.gov 
 
B. Model Denial Letter  
 
[month] [day], [year]  
 
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
 
Reference # (Contractor Control Number or NPI)  
 
Dear [Provider/Supplier Name]:  
 
Your application to enroll in Medicare is denied for the following reason(s):  
 
xx CFR xxx.(x) [heading]  
[Specific reason]  
 
xx CFR xxx.(x) [heading]  
[Specific reason]  
 
Right to Submit a Corrective Action Plan (CAP) and Reconsideration Request: 
 
Corrective Action Plan: (Only if denied under 42 C.F.R.  424.530(a)(1)) 
 
You may submit a corrective action plan (CAP) in response to the denial of an enrollment 
application under 42 C.F.R.  424.530(a)(1). You may also request a reconsideration (described 
below). If your enrollment application was denied under authorities other than 42 C.F.R.  
424.530(a)(1), you may only submit a reconsideration request in response to those denial bases. 
 
The CAP is an opportunity to demonstrate that you have corrected the deficiencies identified above 
and thereby, establish your eligibility to enroll in the Medicare program. (Optional Coversheet 
sentence: [To facilitate the processing of your CAP, please utilize and include the [attached] 
coversheet [also found at [[insert web address for coversheet]] with your submission.]) The CAP 
must-- 
 
  Be received in writing within 35 calendar days of the date of this letter and mailed to the 
address below or emailed to the address below; 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, 
o supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a CAP on 
o
behalf of a reassigned provider/supplier without the provider/supplier submitting 
a signed statement authorizing that individual from the group to act on his/her 
behalf. 
  Provide evidence to demonstrate that you are in compliance with Medicare 
requirements. 
 
Please note that CAPs may not be appealed further to the Departmental Appeals Board. Further 
appeal rights do exist for reconsideration requests (described below). CAP requests should be sent 
to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for reviewing the CAP) 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], ST [Zip]  Provider Enrollment & Oversight Group 
     Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
     
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review conducted 
by a person not involved in the initial determination. (Optional Coversheet sentence [To facilitate 
the processing of your reconsideration request, please utilize and include the [attached] coversheet 
[also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must-- 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below. 
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement. 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or 
o she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may-- 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be 
submitted. 
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
  (If denied under 42 C.F.R.  424.530(a)(2)) Please note that you may not appeal through 
this process the merits of any exclusion by another Federal agency. Any further 
permissible administrative appeal involving the merits of such exclusion must be filed 
with the Federal agency that took the action. 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further administrative 
review. More information regarding appeal rights can be found at 42 C.F.R. Part 498. 
 
The reconsideration request should be sent to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or                       Center for Program Integrity 
[City], ST [Zip]     Provider Enrollment & Oversight Group 
     Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
  If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM].  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
C. Denial Example Letters  
 
Note that each example contains appeal rights for both CMS and the MAC, regardless of the 
example reason, so that the contractors may include the appropriate appeal address based on the 
provider or supplier type that has been denied. 
 
1. Discipline Not Eligible Example 
 
[month] [day], [year]  
 
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
 
Reference # (Contractor Control Number or NPI)  
 
Dear [Provider/Supplier Name]:  
 
Your application to enroll in Medicare is denied for the following reason(s):  
 
42 CFR 424.530(a)(1)  Not in Compliance with Medicare Requirements  
There is no statutory or regulatory basis which permits a Marriage and Family Therapist to enroll 
or receive payment in the Medicare Program.  
 
Right to Submit a Corrective Action Plan (CAP) and Reconsideration Request: 
 
Corrective Action Plan: (Only if denied under 42 C.F.R.  424.530(a)(1)) 
 
You may submit a corrective action plan (CAP) in response to the denial of an enrollment 
application under 42 C.F.R.  424.530(a)(1). You may also request a reconsideration (described 
below). If your enrollment application was denied under authorities other than 42 C.F.R.  
424.530(a)(1), you may only submit a reconsideration request in response to those denial bases. 
 
The CAP is an opportunity to demonstrate that you have corrected the deficiencies identified above 
and thereby, establish your eligibility to enroll in the Medicare program. (Optional Coversheet 
sentence: [To facilitate the processing of your CAP, please utilize and include the [attached] 
coversheet [also found at [[insert web address for coversheet]] with your submission.]) The CAP 
must--   
  Be received in writing within 35 calendar days of the date of this letter and mailed to the 
address below or emailed to the address below; 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a CAP on 
o
behalf of a reassigned provider/supplier without the provider/supplier submitting 
a signed statement authorizing that individual from the group to act on his/her 
behalf. 
  Provide evidence to demonstrate that you are in compliance with Medicare 
requirements. 
 
Please note that CAPs may not be appealed further to the Departmental Appeals Board. Further 
appeal rights do exist for reconsideration requests (described below). CAP requests should be sent 
to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for reviewing the CAP) 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or                        Center for Program Integrity 
[City], ST [Zip]     Provider Enrollment & Oversight Group 
     Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review conducted 
by a person not involved in the initial determination. (Optional Coversheet sentence [To facilitate 
the processing of your reconsideration request, please utilize and include the [attached] coversheet 
[also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must-- 
      Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below. 
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement. 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may-- 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be 
submitted. 
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
  (If denied under 42 C.F.R.  424.530(a)(2)) Please note that you may not appeal through 
this process the merits of any exclusion by another Federal agency. Any further 
permissible administrative appeal involving the merits of such exclusion must be filed 
with the Federal agency that took the action. 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further administrative 
review. More information regarding appeal rights can be found at 42 C.F.R. Part 498. 
 
The reconsideration request should be sent to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], ST [Zip]  Provider Enrollment & Oversight Group 
        Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard  Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM]. 
 
Sincerely,  
[Name]  
 
[Title]  
[Company]  
 
2.  Criteria for Eligible Discipline Not Met Example 
 
[month] [day], [year]  
 
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
 
Reference # (Contractor Control Number or NPI)  
 
Dear [Provider/Supplier Name]:  
 
Your application to enroll in Medicare is denied for the following reason(s):  
 
42 CFR 424.530(a)(1) - Not in Compliance with Medicare Requirements  
Per 42 CFR 410.75(b)(1)(i), the provider or supplier is not certified by a recognized national 
certifying body that has established standards for nurse practitioners.  
 
Right to Submit a Corrective Action Plan (CAP) and Reconsideration Request: 
 
Corrective Action Plan: (Only if denied under 42 C.F.R.  424.530(a)(1)) 
 
You may submit a corrective action plan (CAP) in response to the denial of an enrollment 
application under 42 C.F.R.  424.530(a)(1). You may also request a reconsideration (described 
below). If your enrollment application was denied under authorities other than 42 C.F.R.  
424.530(a)(1), you may only submit a reconsideration request in response to those denial bases. 
 
The CAP is an opportunity to demonstrate that you have corrected the deficiencies identified above 
and thereby, establish your eligibility to enroll in the Medicare program. (Optional Coversheet 
sentence: [To facilitate the processing of your CAP, please utilize and include the [attached]  coversheet [also found at [[insert web address for coversheet]] with your submission.]) The CAP 
must-- 
 
  Be received in writing within 35 calendar days of the date of this letter and mailed to the 
address below or emailed to the address below; 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a CAP on 
o
behalf of a reassigned provider/supplier without the provider/supplier submitting 
a signed statement authorizing that individual from the group to act on his/her 
behalf. 
  Provide evidence to demonstrate that you are in compliance with Medicare 
requirements. 
 
Please note that CAPs may not be appealed further to the Departmental Appeals Board. Further 
appeal rights do exist for reconsideration requests (described below). CAP requests should be sent 
to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for reviewing the CAP) 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], ST [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals  
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review conducted 
by a person not involved in the initial determination. (Optional Coversheet sentence [To facilitate 
the processing of your reconsideration request, please utilize and include the [attached] coversheet 
[also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must--   
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below. 
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement. 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may-- 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be 
submitted. 
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
  (If denied under 42 C.F.R.  424.530(a)(2)) Please note that you may not appeal through 
this process the merits of any exclusion by another Federal agency. Any further 
permissible administrative appeal involving the merits of such exclusion must be filed 
with the Federal agency that took the action. 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further administrative 
review. More information regarding appeal rights can be found at 42 C.F.R. Part 498. 
 
The reconsideration request should be sent to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], ST [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals  7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM]. 
 
Sincerely,  
[Name]  
 
[Title]  
[Company]  
 
3. Provider Standards Not Met Example 
 
[month] [day], [year]  
 
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
 
Reference # (Contractor Control Number or NPI)  
 
Dear IDTF Services, Inc.:  
 
Your application to enroll in Medicare is denied for the following reason(s): 
 
42 CFR 424.530(a)(5) - On-site Review - Requirements Not Met  
Specifically, the following standards were not met:  
 
42 CFR 410.33(g) 4 - Have all applicable diagnostic testing equipment available at the physical 
site excluding portable diagnostic testing equipment. A catalog of portable diagnostic equipment, 
including diagnostic testing equipment serial numbers, must be maintained at the physical site. In 
addition, portable diagnostic testing equipment must be available for inspection within two 
business days of a CMS inspection request. The IDTF must maintain a current inventory of the 
diagnostic testing equipment, including serial and registration numbers, provide this information 
to the designated fee-for-service contractor upon request, and notify the contractor of any 
changes in equipment within 90 days.  
 
42 CFR 410.33(g) 9 - Openly post these [IDTF] standards for review by patients and the public  
 
42 CFR 410.33(g) 11 - Have its testing equipment calibrated and maintained per equipment 
instructions and in compliance with applicable manufacturers suggested maintenance and 
calibration standards.    
42 CFR 410.33(g) 12 - Have technical staff on duty with the appropriate credentials to perform 
tests. The IDTF must be able to produce the applicable Federal or State licenses or certifications 
of the individuals performing these services.  
 
Right to Submit a Corrective Action Plan (CAP) and Reconsideration Request: 
 
Corrective Action Plan: (Only if denied under 42 C.F.R.  424.530(a)(1)) 
 
You may submit a corrective action plan (CAP) in response to the denial of an enrollment 
application under 42 C.F.R.  424.530(a)(1). You may also request a reconsideration (described 
below). If your enrollment application was denied under authorities other than 42 C.F.R.  
424.530(a)(1), you may only submit a reconsideration request in response to those denial bases. 
 
The CAP is an opportunity to demonstrate that you have corrected the deficiencies identified above 
and thereby, establish your eligibility to enroll in the Medicare program. (Optional Coversheet 
sentence: [To facilitate the processing of your CAP, please utilize and include the [attached] 
coversheet [also found at [[insert web address for coversheet]] with your submission.]). The CAP 
must-- 
 
  Be received in writing within 35 calendar days of the date of this letter and mailed to the 
address below or emailed to the address below; 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a CAP on 
o
behalf of a reassigned provider/supplier without the provider/supplier submitting 
a signed statement authorizing that individual from the group to act on his/her 
behalf. 
  Provide evidence to demonstrate that you are in compliance with Medicare 
requirements. 
 
Please note that CAPs may not be appealed further to the Departmental Appeals Board. Further 
appeal rights do exist for reconsideration requests (described below). CAP requests should be sent 
to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for reviewing the CAP) 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], ST [Zip]  Provider Enrollment & Oversight Group  Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address]or  [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review conducted 
by a person not involved in the initial determination. (Optional Coversheet sentence [To facilitate 
the processing of your reconsideration request, please utilize and include the [attached] coversheet 
[also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must-- 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below. 
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement. 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may-- 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be 
submitted. 
  Include an email address if you want to receive correspondence regarding your appeal via 
email.    (If denied under 42 C.F.R.  424.530(a)(2)) Please note that you may not appeal through 
this process the merits of any exclusion by another Federal agency. Any further 
permissible administrative appeal involving the merits of such exclusion must be filed 
with the Federal agency that took the action. 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further administrative 
review. More information regarding appeal rights can be found at 42 C.F.R. Part 498. 
 
The reconsideration request should be sent to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], ST [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM].  
 
Sincerely,  
[Name]  
 
[Title]  
[Company]  
 
4. Business Type Not Met Example 
 
[month] [day], [year]  
 
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
 
Reference # (Contractor Control Number or NPI)  
 
Dear [Provider/Supplier Name]:  
Your application to enroll in Medicare is denied for the following reason(s):  
 
42 CFR 424.530(a)(1) - Not in Compliance with Medicare Requirements   42 CFR 410.62(c)(ii) states that speech language pathologists in private practice must be 
engaged in one of the following practice types if allowed by State and local law: (A) An 
unincorporated solo practice; (B) An unincorporated partnership or unincorporated group 
practice; (C) An employee in an unincorporated solo practice, partnership, or group practice, or a 
professional corporation or other incorporated speech-language pathology practice; (D) An 
employee of a physician group (includes certain Non-Physician Practitioners [NPPs], as 
appropriate); or (E) An employee of a group that is not a professional corporation.  
 
Your current private practice status is an incorporated solo practice; therefore, you do not qualify 
as a Medicare provider or supplier.  
 
Right to Submit a Corrective Action Plan (CAP) and Reconsideration Request: 
 
Corrective Action Plan: (Only if denied under 42 C.F.R.  424.530(a)(1)) 
 
You may submit a corrective action plan (CAP) in response to the denial of an enrollment 
application under 42 C.F.R.  424.530(a)(1). You may also request a reconsideration (described 
below). If your enrollment application was denied under authorities other than 42 C.F.R.  
424.530(a)(1), you may only submit a reconsideration request in response to those denial bases. 
 
The CAP is an opportunity to demonstrate that you have corrected the deficiencies identified above 
and thereby, establish your eligibility to enroll in the Medicare program. (Optional Coversheet 
sentence: [To facilitate the processing of your CAP, please utilize and include the [attached] 
coversheet [also found at [[insert web address for coversheet]] with your submission.]). The CAP 
must-- 
 
  Be received in writing within 35 calendar days of the date of this letter and mailed to the 
address below or emailed to the address below; 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a CAP on 
o
behalf of a reassigned provider/supplier without the provider/supplier submitting 
a signed statement authorizing that individual from the group to act on his/her 
behalf. 
  Provide evidence to demonstrate that you are in compliance with Medicare 
requirements. 
  Please note that CAPs may not be appealed further to the Departmental Appeals Board. Further 
appeal rights do exist for reconsideration requests (described below). CAP requests should be sent 
to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for reviewing the CAP) 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], ST [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review conducted 
by a person not involved in the initial determination. (Optional Coversheet sentence [To facilitate 
the processing of your reconsideration request, please utilize and include the [attached] coversheet 
[also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must-- 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below. 
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement. 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may-- 
    Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be 
submitted. 
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
  (If denied under 42 C.F.R.  424.530(a)(2)) Please note that you may not appeal through 
this process the merits of any exclusion by another Federal agency. Any further 
permissible administrative appeal involving the merits of such exclusion must be filed 
with the Federal agency that took the action. 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further administrative 
review. More information regarding appeal rights can be found at 42 C.F.R. Part 498. 
 
The reconsideration request should be sent to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], ST [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM]. 
 
Sincerely,  
[Name]  
 
[Title]  
[Company]  
 
5. Existing or Delinquent Overpayments Example 
 
[month] [day], [year]  
 
[Provider/Supplier Name]   [Address]  
[City] ST [Zip]  
 
Reference # (Contractor Control Number or NPI)  
 
Dear [Provider/Supplier Name]:  
 
Your application to enroll in Medicare is denied for the following reason(s):  
 
42 CFR 424.530(a)(6)  Existing Overpayment at Time of Application 
 
The current owner (as defined in  424.502), physician or non-physician practitioner has an 
existing overpayment at the time of filing an enrollment application.  
 
Dates: (enter date of existing or delinquent overpayment period)  
 
Pertinent details of action(s) (Whether the person or entity is on a Medicare-approved plan of 
repayment of payments are currently being offset: Whether the overpayment is currently being 
appealed; the reason for the overpayment)  
 
Right to Submit a Corrective Action Plan (CAP) and Reconsideration Request: 
 
Corrective Action Plan: (Only if denied under 42 C.F.R.  424.530(a)(1)) 
 
You may submit a corrective action plan (CAP) in response to the denial of an enrollment 
application under 42 C.F.R.  424.530(a)(1). You may also request a reconsideration (described 
below). If your enrollment application was denied under authorities other than 42 C.F.R.  
424.530(a)(1), you may only submit a reconsideration request in response to those denial bases. 
 
The CAP is an opportunity to demonstrate that you have corrected the deficiencies identified above 
and thereby, establish your eligibility to enroll in the Medicare program. (Optional Coversheet 
sentence: [To facilitate the processing of your CAP, please utilize and include the [attached] 
coversheet [also found at [[insert web address for coversheet]] with your submission.]). The CAP 
must-- 
 
  Be received in writing within 35 calendar days of the date of this letter and mailed to the 
address below or emailed to the address below; 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a CAP on 
o behalf of a reassigned provider/supplier without the provider/supplier submitting 
a signed statement authorizing that individual from the group to act on his/her 
behalf. 
  Provide evidence to demonstrate that you are in compliance with Medicare 
requirements. 
 
Please note that CAPs may not be appealed further to the Departmental Appeals Board. Further 
appeal rights do exist for reconsideration requests (described below). CAP requests should be sent 
to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for reviewing the CAP) 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], ST [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review conducted 
by a person not involved in the initial determination. (Optional Coversheet sentence [To facilitate 
the processing of your reconsideration request, please utilize and include the [attached] coversheet 
[also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must-- 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below. 
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement. 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may-- 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be 
submitted. 
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
  (If denied under 42 C.F.R.  424.530(a)(2)) Please note that you may not appeal through 
this process the merits of any exclusion by another Federal agency. Any further 
permissible administrative appeal involving the merits of such exclusion must be filed 
with the Federal agency that took the action. 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further administrative 
review. More information regarding appeal rights can be found at 42 C.F.R. Part 498. 
 
The reconsideration request should be sent to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], ST [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM]. 
 
Sincerely,  
[Name]  
 
[Title]  
[Company]    
6. MDPP Supplier Standards Not Met  Ineligible Coach Example 
 
[month] [day], [year]  
 
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
 
Reference # (Contractor Control Number or NPI)  
 
Dear [Provider/Supplier Name]:  
 
Your application to enroll in Medicare is denied for the following reason(s):  
42 CFR 424.530(a)(1) - Not in Compliance with Medicare Requirements 
  
Specifically, the following standards were not met:  
 
42 CFR 424.205(d)(3) - The MDPP supplier must not include on the roster of coaches nor 
permit MDPP services to be furnished by any individual coach who meets any of ineligibility 
criteria.  
42 CFR 424.205(e)(v)(a) specifies that an individual with a state or federal felony conviction in 
the previous 10 years of any crime against persons, such as murder, rape, assault, and other 
similar crimes, would not meet the eligibility criteria to be an MDPP coach.  
 
The following coach included on Section 7 of your Form CMS-20134 or its electronic equivalent 
meets this ineligibility criteria:  
 
John B. Doe | DOB: June 19, 1991 | NPI: 1234567  
 
Please see attached documentation of the felony conviction.  
 
Right to Submit a Corrective Action Plan (CAP) and Reconsideration Request: 
 
Corrective Action Plan: (Only if denied under 42 C.F.R.  424.530(a)(1)) 
 
You may submit a corrective action plan (CAP) in response to the denial of an enrollment 
application under 42 C.F.R.  424.530(a)(1). You may also request a reconsideration (described 
below). If your enrollment application was denied under authorities other than 42 C.F.R.  
424.530(a)(1), you may only submit a reconsideration request in response to those denial bases. 
 
The CAP is an opportunity to demonstrate that you have corrected the deficiencies identified above 
and thereby, establish your eligibility to enroll in the Medicare program. (Optional Coversheet 
sentence: [To facilitate the processing of your CAP, please utilize and include the [attached] 
coversheet [also found at [[insert web address for coversheet]] with your submission.]). The CAP 
must-- 
    Be received in writing within 35 calendar days of the date of this letter and mailed to the 
address below or emailed to the address below; 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a CAP on 
o
behalf of a reassigned provider/supplier without the provider/supplier submitting 
a signed statement authorizing that individual from the group to act on his/her 
behalf. 
  Provide evidence to demonstrate that you are in compliance with Medicare 
requirements. 
 
Please note that CAPs may not be appealed further to the Departmental Appeals Board. Further 
appeal rights do exist for reconsideration requests (described below). CAP requests should be sent 
to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for reviewing the CAP) 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], ST [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review conducted 
by a person not involved in the initial determination. (Optional Coversheet sentence [To facilitate 
the processing of your reconsideration request, please utilize and include the [attached] coversheet 
[also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must-- 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below.    State the issues or findings of fact with which you disagree and the reasons for 
disagreement. 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or 
o
she has the authority to represent the provider or supplier is sufficient to accept 
this individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, 
o
supplier, or authorized or delegated official must file written notice of the 
appointment of its representative with the submission of the reconsideration 
request. 
  Authorized or delegated officials for groups cannot sign and submit a 
o
reconsideration request on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from 
the group to act on his/her behalf. 
 
Providers and suppliers may-- 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be 
submitted. 
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
  (If denied under 42 C.F.R.  424.530(a)(2)) Please note that you may not appeal through 
this process the merits of any exclusion by another Federal agency. Any further 
permissible administrative appeal involving the merits of such exclusion must be filed 
with the Federal agency that took the action. 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further administrative 
review. More information regarding appeal rights can be found at 42 C.F.R. Part 498. 
 
The reconsideration request should be sent to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], ST [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals  
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850   
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM]. 
 
Sincerely,  
[Name]  
 
[Title]  
[Company]  
10.7.9  Revocation Letters  
(Rev.12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 
 
A.  Revocation Letter Guidance 
 
The contractor-- 
 
  Must submit one or more of the Primary Revocation Reasons as found in section 10.4.7.3 
into the appropriate section on the specific Revocation Letter.  Only the CFR citation and 
a short heading shall be cited for the primary revocation reason. 
 
  Shall include sufficient details to support the reason for the provider or suppliers 
revocation; 
 
  Shall issue all revocation letters via certified letter, per regulations found in 42 CFR 
405.800(b)(1); and 
 
  Shall issue two revocation letters to any solely owned organizations, one for the individual 
and the other for the organization. 
 
B.  Model Revocation Letters 
 
1.  Revocation Example - Letter for DMEPOS Suppliers 
 
[month] [day], [year] 
 
[Supplier Name]  
[Address] 
[City] ST [Zip] 
Reference # (PTAN #, Enrollment #, Case #, etc.)  Certified mail number: [number] 
Returned receipt requested  
Dear [Supplier Name]: 
The purpose of this letter is to inform you that pursuant to 42 CFR  405.800, 424.57(x), 
424.535(g), and 424.535(a)[(x)], your Medicare supplier number [xxxxxxxxxx], Medicare 
enrollment, and Medicare billing privileges for Durable Medical Equipment, Prosthetics, 
Orthotics and Supplies (DMEPOS), 
 
[will be revoked effective 30 days from the postmarked date of this letter] 
 
[are revoked. The effective date of this revocation has been made retroactive to [month] [day], 
[year], which is the date [revocation reason]] 
 
Pursuant to 42 CFR 424.535(c), the supplier is barred from re-enrolling for a period of [number 
of years] year(s) in the Medicare program from the effective date of the revocation. In order to 
re-enroll, you must meet all requirements for your supplier type. 
 
[The Supplier Audit and Compliance Unit (SACU) reviewed and evaluated the documents you 
submitted in response to the developmental letter dated [date]. This letter allowed you to 
demonstrate your full compliance with the DMEPOS supplier standards and/or to correct the 
deficient compliance requirement(s).] 
 
[The Supplier Audit and Compliance Unit (SACU) has not received a response to the 
developmental letter sent to you on [date]. This letter allowed you to demonstrate your full 
compliance with the DMEPOS supplier standards and/or to correct the deficient compliance 
requirement(s)] 
 
[[Contractor Name] has not received a response to the developmental letter sent to you on [date] 
informing you that the request for a hardship exception for the required application fee was 
denied. The notification afforded you the opportunity to pay the mandatory application fee for 
processing your enrollment application and an appeal period which you did not select.] 
 
[[Contractor Name] has not received a response to the developmental letter sent to you on [date] 
informing you that the application fee was not paid at the time you filed the Form CMS-855S 
enrollment application. The 30-day notification afforded you the opportunity to pay the 
mandatory application fee for processing your enrollment application] 
 
We have determined that you are not in compliance with the supplier standards noted below: 
 
42 CFR 424.57(c) [1-30] [Insert the specific performance standard not met] 
 
Section 1834(j) of the Social Security Act states that, with the exception of medical equipment 
and supplies furnished incident to a physicians service, no payment may be made by Medicare 
for items furnished by a supplier unless the supplier has a valid Medicare billing number. 
Therefore, any expenses for items you supply to a Medicare beneficiary on or after the effective 
date of the revocation of your billing numbers are your responsibility and not the beneficiarys,  unless you have proof that you have notified the beneficiary in accordance with section 1834 
(a)(A)(ii) of the Social Security Act and the beneficiary has agreed to take financial 
responsibility if the items you supply are not covered by Medicare. You will be required to 
refund on a timely basis to the beneficiary (and will be liable to the beneficiary for) any amounts 
collected from the beneficiary for such items. If you fail to refund the beneficiary as required 
under 1834 (j) (4) and 1879(h) of the Social Security Act, you may be liable for Civil Monetary 
penalties. 
 
You may not appeal through this process the merits of any exclusion by another Federal agency. 
Any further permissible administrative appeal involving the merits of such exclusion must be 
filed with the Federal agency that took the action. 
 
Right to Submit a Corrective Action Plan (CAP) and Reconsideration Request: 
 
Corrective Action Plan: (Only if revoked under 42 C.F.R.  424.535(a)(1)) 
 
You may submit a corrective action plan (CAP) in response to an enrollment revocation under 42 
C.F.R.  424.535(a)(1). You may also request a reconsideration (described below). If your 
enrollment was revoked under authorities other than 42 C.F.R.  424.535(a)(1), you may only 
submit a reconsideration request in response to those denial bases. 
 
The CAP is an opportunity to demonstrate that you have corrected the deficiencies identified above 
and thereby, establish your eligibility to enroll in the Medicare program. (Optional Coversheet 
sentence: [To facilitate the processing of your CAP, please utilize and include the [attached] 
coversheet [also found at [[insert web address for coversheet]] with your submission.]). The CAP 
must-- 
 
  Be received in writing within 35 calendar days of the date of this letter and mailed to the 
address below or emailed to the address below; 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or she 
o
has the authority to represent the provider or supplier is sufficient to accept this 
individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a CAP on behalf 
o
of a reassigned provider/supplier without the provider/supplier submitting a signed 
statement authorizing that individual from the group to act on his/her behalf. 
 
  Provide evidence to demonstrate that you are in compliance with Medicare requirements. 
 
Please note that CAPs may not be appealed further to the Departmental Appeals Board. Further 
appeal rights do exist for reconsideration requests (described below). CAP requests should be sent 
to:   
(Insert correct address based on whether the MAC or CMS is responsible for reviewing the CAP) 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], [ST] [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review conducted 
by a person not involved in the initial determination. (Optional Coversheet sentence [To facilitate 
the processing of your reconsideration request, please utilize and include the [attached] coversheet 
[also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must-- 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or  
  emailed to the address below. 
  State the issues or findings of fact with which you disagree and the reasons for  
  disagreement. 
  Be signed by the provider or supplier, an authorized or delegated official that has been  
  reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or she has 
o
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative. 
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her 
behalf. 
 
Providers and suppliers may-- 
 
  Submit additional information with the reconsideration that may have a bearing on 
the decision. However, if you have additional information that you would like a 
Hearing Officer to consider during the reconsideration or, if necessary, an 
Administrative Law Judge (ALJ) to consider during a hearing, you must submit  that information with your request for reconsideration. This is your only 
opportunity to submit information during the administrative appeals process unless 
an ALJ allows additional information to be submitted. 
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
  (If revoked under 42 C.F.R.  424.535(a)(2)) Please note that you may not appeal through 
this process the merits of any exclusion by another Federal agency. Any further 
permissible administrative appeal involving the merits of such exclusion must be filed 
with the Federal agency that took the action. 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further administrative 
review. More information regarding appeal rights can be found at 42 C.F.R. Part 498. 
 
The reconsideration request should be sent to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], [ST] [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
If you have any questions, please contact our office at [phone number] between the hours of [x:00 
 
AM/PM] and [x:00 AM/PM].
 
Sincerely, 
 
[Name] 
[Title] 
[Company] 
 
2.  Model Revocation Letter for Part B Suppliers and Certified Providers and Suppliers 
 
[Month] [day], [year] 
 
[Provider/Supplier Name]  
[Address] 
[City] ST [Zip] 
 
Reference # (Contractor Control Number or NPI)   
 
Dear [Provider/Supplier Name]: 
 
Your Medicare enrollment and Medicare billing privileges are being revoked effective [Date of 
revocation] for the following reasons: 
 
xx CFR xxx.(x) [heading]  
[Specific reason] 
 
xx CFR xxx.(x) [heading]  
[Specific reason] 
 
(For certified providers and certified suppliers only: Pursuant to 42 CFR 424.535(b), this action 
will also terminate your corresponding (provider or supplier) agreement.) 
 
Pursuant to 42 CFR 424.535(c), CMS is establishing a re-enrollment bar for a period of [Insert 
amount of time] that shall begin 30 days after the postmark date of this letter. This re-enrollment 
bar only applies to your ability to submit a new enrollment application to the Medicare program. 
In order to re-enroll, you must meet all requirements for your provider or supplier type. 
 
Right to Submit a Corrective Action Plan (CAP) and Reconsideration Request: 
 
Corrective Action Plan: (Only if revoked under 42 C.F.R.  424.535(a)(1)) 
 
You may submit a corrective action plan (CAP) in response to the revocation of Medicare billing 
privileges under 42 C.F.R.  424.535(a)(1). You may also request a reconsideration (described 
below). If your Medicare billing privileges were revoked under authorities other than 42 C.F.R.  
424.535(a)(1), you may only submit a reconsideration request in response to those revocation 
bases. 
 
The CAP is an opportunity to demonstrate that you have corrected the deficiencies identified 
above and thereby, establish your eligibility to maintain enrollment in the Medicare program. 
(Optional Coversheet sentence [To facilitate the processing of your CAP, please utilize and 
include the [attached] coversheet [also found at [[insert web address for coversheet]] with your 
submission.]). The CAP must-- 
 
  Be received in writing within 35 calendar days of the date of this letter and mailed or emailed 
to the address below; 
 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or she has 
o
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative. 
 
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
 
  Authorized or delegated officials for groups cannot sign and submit a CAP on behalf of a 
o
reassigned provider/supplier without the provider/supplier submitting a signed statement 
authorizing that individual from the group to act on his/her behalf. 
 
  Provide evidence to demonstrate that you are in compliance with Medicare requirements. 
 
(Insert correct address based on whether the MAC or CMS is responsible for reviewing the CAP) 
 
The CAP should be sent to: 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], [ST] [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must-- 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or  
emailed to the address below. 
  State the issues or findings of fact with which you disagree and the reasons for  
disagreement. 
  Be signed by the provider or supplier, an authorized or delegated official that has been  
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or she 
o
has the authority to represent the provider or supplier is sufficient to accept this 
individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on 
his/her behalf. 
 
Providers and suppliers may-- 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during 
the administrative appeals process unless an ALJ allows additional information to be 
submitted. 
  Include an email address if you want to receive correspondence regarding your appeal 
via email. 
  (If revoked under 42 C.F.R.  424.535(a)(2)) Please note that you may not appeal 
through this process the merits of any exclusion by another Federal agency. Any 
further permissible administrative appeal involving the merits of such exclusion must 
be filed with the Federal agency that took the action. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], [ST] [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
Pursuant to 42 CFR 424.535(c), CMS is establishing a re-enrollment bar for a period of [Insert 
amount of time] that shall begin 30 days after the postmark date of this letter. This re- enrollment 
bar only applies to your ability to submit a new enrollment application to the Medicare program. 
In order to re-enroll, you must meet all requirements for your provider or supplier type. 
 
If you have any questions, please contact our office at [phone number] between the hours of  [x:00 AM/PM] and [x:00 AM/PM]. 
 
Sincerely, 
 
[Name] 
[Title] 
[Company] 
 
C. Revocation Letter Examples 
 
Note that each example contains instructions to send appeals to both CMS and the contractor, 
regardless of the example reason, so that the contractors may include the appropriate appeal 
address based on the provider or supplier type that has been revoked. In addition, note that the 
section advising the provider/supplier of their right to submit a CAP are only included in the 
examples of revocations based on 42 C.F.R.  424.535(a)(1). 
 
1. Abuse of Billing Revocation Letter Example 
 
[month] [day], [year]  
 
[Entity name] 
[Address] 
[City, State & ZIP Code] 
 
Reference # (PTAN #, Enrollment #, Case #, etc.)  
 
Dear [Provider/Supplier Name]:  
 
Your Medicare enrollment and Medicare billing privileges are being revoked effective June 16, 
2012 for the following reasons:  
 
Revocation reason: 42 CFR  424.535(a)(8)  
 
Specifically, you submitted 186 claims to Medicare for services provided after the date of death 
of 15 beneficiaries.  
 
Pursuant to 42 CFR 424.535(c), CMS is establishing a re-enrollment bar for a period of [Insert 
amount of time] that shall begin 30 days after the postmark date of this letter. This re- enrollment 
bar only applies to your ability to submit a new enrollment application to the Medicare program. 
In order to re-enroll, you must meet all requirements for your provider or supplier type. 
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.])   
Reconsideration requests must-- 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below. 
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement. 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or she 
o
has the authority to represent the provider or supplier is sufficient to accept this 
individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on 
his/her behalf. 
 
Providers and suppliers may-- 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during 
the administrative appeals process unless an ALJ allows additional information to be 
submitted. 
  Include an email address if you want to receive correspondence regarding your appeal 
via email. 
  (If revoked under 42 C.F.R.  424.535(a)(2)) Please note that you may not appeal 
through this process the merits of any exclusion by another Federal agency. Any 
further permissible administrative appeal involving the merits of such exclusion must 
be filed with the Federal agency that took the action. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
  [Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], [ST] [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
Pursuant to 42 CFR 424.535(c), CMS is establishing a re-enrollment bar for a period of [Insert 
amount of time] that shall begin 30 days after the postmark date of this letter. This re- enrollment 
bar only applies to your ability to submit a new enrollment application to the Medicare program. 
In order to re-enroll, you must meet all requirements for your provider or supplier type. 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM]. 
 
Sincerely,  
 
[Name] 
[Title] 
[Company] 
 
2. DMEPOS Supplier Revocation Letter Example  
 
[month] [day], [year]  
 
[Entity name] 
[Address] 
[City], [ST] [Zip]  
 
 
Reference #: [PTAN #, Enrollment #, Case #, etc.] 
NPI: [xxxxxxxxxx] 
 
Dear [Supplier Name]:  
 
The purpose of this letter is to inform you that pursuant to 42 C.F.R.  405.800, 42 C.F.R. 
424.57(e), and 42 C.F.R.  424.535(a)(5), your Medicare supplier number [xxxxxxxxxxx], 
Medicare enrollment, and Medicare billing privileges for Durable Medical Equipment, 
Prosthetics, Orthotics and Supplies (DMEPOS) issued by [Contractor name) is revoked. The 
effective date of this revocation has been made retroactive to April 26, 2012, which is the date 
the Centers for Medicare & Medicaid Services (CMS) determined that your practice location is 
not operational.  
  We have determined that you are not in compliance with the supplier standards noted below:  
 
42 C.F.R.  424.57(c)(7) Maintain a physical facility on an appropriate site, accessible to the 
public and staffed during posted hours of business with visible signage.  
 
Recently a representative of [Contractor name] attempted to conduct a visit of your facility on 
April 26, 2012. However, the visit was unsuccessful because your facility was closed, locked, 
and vacant. There was a For Rent sign on the window along with a sign directing customers to 
a nearby Rite Aid Pharmacy. Because we could not complete an inspection of your facility, we 
could not verify your compliance with the supplier standards. Based on a review of the facts, we 
have determined that your facility is not operational to furnish Medicare covered items and 
services. Thus, you are in violation of 42 CFR  424.535(a)(5).  
 
42 C.F.R.  424.57(c)(26) must meet the surety bond requirements specified in 42 C.F.R.  
424.57(d).  
 
We received a cancellation notice from Cook, Books & Hyde Surety indicating that the surety 
bond on file with the billing number 99999999 has been cancelled effective January 19, 2012. 
You failed to maintain a valid surety bond as required by law.  
 
Section 1834 (j) of the Social Security Act states that, with the exception of medical equipment 
and supplies furnished incident to a physicians service, no payment may be made by Medicare 
for items furnished by a supplier unless the supplier has a valid Medicare billing number. 
Therefore, any expenses for items you supply to a Medicare beneficiary on or after the effective 
date of the revocation of your billing numbers are your responsibility and not the beneficiarys, 
unless you have proof that you have notified the beneficiary in accordance with section 
1834(a)(18)(ii) of the Social Security Act and the beneficiary has agreed to take financial 
responsibility if the items you supply are not covered by Medicare. You will be required to 
refund on a timely basis to the beneficiary (and will be liable to the beneficiary for) any amounts 
collected from the beneficiary for such items. If you fail to refund the beneficiary as required 
under sections 1834(j)(4) and 1879(h) of the Social Security Act, you may be liable for Civil 
Monetary penalties. 
 
(Delete the following paragraph if no re-enrollment bar established.)[Pursuant to 42 C.F.R.  
424.535(c), CMS is establishing a re-enrollment bar for a period of [Insert amount of time] that 
shall begin 30 days after the postmark date of this letter. This re-enrollment bar only applies to 
your ability to submit a new enrollment application to the Medicare program. In order to re-
enroll, you must meet all requirements for your provider or supplier type.] 
 
In addition, if submitting a Form CMS-855S application after the re-enrollment bar has expired, 
42 C.F.R.  424.57(d)(3)(ii) states suppliers will be required to maintain an elevated surety bond 
amount of $50,000 for each final adverse action imposed. Therefore, if you do not request a 
reconsideration of this decision or receive an unfavorable decision through the administrative 
review process, you must submit an elevated surety bond. Please note this amount is in addition 
to, and not in lieu of, the base $50,000 amount that must be maintained.  
 
Right to Submit a Reconsideration Request: 
  You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the implementation of the initial determination. (Optional 
Coversheet sentence [To facilitate the processing of your reconsideration request, please utilize 
and include the attached coversheet [also found at [[insert web address for coversheet]] with your 
submission.]) 
 
Reconsideration requests must-- 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that 
o
he/she/they have the authority to represent the provider or supplier is sufficient to 
accept this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on 
his/her/their behalf. 
 
Providers and suppliers may-- 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during 
the administrative appeals process unless an ALJ allows additional information to be 
submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to:  
 
[Contractor name] 
[Address] 
[City], [ST] [Zip] 
  If you choose not to request a reconsideration of this decision, or you do not receive a favorable 
decision through the administrative review process, you must wait [insert number] years before 
resubmitting your CMS-855S application, per the re-enrollment bar cited above. Applications 
received by [Contractor name] prior to this timeframe will be returned.  
 
If you have any questions, please contact our office at [Contractor call center phone number] 
between the hours of [x:00 AM/PM ET/CT/PT/MT] and [x:00 AM/PM ET/CT/PT/MT].  
 
Sincerely,  
 
[Name] 
[Title] 
[Company] 
 
3. MDPP Supplier Use of an Ineligible Coach Revocation Letter Example 
 
[month] [day], [year]  
 
[Entity name] 
[Address] 
[City, State & ZIP Code] 
 
Reference # (PTAN #, Enrollment #, Case #, etc.)  
 
Dear [MDPP Supplier Name]:  
 
Your Medicare enrollment and Medicare billing privileges are being revoked effective June 16, 
2018 for the following reasons:  
 
Revocation reason: 42 CFR 424.535(a)(1)  Not in Compliance with Medicare Requirements  
 
Per 42 CFR 424.205(d)(3), MDPP suppliers must only use eligible coaches.  
 
Revocation reason: 42 CFR 424.205(h)(v)  Use of an Ineligible coach  
 
Specifically, you were notified on April 1, 2018 that John Doe was ineligible to serve as an 
MDPP coach due to an assault conviction in June 2015. On April 15, 2018, you submitted a 
corrective action plan (CAP), which removed John Doe from Section 7 of your Form CMS-
20134. On June 1, 2018, you submitted a claim with the NPI of John Doe for services rendered 
May 1st, after he was removed from your coach roster. This indicates knowingly use of an 
ineligible MDPP coach. 
  
Revocations under 42 CFR 424.205(h)(v) are not eligible for CAP submission. The revocation 
becomes effective 30 days after the date of this notice.  
 
Pursuant to 42 CFR 424.535(c), CMS is establishing a re-enrollment bar for a period of [Insert 
amount of time] that shall begin 30 days after the postmark date of this letter. This re- enrollment 
bar only applies to your ability to submit a new enrollment application to the Medicare program.  In order to re-enroll, you must meet all requirements for your provider or supplier type. 
 
Right to Submit a Corrective Action Plan (CAP) and Reconsideration Request: 
 
Corrective Action Plan: (Only if revoked under 42 C.F.R.  424.535(a)(1)) 
 
You may submit a corrective action plan (CAP) in response to the revocation of Medicare billing 
privileges under 42 C.F.R.  424.535(a)(1). You may also request a reconsideration (described 
below). If your Medicare billing privileges were revoked under authorities other than 42 C.F.R.  
424.535(a)(1), you may only submit a reconsideration request in response to those revocation 
bases. 
 
The CAP is an opportunity to demonstrate that you have corrected the deficiencies identified 
above and thereby, establish your eligibility to maintain enrollment in the Medicare program. 
(Optional Coversheet sentence [To facilitate the processing of your CAP, please utilize and 
include the [attached] coversheet [also found at [[insert web address for coversheet]] with your 
submission.]) The CAP must-- 
 
  Be received in writing within 35 calendar days of the date of this letter and mailed or 
emailed to the address below; 
 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or she 
o
has the authority to represent the provider or supplier is sufficient to accept this 
individual as the representative. 
 
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
 
  Authorized or delegated officials for groups cannot sign and submit a CAP on behalf 
o
of a reassigned provider/supplier without the provider/supplier submitting a signed 
statement authorizing that individual from the group to act on his/her behalf. 
 
  Provide evidence to demonstrate that you are in compliance with Medicare requirements. 
 
(Insert correct address based on whether the MAC or CMS is responsible for reviewing the CAP) 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], [ST] [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
  Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must-- 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below. 
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement. 
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
  If the authorized representative is an attorney, the attorneys statement that he or she 
o
has the authority to represent the provider or supplier is sufficient to accept this 
individual as the representative. 
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on 
his/her behalf. 
 
Providers and suppliers may-- 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during 
the administrative appeals process unless an ALJ allows additional information to be 
submitted. 
  Include an email address if you want to receive correspondence regarding your appeal 
via email. 
  (If revoked under 42 C.F.R.  424.535(a)(2)) Please note that you may not appeal 
through this process the merits of any exclusion by another Federal agency. Any 
further permissible administrative appeal involving the merits of such exclusion must 
be filed with the Federal agency that took the action. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further  administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to: 
 
(Insert correct address based on whether the MAC or CMS is responsible for handling the 
reconsideration. 
 
[Name of MAC]    Centers for Medicare & Medicaid Services 
[Address]  or  Center for Program Integrity 
[City], [ST] [Zip]  Provider Enrollment & Oversight Group 
Attn: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop AR-19-51 
Baltimore, MD 21244-1850 
Or emailed to: 
 
[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov] 
 
Pursuant to 42 CFR 424.535(c), CMS is establishing a re-enrollment bar for a period of [Insert 
amount of time] that shall begin 30 days after the postmark date of this letter. This re- enrollment 
bar only applies to your ability to submit a new enrollment application to the Medicare program. 
In order to re-enroll, you must meet all requirements for your provider or supplier type. 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM].  
 
Sincerely,  
 
[Name] 
[Title] 
[Company] 
10.7.10  Corrective Action Plan (CAP) Model Letters 
(Rev. 10611; Issued: 03-19-21; Effective:11-19-20; Implementation: 11-19-20) 
 
A. CAP Withdrawn Acknowledgement Template  
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
1. Email Template 
 
To: [Email address provided by the person who submitted the CAP]  
Subject: Medicare Provider Enrollment CAP re: [Provider/Supplier Name]   Dear [Name of the person(s) who submitted the CAP]: 
We are in receipt of your written withdrawal request in regard to your corrective 
action plan (CAP) received on [Month] [DD], [YYYY]. [MAC Name] has not 
yet issued a decision regarding your CAP. Therefore, [MAC Name] considers 
your CAP dated [Month] [DD], [YYYY] to be withdrawn. As a result, a decision 
will not be issued in response to your CAP. 
 
If you have not yet filed a reconsideration request, please be advised that failure 
to timely submit a reconsideration request is deemed a waiver of all further 
administrative review. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
2. Hard-Copy Letter Template 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name]  
Attn: [Signer/Submitter of CAP] 
[Address] (Address from which the CAP was sent)  
[City], [State] [Zip Code] 
 
Re: Corrective Action Plan Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the CAP]: 
 
We are in receipt of your written withdrawal request in regard to your corrective 
action plan (CAP) received on [Month] [DD], [YYYY]. [MAC Name] has not 
yet issued a decision regarding your CAP. Therefore, [MAC Name] considers 
your CAP dated [Month] [DD], [YYYY] to be withdrawn. As a result, a decision 
will not be issued in response to your CAP.   
If you have not yet filed a reconsideration request, please be advised that failure 
to timely submit a reconsideration request is deemed a waiver of all further 
administrative review. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
B. CAP Receipt Acknowledgement Email Template to Provider/Supplier/ 
Representative 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
1. Email Template 
 
To: [Email address provided by the person who submitted the CAP]  
Subject: Medicare Provider Enrollment CAP re: [Provider/Supplier Name]  
Dear [Name of the person(s) who submitted the CAP]: 
We  are  in  receipt  of  your  corrective  action  plan  (CAP)  on  behalf  of 
[Provider/Supplier Name]. Please be advised that [MAC Name] has 60 calendar 
days to review your CAP and render a decision. 
 
If you have additional information that you would like a hearing officer to 
consider during the CAP review you must submit that information prior to a 
decision being issued. 
 
Please be advised that failure to timely submit a reconsideration request is 
deemed a waiver of all further administrative review. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number]   
Sincerely 
, 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
2. Hard-Copy Letter Template 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name]  
Attn: [Signer/Submitter of CAP] 
[Address] (Address from which the CAP was sent)  
[City], [State] [Zip Code] 
 
Re: Corrective Action Plan Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the CAP]: 
 
We  are  in  receipt  of  your  corrective  action  plan  (CAP)  on  behalf  of 
[Provider/Supplier Name]. Please be advised that [MAC Name] has 60 calendar 
days to review your CAP and render a decision. 
 
If you have additional information that you would like a hearing officer to 
consider during the CAP review you must submit that information prior to a 
decision being issued. 
 
Please be advised that failure to timely submit a reconsideration request is 
deemed a waiver of all further administrative review. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
[Signature of Hearing Officer] (May be electronic)   [Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
C. CAP Decision Email Template to Provider/Supplier/Representative 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
To: [Email address provided by the person who submitted the CAP]  
Subject: Medicare Provider Enrollment CAP re: [Provider/Supplier Name]  
(Be sure to attach a copy of the final decision[s] in PDF format.) 
Dear [Name of the person(s) who submitted the CAP]: 
 
Please see the attached decision regarding your Medicare Provider Enrollment CAP. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic)  
 
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[MAC Name] 
 
D. CAP Not Actionable (Moot) Model Letter 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name]  
Attn: [Signer/Submitter of CAP] 
[Address] (Address from which the CAP was sent)  
[City], [State] [Zip Code] 
 
Re: Corrective Action Plan Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)   NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the CAP]: 
 
This letter is in response to the CAP received by [MAC Name] based on the initial 
determination letter, dated [Month] [DD], [YYYY]. 
 
In correspondence dated [Month] [DD], [YYYY], the initial determination letter, 
dated [Month] [DD], [YYYY] informing you of the [denial of your Medicare 
enrollment application or revocation of your Medicare billing privileges] was [insert 
description]  (describe  action  taken  in  regards  to  the  initial  determination,  i.e. 
rescission of denial or revocation). For your convenience, a copy of the initial 
determination is included. Therefore, the issue set forth in the CAP is no longer 
actionable. This issue is moot, and we are unable to render a decision on the matter. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic)  
 
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[MAC Name] 
 
E. Untimely CAP Dismissal Model Letter 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name]  
Attn: [Signer/Submitter of CAP] 
[Address] (Address from which the CAP was sent)  
[City], [State] [Zip Code] 
 
Re: Corrective Action Plan Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional)   
Dear [Name of the person(s) who submitted the CAP]: 
 
This letter is in response to the CAP received by [MAC Name] based on the initial 
determination letter, dated [Month] [DD], [YYYY]. 
 
[MAC Name] is unable to accept your CAP as it was not timely submitted. The 
initial determination letter was dated [Month] [DD], [YYYY]. A CAP must be 
received within 35 calendar days of the date of the initial determination letter. Your 
CAP was not received until [Month] [DD], [YYYY], which is beyond the applicable 
submission time frame. [Provider/Supplier/Representative] failed to show good 
cause for its late request. Therefore, [MAC Name] is unable to render a decision in 
this matter. 
 
Please refer to the initial determination letter, dated [Month] [DD], [YYYY], for 
instructions on how to properly file a reconsideration request. If you have already 
submitted a reconsideration request, you will receive further communication related 
to that submission. Failure to timely file a reconsideration request is deemed a 
waiver of all further administrative review. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
 
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[MAC Name] 
 
F. Improperly Signed CAP Dismissal Model Letter 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name]  
Attn: [Signer/Submitter of CAP] 
[Address] (Address from which the CAP was sent)  
[City], [State] [Zip Code] 
 
Re: Corrective Action Plan Decision  Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS) 
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the CAP]: 
 
This letter is in response to the corrective action plan (CAP) received by [MAC 
Name] based on the initial determination letter, dated [Month] [DD], [YYYY]. 
 
[MAC Name] is unable to accept your CAP as it was not signed by an authorized or 
delegated  official  currently  on  file  in  your  Medicare  enrollment  record,  the 
individual  provider  or  supplier,  or  a  properly  appointed  representative.  The 
signature requirement was stated in the initial determination letter, dated [Month] 
[DD], [YYYY], as well as in Chapter 10 of the Medicare Program Integrity Manual. 
 
Please refer to the initial determination letter, dated [Month] [DD], [YYYY], for 
instructions on how to properly file a reconsideration request. If you have already 
submitted a reconsideration request, you will receive further communication related 
to that submission. Failure to timely file a reconsideration request is deemed a 
waiver of all further administrative review. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
 
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[MAC Name] 
 
G. No CAP Rights Dismissal Model Letter 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name]  
Attn: [Signer/Submitter of CAP] 
[Address] (Address from which the CAP was sent)   [City], [State] [Zip Code] 
 
Re: Corrective Action Plan Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the CAP]: 
 
This letter is in response to the corrective action plan (CAP) received by [MAC 
Name] based on the initial determination letter, dated [Month] [DD], [YYYY]. 
 
[MAC Name] is unable to accept your CAP. A provider or supplier may only submit 
a CAP if there has been a denial of enrollment in the Medicare program under 42 
C.F.R  424.530(a)(1) or the revocation of Medicare billing privileges under 42 
C.F.R.  424.535(a)(1). Your enrollment was not denied or revoked under one of 
the aforementioned authorities. Therefore, a CAP decision cannot be rendered based 
on this submission. 
 
Please refer to the initial determination letter, dated [Month] [DD], [YYYY], for 
instructions on how to properly file a reconsideration request. If you have already 
submitted a reconsideration request, you will receive further communication related 
to that submission. Please be advised that failure to timely submit a reconsideration 
request is deemed a waiver of all further administrative review. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
 
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[MAC Name] 
 
H. Not Eligible to Submit CAP Dismissal Model Letter 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [DD], [YYYY]   
[Provider/Supplier/Attorney/Firm Name]  
Attn: [Signer/Submitter of CAP] 
[Address] (Address from which the CAP was sent)  
[City], [State] [Zip Code] 
 
Re: Corrective Action Plan Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the CAP]: 
 
This letter is in response to the [corrective action plan (CAP)] received by [MAC 
Name], based on the [Month] [DD], [YYYY] initial determination. 
 
[MAC Name] is unable to accept your [CAP] submission because the action taken in 
regards to  your Medicare enrollment is not an initial determination subject to 
administrative review. More specifically, an initial determination has not been made 
as described in 42 C.F.R.  498.3(b). Under 42 C.F.R.  498.5(l), appeal rights 
extend only to initial determinations related to the denial or revocation of Medicare 
billing privileges. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
 
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[MAC Name] 
 
I. CAP Signature Development Model Letter 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name]  
Attn: [Signer/Submitter of CAP]  [Address] (Address from which the CAP was sent)  
[City], [State] [Zip Code] 
 
Re: Corrective Action Plan Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the CAP]: 
 
We are in receipt of your CAP submission, received on [Month] [DD], [YYYY]. 
 
(If the submission is not properly signed, use the following.) [Your submission is 
not appropriately signed, as stated in the initial determination letter and in the 
Medicare Program Integrity Manual, Ch. 10, Section 10.6.18. [MAC Name] is 
requesting that you submit a CAP that is properly signed by the individual provider, 
supplier, the authorized or delegated official, or a properly appointed representative. 
Your properly signed submission must be received within 15 calendar days of the 
date of this notice. If you do not timely respond to this request, your CAP submission 
may be dismissed.] 
 
(If the submission is missing a statement by the attorney, use the following.) [Your 
submission is missing an attorney statement that he or she has the authority to 
represent the provider or supplier. [MAC Name] is requesting that you submit a 
CAP that includes an attorney statement that he or she has the authority to represent 
the provider or supplier within 15 calendar days of the date of this notice. If you do 
not timely respond to this request, your CAP submission may be dismissed.] 
 
(If the submission is missing a signed written notice from the provider/supplier 
authorizing the representative to act on his/her/its behalf, use the following.) [Your 
submission is missing a written notice of the appointment of a representative signed 
by the provider or supplier. [MAC Name] is requesting that you submit written 
notice of the appointment of a representative that is signed by the provider or 
supplier within 15 calendar days of the date of this notice. If you do not timely 
respond to this request, your CAP submission may be dismissed.] 
 
Your submission should be sent to [MAC Appeal Receipt Email Address] or mailed 
to the following address: 
 
[MAC Appeal Receipt Address] [MAC Fax number] 
 
If you have any questions, please contact our office at [phone number] between the 
hours of [x:00 AM/PM] and [x:00 AM/PM]. 
 
Sincerely, 
   
[Signature of Hearing Officer] (May be electronic)  
 
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[MAC Name] 
 
J. Favorable CAP Model Letter in Response to an Enrollment Denial 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name]  
Attn: [Signer/Submitter of CAP] 
[Address] (Address from which the CAP was sent)  
[City], [State] [Zip Code] 
 
Re: Corrective Action Plan Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the CAP]: 
 
This letter is in response to the corrective action plan (CAP) received by [MAC 
Name] based on an enrollment denial. The initial determination letter was dated 
[Month] [DD], [YYYY] and the CAP was received on [Month] [DD], [YYYY]; 
therefore, this CAP is considered timely. (if the CAP is untimely, but good cause 
has been found to accept the CAP, use the following [This CAP was not timely 
submitted, but a good cause waiver has been granted.) The following decision is 
based on the Social Security Act (Act), Medicare regulations, the CMS manual 
instructions, the Medicare enrollment record, and any information received before 
this decision was rendered. 
 
DENIAL REASON: 
 
  42 C.F.R.  424.530(a)(1) 
 
OTHER APPLICABLE AUTHORITIES: 
 
  (Ex: Medicare Program Integrity Manual chapter 10, section 10.XX) 
 
EXHIBITS: 
    Exhibit 1: (Ex.: CAP, signed by Jane Doe, dated [Month] [DD], [YYYY].) 
  Exhibit 2: (Ex: Copy of a medical license for Jane Doe from the Wisconsin 
Medical Board, effective [Month] [DD], [YYYY].) 
 
(In this section list each document submitted by the provider or supplier. Each 
exhibit should include the date, as well as a brief description of the document. You 
shall also include all other documentation not submitted by the provider that the 
hearing officer reviewed in making the decision, e.g., enrollment applications, 
development letters, etc.) 
 
BACKGROUND: 
 
The documentation related to the matter for [Provider/Supplier Name] has been 
reviewed  and  the  decision  has  been  made  in  accordance  with  the  applicable 
Medicare rules, policies and program instructions. 
 
(Summarize the facts underlying the case which led up to the submission of the 
CAP.) 
 
CORRECTIVE ACTION PLAN ANALYSIS: 
 
[A  [Provider/Supplier  Name]  may  only  submit  a  corrective  action  plan  for 
noncompliance under 42 C.F.R.  424.530(a)(1). If the initial determination was 
based on any other denial reasons other than 42 C.F.R.  424.530(a)(1), this decision 
will not review those authorities.] 
 
(A  CAP  is  an  opportunity  to  correct  the  deficiencies  identified  in  the  initial 
determination. This section should include: A clear explanation of why the denial 
was overturned in sufficient detail for the provider or supplier to understand the 
decision and; if applicable: the nature of the provider or suppliers deficiencies, the 
regulatory or other policy basis to support each reason for the denial, and an 
explanation of how the provider or supplier now meets the enrollment criteria or 
requirements. This section shall not reference a CAP decision without explaining 
how and why you came to that decision.) 
 
DECISION: 
 
(A short conclusory restatement. Approval date should be based on the date the 
provider  or  supplier  came  into  compliance  with  all  applicable  Medicare 
requirements.) 
 
(Ex: On [Month] [DD], [YYYY], Jane Does medical license expired. However, on 
[Month] [DD], [YYYY] John Smith submitted a copy of his renewed medical 
license, which was reinstated back to the date of expiration by the Wisconsin 
Medical Board. As a result, [MAC Name] finds that Jane Doe came into compliance 
with the applicable Medicare requirements on [Month] [DD], [YYYY]. Therefore,  [MAC Name] overturns the denial of Jane Does Medicare enrollment application 
as it relates to 42 C.F.R.  424.530(a)(1). 
 
This decision is a FAVORABLE DECISION. To effectuate this decision, [MAC 
name] will continue processing the enrollment application. 
 
(If additional information is needed from the provider or supplier in order to 
reactivate the enrollment, the MAC shall state what information is needed 
from the provider or supplier in this CAP decision. MACs shall state that the 
requested information/documentation must be received within 30 calendar 
days of the date of this decision letter.) 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
 
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[MAC Name] 
 
K. Favorable CAP Model Letter for Revocation Determination 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name]  
Attn: [Signer/Submitter of CAP] 
[Address] (Address from which the CAP was sent)  
[City], [State] [Zip Code] 
 
Re: Corrective Action Plan Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Person(s) who submitted the CAP]: 
  This letter is in response to the corrective action plan (CAP) received by [MAC 
Name]  based  on  a  revocation  of  Medicare  billing  privileges.  The  initial 
determination letter was dated [Month] [DD], [YYYY] and the CAP was received 
by [MAC Name] on [Month] [DD], [YYYY]; therefore, this appeal is considered 
timely. (if the CAP is untimely, but good cause has been found to accept the CAP, 
use the following [This CAP was not timely submitted, but a good cause waiver has 
been granted.]) The following decision is based on the Social Security Act (Act), 
Medicare regulations, the CMS manual instructions, evidence in the file, and any 
information received before this decision was rendered. 
 
REVOCATION REASON: 
 
  42 C.F.R.  424.535(a)(1) 
 
OTHER APPLICABLE AUTHORITIES: 
 
  (Ex: Medicare Program Integrity Manual chapter 10, section 10.XX) 
 
EXHIBITS: 
 
  Exhibit 1: (Ex.: CAP, signed by Jane Doe, dated [Month] [DD], [YYYY].) 
  Exhibit 2: (Ex: Copy of a medical license for Jane Doe from the Wisconsin 
Medical Board, effective [Month] [DD], [YYYY].) 
 
(In this section list each document submitted by the provider or supplier. Each 
exhibit should include the date, as well as a brief description of the document. You 
shall also include all other documentation not submitted by the provider that the 
hearing officer reviewed in making the decision, e.g., enrollment applications, 
development letters, etc.) 
 
BACKGROUND: 
 
The documentation related to the matter for [Provider/Supplier Name] has been 
reviewed  and  the  decision  has  been  made  in  accordance  with  the  applicable 
Medicare rules, policies, and program instructions. 
 
(Summarize the facts underlying the case which led up to the submission of the 
CAP.) 
 
CORRECTIVE ACTION PLAN ANALYSIS: 
 
[A  [Provider/Supplier  Name]  may  only  submit  a  corrective  action  plan  for 
noncompliance. If the initial determination was based on revocation reasons other 
than 42 C.F.R.  424.535(a)(1), this decision will not review those authorities.] 
 
(A  CAP  is  an  opportunity  to  correct  the  deficiencies  identified  in  the  initial 
determination.  This  section  should  include:  A  clear  explanation  of  why  the  revocation is being upheld or overturned in sufficient detail for the provider or 
supplier to understand the decision and; if applicable: the nature of the provider or 
suppliers  deficiencies,  the  regulatory  basis  to  support  the  revocation  for 
noncompliance, and an explanation of how the provider or supplier now meets the 
enrollment compliance criteria or requirements. This section shall not reference a 
CAP decision without explaining how and why you came to that decision.) 
 
DECISION: 
 
(A short conclusory restatement.) 
 
(Ex: On [Month] [DD], [YYYY], Jane Does medical license was suspended. 
However,  as  part  of  her  CAP,  Jane  Doe  submitted  a  revised  order  from  the 
Wisconsin Medical Board, which reinstated her medical back license back to the 
date of suspension. As a result, [MAC Name] finds that Jane Doe came into 
compliance with the applicable Medicare requirements on [Month] [DD], [YYYY]. 
Therefore, [MAC Name] overturns the revocation of Jane Does Medicare billing 
privileges as it relates to 42 C.F.R.  424.535(a)(1). 
 
This decision is a FAVORABLE DECISION. To effectuate this decision, [MAC 
name] [will reinstate/has reinstated] your Medicare billing privileges, effective 
[Month] [DD], [YYYY]. 
 
(The reinstatement date is based on chapter 10 of the MPIM and the date of the 
providers or suppliers revocation or the date the providers or suppliers license 
was reinstated if the revocation involves a licensure issue.) 
 
(If additional information is needed from the provider or supplier in order to 
reactivate the enrollment, the MAC shall state what information is needed 
from the provider or supplier in this CAP decision. MACs shall state that the 
requested information/documentation must be received within 30 calendar 
days of the date of this decision letter.) 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
 
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[MAC Name]   
L. Unfavorable CAP Model Letter in Response to an Enrollment Denial 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name]  
Attn: [Signer/Submitter of CAP] 
[Address] (Address from which the CAP was sent)  
[City], [State] [Zip Code] 
 
Re: Corrective Action Plan Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Person(s) who submitted the CAP]: 
 
This letter is in response to the corrective action plan (CAP) received by [MAC 
Name] based on an enrollment denial. The initial determination letter was dated 
[Month] [DD], [YYYY] and the CAP was received by [MAC Name] on [Month] 
[DD], [YYYY]; therefore, this appeal is considered timely. (if the CAP is untimely, 
but good cause has been found to accept the CAP, use the following [This CAP was 
not timely submitted, but a good cause waiver has been granted.])The following 
decision is based on the Social Security Act (Act), Medicare regulations, the CMS 
manual instructions, the Medicare enrollment record, and any information received 
before this decision was rendered. 
 
DENIAL REASON: 
 
  42 C.F.R.  424.530(a)(1) 
 
OTHER APPLICABLE AUTHORITIES: 
 
  (Ex: Medicare Program Integrity Manual chapter 10, section 10.XX) 
 
EXHIBITS: 
 
  Exhibit 1: (Ex.: (Ex.: CAP, signed by Jane Doe, dated [Month] [DD], 
[YYYY].) 
  Exhibit 2: (Ex: Copy of a medical license for Jane Doe from the Wisconsin 
Medical Board, effective [Month] [DD], [YYYY].) 
  (In this section list each document submitted by the provider or supplier. Each 
exhibit should include the date, as well as a brief description of the document. You 
shall also include all other documentation not submitted by the provider that the 
hearing officer reviewed in making the decision, e.g., enrollment applications, 
development letters, etc.) 
 
BACKGROUND: 
 
The documentation related to the matter for [Provider/Supplier Name] has been 
reviewed  and  the  decision  has  been  made  in  accordance  with  the  applicable 
Medicare rules, policies, and program instructions. 
 
(Summarize the facts underlying the case which led up to the submission of the 
CAP). 
 
CORRECTIVE ACTION PLAN ANALYSIS: 
 
[A  [Provider/Supplier  Name]  may  only  submit  a  corrective  action  plan  for 
noncompliance under 42 C.F.R.  424.530(a)(1). If the initial determination was 
based on any other denial reasons other than 42 C.F.R.  424.530(a)(1), this decision 
will not review those authorities.] 
 
(A  CAP  is  an  opportunity  to  correct  the  deficiencies  identified  in  the  initial 
determination. This section should include: A clear explanation of why the denial is 
being upheld in sufficient detail for the provider or supplier to understand the 
decision and; if applicable: the nature of the provider or suppliers deficiencies, the 
regulatory or other policy basis to support each reason for the denial, and an 
explanation of how the provider or supplier now meets the enrollment criteria or 
requirements. This section shall not reference a CAP decision without explaining 
how and why you came to that decision.) 
 
DECISION: 
 
(A short conclusory restatement.) 
 
(On [Month] [DD], [YYYY], Jane Does medical license was suspended by the 
Wisconsin Medical Board. [MAC Name] has confirmed that Jane Does medical 
license remains suspended. As a result, [MAC Name] upholds the denial of Jane 
Does Medicare enrollment application under 42 C.F.R.  424.530(a)(1).) 
 
This decision is an UNFAVORABLE DECISION. [MAC name] concludes that the 
CAP does not correct the deficiencies that led to the denial of your Medicare 
enrollment. As a result, the denial of your Medicare enrollment is upheld. 
 
Failure to timely file a reconsideration request is deemed a waiver of all further 
administrative review. However, if you have submitted a reconsideration request, a 
separate decision is forthcoming.   
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
 
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[MAC Name] 
 
M. Unfavorable CAP Model Letter for Revocation Determination 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name]  
Attn: [Signer/Submitter of CAP] 
[Address] (Address from which the CAP was sent)  
[City], [State] [Zip Code] 
 
Re: Corrective Action Plan Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional)  
Dear [Person(s) who submitted the CAP]: 
This letter is in response to the corrective action plan (CAP) received by [MAC 
Name]  based  on  a  revocation  of  Medicare  billing  privileges.  The  initial 
determination letter was dated [Month] [DD], [YYYY] and the CAP was received 
by [MAC Name] on [Month] [DD], [YYYY]; therefore, this appeal is considered 
timely. (if the CAP is untimely, but good cause has been found to accept the CAP, 
use the following [This CAP was not timely submitted, but a good cause waiver has 
been granted.]) The following decision is based on the Social Security Act (Act), 
Medicare  regulations,  the  CMS  manual  instructions,  the  Medicare  enrollment 
record, and any information received before this decision was rendered. 
 
REVOCATION REASON: 
    42 C.F.R.  424.535(a)(1) 
 
OTHER APPLICABLE AUTHORITIES: 
 
  (Ex: Medicare Program Integrity Manual chapter 10, section 10.XX) 
 
EXHIBITS: 
 
  Exhibit 1: (Ex.: (Ex.: CAP, signed by Jane Doe, dated [Month] [DD], 
[YYYY].) 
  Exhibit 2: (Ex: Copy of a medical license for Jane Doe from the Wisconsin 
Medical Board, effective [Month] [DD], [YYYY].) 
(In this section list each document submitted by the provider or supplier. Each 
exhibit should include the date, as well as a brief description of the document. You 
shall also include all other documentation not submitted by the provider that the 
hearing officer reviewed in making the decision, e.g., enrollment applications, 
development letters, etc.) 
 
BACKGROUND: 
 
The documentation related to the matter for [Provider/Supplier Name] has been 
reviewed  and  the  decision  has  been  made  in  accordance  with  the  applicable 
Medicare rules, policies, and program instructions. 
 
(Summarize the facts underlying the case which led up to the submission of the 
CAP.) 
 
CORRECTIVE ACTION PLAN ANALYSIS: 
 
[A  [Provider/Supplier  Name]  may  only  submit  a  corrective  action  plan  for 
noncompliance. If the initial determination was based on revocation reasons other 
than 42 C.F.R.  424.535(a)(1), this decision will not review those authorities.] 
 
(A  CAP  is  an  opportunity  to  correct  the  deficiencies  identified  in  the  initial 
determination.  This  section  should  include:  A  clear  explanation  of  why  the 
revocation  is  being  upheld  in  sufficient  detail for  the  provider  or  supplier  to 
understand the decision and; if applicable: the nature of the provider or suppliers 
deficiencies, the regulatory or other policy basis to support compliance and how the 
provider or supplier now meets the enrollment criteria or requirements. This section 
shall not reference a CAP decision without explaining how and why you came to 
that decision.) 
 
DECISION: 
 
(A short conclusory restatement.) 
  (On [Month] [DD], [YYYY], Jane Does medical license was suspended by the 
Wisconsin Medical Board. Jane Doe has not submitted evidence to demonstrate that 
her medical license has been reinstated. In addition, [MAC Name] has confirmed 
that Jane Does medical license remains suspended. As a result, [MAC Name] 
upholds the revocation of Jane Does Medicare billing privileges under 42 C.F.R.  
424.535(a)(1).) 
 
This decision is an UNFAVORABLE DECISION. [MAC name] concludes that 
the  CAP  did  not  correct  the  deficiencies  noted  in  the  implementation  of  the 
revocation. As a result, the revocation of your Medicare billing privileges is upheld. 
 
Failure to timely file a reconsideration request is deemed a waiver of all further 
administrative review. However, if you have submitted a reconsideration request, a 
separate decision is forthcoming. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
 
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[MAC Name] 
 
N. CAP Further Information Required for Development Model Letter 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
To: [Email address provided by the person who submitted the CAP.]  
Subject: Medicare Provider Enrollment CAP re: [Provider/Supplier Name]  
Dear [Name of the person(s) who submitted the CAP] 
[Month] [DD], [YYYY] 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of CAP] (If submitted on behalf of an organization or 
group)  
[Address] (Address from which the CAP was sent)  [City], [State] [Zip Code] 
 
Re: CAP Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (Internal Tracking) 
 
Dear [Name of the person(s) who submitted the CAP]: 
 
On [Month] [DD]. [YYYY], [MAC Name] issued a CAP decision. As stated in the 
[Month] [DD], [YYYY] CAP decision letter, the approval of [Provider/Supplier 
Name]s Medicare enrollment is contingent upon the submission of [list required 
documentation]. Please send the required documentation within 30 calendar days to: 
[MAC CAP Receipt Address]  
[MAC CAP Receipt Email Address] [MAC CAP Receipt Fax Number] 
If you have any questions, please contact our office at [phone number] between the 
hours of [x:00 AM/PM] and [x:00 AM/PM]. 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
 
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[MAC Name] 
 
 
 10.7.11  Reconsideration Request Model Letters 
(Rev. 10611; Issued: 03-19-21; Effective:11-19-20; Implementation: 11-19-20) 
 
A. Reconsideration Request Withdrawn Acknowledgement Template 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
1. Email Template 
 
To: [Email address provided by the person who submitted the reconsideration 
request]   Subject:  Medicare  Provider  Enrollment  Reconsideration  Request  re: 
[Provider/Supplier Name]  
Dear [Name of the person(s) who submitted the reconsideration request]: 
We  are  in  receipt  of  your  written  withdrawal  request  in  regard  to  your 
reconsideration request received on [Month] [DD], [YYYY]. [MAC Name] has 
not yet issued a reconsidered decision, and therefore, [MAC Name] considers 
your reconsideration request to be withdrawn. As a result, a decision will not be 
issued in response to your reconsideration request. 
 
Please be advised that failure to timely submit a reconsideration request is 
deemed a waiver of all further administrative review. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
2. Hard-Copy Letter Template 
 
[Month] [Day], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Reconsideration Request] 
[Address] (Address from which the Reconsideration Request was sent)  
[City], [State] [Zip Code] 
 
Re: Reconsideration Request Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the reconsideration request]: 
 
We  are  in  receipt  of  your  written  withdrawal  request  in  regard  to  your 
reconsideration request received on [Month] [DD], [YYYY]. [MAC Name] has  not yet issued a reconsidered decision, and therefore, [MAC Name] considers 
your reconsideration request to be withdrawn. As a result, a decision will not be 
issued in response to your reconsideration request. 
 
Please be advised that failure to timely submit a reconsideration request is 
deemed a waiver of all further administrative review. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address]  
[Call Center Telephone Number] 
 
Sincerely, 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
B. Reconsideration Request Receipt Acknowledgement Template to 
Provider/Supplier/Representative 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
1. Email Template 
 
To: [Email address provided by the person who submitted the reconsideration 
request] 
Subject: Medicare Provider Enrollment Reconsideration Request re: 
[Provider/Supplier Name]  
 
Dear [Name of the person(s) who submitted the reconsideration request]: 
 
We are in receipt of your reconsideration request on behalf of 
[Provider/Supplier Name]. Please be advised that [MAC Name] has 90 calendar 
days to review your reconsideration request and render a decision. 
 
If you have additional information that you would like a hearing officer to 
consider during the reconsideration or, if necessary, an administrative law judge 
(ALJ) to consider during a hearing, you must submit that information to the 
hearing office before a decision is rendered. This is your only opportunity to 
submit information during the administrative appeals process; you will not have 
another opportunity to do so unless an ALJ specifically allows you to do so  under 42 C.F.R. 498.56(e). 
 
If you have any further questions, please forward your inquiries to [MAC 
Appeal Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
2. Hard-Copy Letter Template 
 
[Month] [Day], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Reconsideration Request] 
[Address] (Address from which the Reconsideration Request was sent)  
[City], [State] [Zip Code] 
 
Re: Reconsideration Request Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the reconsideration request]: 
 
We are in receipt of your reconsideration request on behalf of 
[Provider/Supplier Name]. Please be advised that [MAC Name] has 90 calendar 
days to review your reconsideration request and render a decision. 
 
If you have additional information that you would like a hearing officer to 
consider during the reconsideration or, if necessary, an administrative law judge 
(ALJ) to consider during a hearing, you must submit that information to the 
hearing office before a decision is rendered. This is your only opportunity to 
submit information during the administrative appeals process; you will not have 
another opportunity to do so unless an ALJ specifically allows you to do so 
under 42 C.F.R. 498.56(e). 
 
If you have any further questions, please forward your inquiries to [MAC 
Appeal Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number]   
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
C. Reconsideration Request Decision Email Template to 
Provider/Supplier/Representative 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
To: [Email address provided by the person who submitted the Reconsideration 
Request]  
Subject:  Medicare  Provider  Enrollment  Reconsideration  Request  re: 
[Provider/Supplier Name]  
Dear [Name of the person(s) who submitted the reconsideration] 
(Be sure to attach a copy of the final decision[s] in PDF format.) 
 
Dear [Name of the person(s) who submitted the Reconsideration Request]: 
 
Please see the attached decision regarding your Medicare Provider Enrollment 
Reconsideration Request. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
D. Reconsideration Request Not Actionable (Moot) Model Letter 
  (To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [Day], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Reconsideration Request] 
[Address] (Address from which the Reconsideration Request was sent)  
[City], [State] [Zip Code] 
 
Re: Reconsideration Request Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the reconsideration request]: 
 
This letter is in response to the reconsideration request received by [MAC Name] 
based on the initial determination letter, dated [Month] [DD], [YYYY]. 
 
In correspondence dated [Month] [DD], [YYYY], the initial determination letter, 
dated [Month] [DD], [YYYY] informing you of the [denial of your Medicare 
enrollment application or revocation of your Medicare billing privileges] was 
[insert description] (describe action taken in regards to the initial determination, 
i.e. rescission of the denial or revocation). For your convenience, a copy of the 
initial determination is included. Therefore, the issue set forth in the 
reconsideration request is no longer actionable. This issue is moot, and we are 
unable to render a decision on the matter. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
E. Untimely Reconsideration Request Dismissal Model Letter 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
  [Month] [Day], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Reconsideration Request] 
[Address] (Address from which the Reconsideration Request was sent)  
[City], [State] [Zip Code] 
 
Re: Reconsideration Request Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the reconsideration request]: 
 
This letter is in response to the reconsideration request received by [MAC Name], 
based on the initial determination letter dated [Month] [DD], [YYYY]. 
 
[MAC Name] is unable to accept your reconsideration request as it was not timely 
submitted. The initial determination letter was dated [Month] [DD], [YYYY]. A 
reconsideration request must be received within 65 calendar days of the date of the 
initial determination letter. Your reconsideration request was not received by 
[MAC Name] until [Month] [DD], [YYYY], which is beyond the applicable 
submission time frame. You have failed to show good cause for your late request. 
Therefore, [MAC Name] is unable to render a decision in this matter. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[MAC Name] 
 
F. Improperly Signed Reconsideration Request Dismissal Model Letter 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [Day], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name]  Attn: [Signer/Submitter of Reconsideration Request] 
[Address] (Address from which the Reconsideration Request was sent)  
[City], [State] [Zip Code] 
 
Re: Reconsideration Request Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the reconsideration request]: 
 
This letter is in response to the reconsideration request received by [MAC Name], 
based on the [Month] [DD], [YYYY] initial determination letter. 
 
[MAC Name] is unable to accept your reconsideration request as it was not signed 
by an authorized or delegated official currently on file in your Medicare 
enrollment record, the individual provider or supplier, or a properly appointed 
representative. The signature requirement is stated in the [Month] [DD], [YYYY] 
initial determination letter, as well as in Chapter 10 of the Medicare Program 
Integrity Manual. 
 
Please be advised that failure to timely submit a proper reconsideration request is 
deemed a waiver of all further administrative review. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
G. Not Eligible to Submit Reconsideration Request Dismissal Model Letter 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [Day], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Reconsideration Request] 
[Address] (Address from which the Reconsideration Request was sent)   [City], [State] [Zip Code] 
 
Re: Reconsideration Request Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the Reconsideration Request]: 
 
This letter is in response to the [reconsideration request] received by [MAC 
Name], based on the [Month] [DD], [YYYY] initial determination. 
 
[MAC Name] is unable to accept your [reconsideration request] submission 
because the action taken in regards to your Medicare enrollment is not an initial 
determination subject to administrative review. More specifically, an initial 
determination has not been made as described in 42 C.F.R.  498.3(b). Under 42 
C.F.R.  498.5(l), appeal rights related to provider enrollment extend only from 
initial determinations. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address] [Call Center Telephone Number] 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
H. Reconsideration Request Signature Development Model Letter 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [Day], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Reconsideration Request] 
[Address] (Address from which the Reconsideration Request was sent)  
[City], [State] [Zip Code] 
 
Re: Reconsideration Request Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)   NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the Reconsideration Request]: 
 
We are in receipt of your reconsideration submission, received on [Month] [DD], 
[YYYY]. (If the submission is not properly signed, use the following.) [Your 
submission is not appropriately signed, as required in the Medicare Program 
Integrity Manual, Ch. 10, Section 10.6.18. [MAC Name] is requesting that you 
submit a reconsideration request that is properly signed by the individual provider, 
supplier, the authorized or delegated official, or a representative. Your properly 
signed submission must be received within 15 calendar days of the date of this 
notice. If you do not timely respond to this request, your reconsideration 
submission may be dismissed.] 
 
(If the submission is missing a statement by the attorney, use the following.) [Your 
submission is missing an attorney statement that he or she has the authority to 
represent the provider or supplier. [MAC Name] is requesting that you submit a 
rebuttal that includes an attorney statement that he or she has the authority to 
represent the provider or supplier within 15 calendar days of the date of this 
notice. If you do not timely respond to this request, your reconsideration 
submission may be dismissed.] 
 
(If the submission is missing a signed written notice from the provider/supplier 
authorizing the representative to act on his/her/its behalf, use the following.) [Your 
submission is missing a written notice of the appointment of a representative 
signed by the provider or supplier. [MAC Name] is requesting that you submit 
written notice of the appointment of a representative that is signed by the provider 
or supplier within 15 calendar days of the date of this notice. If you do not timely 
respond to this request, your reconsideration submission may be dismissed.] 
 
Your submission should be sent to [MAC Appeal Receipt Email Address] or mail 
it to the following address: 
 
[MAC Appeal Receipt Address]  
[MAC Fax number] 
 
 
If you have any questions, please contact our office at [phone number] between the 
hours of [x:00 AM/PM] and [x:00 AM/PM]. 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer]  [Position of Hearing Officer]  
[MAC Name] 
 
I. Favorable Reconsideration Request Model Letter in Response to an 
Enrollment Denial 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [Day], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Reconsideration Request] 
[Address] (Address from which the Reconsideration Request was sent)  
[City], [State] [Zip Code] 
 
Re: Reconsideration Request Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the Person(s) who submitted the Reconsideration Request]: 
 
This letter is in response to the reconsideration request received by [MAC Name] 
based on an enrollment denial. The initial determination letter was dated [Month] 
[DD], [YYYY] and the reconsideration request was received by [MAC Name] on 
[Month] [DD], [YYYY]; therefore, this reconsideration request is considered 
timely. (if the reconsideration request is untimely, but good cause has been found 
to accept the reconsideration request, use the following [This reconsideration 
request was not timely submitted, but a good cause waiver has been granted.]) The 
following decision is based on the Social Security Act (Act), Medicare regulations, 
the CMS manual instructions, the Medicare enrollment record, and any 
information received before this decision was rendered. 
 
DENIAL REASON(S): 
 
  42 C.F.R.  424.530(a)(denial reason 1-14) 
  42 C.F.R.  424.530(a)(denial reason 1-14) 
 
OTHER APPLICABLE AUTHORITIES: 
 
  42 C.F.R.  
  (Ex: Medicare Program Integrity Manual (MPIM) chapter 10, section 
10.XX) 
 
EXHIBITS: 
    Exhibit 1: (Ex.: Reconsideration request, signed by Jane Doe, dated 
[Month] [DD] [YYYY].) 
  Exhibit 2: (Ex: Copy of a medical license for Jane Doe from the Wisconsin 
Medical Board, effective [Month] [DD], [YYYY].) 
(In this section list each document submitted by the provider or supplier. Each 
exhibit should include the date, as well as a brief description of the document. You 
shall also include all other documentation not submitted by the provider that the 
hearing officer reviewed in making the decision, e.g., enrollment applications, 
development letters, etc.) 
 
BACKGROUND: 
 
The documentation related to the matter for [Provider/Supplier Name] has been 
reviewed and the decision has been made in accordance with the applicable 
Medicare rules, policies and program instructions. 
 
(Summarize the facts underlying the case which led up to the submission of the 
reconsideration request.) 
 
RECONSIDERATION ANALYSIS: 
 
(The hearing officer needs to check to determine if a CAP was also submitted and 
approved for this provider or supplier. If so, the reconsideration decision should 
only address the remaining authorities and use the following sentence, [MAC 
Name] has approved the CAP submitted on [Month] [DD], [YYYY] in a decision 
dated [Month] [DD], [YYYY]. Therefore, this decision will only address the 
remaining denial reason(s) 42 C.F.R.  424.530(a)(denial reason 1-14).) 
 
(If the CAP resolves the denial in its entirety, the applicable moot model letter 
should be issued in response to the reconsideration request instead of this decision 
template.) 
 
(A reconsideration request reviews whether or not an error was made at the time the 
initial determination was implemented. This section should summarize the 
statements made by the provider or supplier in its reconsideration request. Then 
conduct analysis of the arguments based on the applicable regulations and sub-
regulations, MPIM. This section shall not reference a reconsideration decision 
without explaining how and why you came to that decision.) 
 
DECISION: 
 
(A short conclusory restatement.) 
 
(Ex: On [Month] [DD], [YYYY], a disciplinary hearing was held regarding the 
medical license of Jane Doe. However, on [Month] [DD], [YYYY], the Wisconsin 
Medical Board declined to take disciplinary action against Jane Does medical 
license. As a result, [MAC Name] overturns the denial of Jane Does Medicare 
enrollment application as it relates to 42 C.F.R.  424.530(a)(1).   
This decision is a FAVORABLE DECISION. To effectuate this decision, [MAC 
name] will continue processing the enrollment application. 
 
(If additional information is needed from the provider or supplier in order to 
reactivate the enrollment, the MAC shall state what information is needed from the 
provider or supplier in this reconsideration decision. MACs shall state that the 
requested information/documentation must be received within 30 calendar days of 
the date of this decision letter.) 
 
FURTHER APPEAL RIGHTS - ADMINISTRATIVE LAW JUDGE 
(ALJ): 
 
If you are satisfied with this decision, you do not need to take further action. If you 
believe that this determination is not correct, you may request ALJ review for the 
reconsideration portion of this decision letter. To request ALJ review, you must 
file your appeal with the Civil Remedies Division of the Departmental Appeals 
Board within 60 calendar days after the date of receipt of this decision. 
 
How to file a hearing request 
 
You can file your appeal electronically at the Departmental Appeals Board 
Electronic Filing System Web site (DAB E-File) at https://dab.efile.hhs.gov/. 
 
To file a new appeal using DAB E-File, you first need to register a new account 
by: 
 
1. Clicking Register on the DAB E-File home page; 
2. Entering the information requested on the Register New Account form; and 
3. Clicking Register Account at the bottom of the form. If you have more than one 
representative, each representative must register separately to use DAB E-File on 
your behalf. 
 
The e-mail address and password provided during registration must be entered on 
the login screen at https://dab.efile.hhs.gov/user_sessions/new to access DAB E-
File. A registered users access to DAB E-File is restricted to the appeals for 
which he or she is a party or authorized representative. 
 
Once registered, you may file your appeal by logging in and: 
 
  Clicking the File New Appeal link on the Manage Existing Appeals screen, 
and then clicking Civil Remedies Division on the File New Appeal screen; 
and 
 
  Entering and uploading the requested information and documents on the 
File New Appeal  Civil Remedies Division form. 
 
All documents must be submitted in PDF form.   
What you must include in a hearing request for ALJ review 
 
At minimum, the Civil Remedies Division (CRD) requires a party to file the 
following: 
  A signed request for hearing that: 
  Identifies the specific issues and the findings of fact and 
o
conclusions of law with which the party disagrees; and 
  Specifies the basis for contending that the findings and conclusions 
o
are incorrect; 
  The underlying notice letter from CMS that sets forth the action taken and 
the partys appeal rights. 
 
In addition, the following identifying information is required with all ALJ hearing 
requests: 
 
  Your legal business name 
  Your Medicare PTAN (if applicable) 
  Tax Identification Number (TIN) or Employer Identification Number (EIN) 
  A copy of the Hearing Officer or the CMS Regional Office (RO) decision 
 
The procedures for ALJ review can be found at Title 42 of the Code of Federal 
Regulations, sections 498.40  498.79. 
 
Guidelines for Using DAB E-file 
 
  Any document, including a request for hearing, will be deemed to have 
been filed on a given day if it is uploaded to DAB E-File on or before 
11:59 p.m. ET of that day. 
 
  A party that files a request for hearing via DAB E-File will be deemed to 
have consented to accept electronic service of appeal-related documents 
that CMS files, or CRD issues on behalf of the ALJ, via DAB E-File. 
Correspondingly, CMS will also be deemed to have consented to electronic 
service. 
 
  Parties are responsible for ensuring that DAB E-file email notifications do 
not go to their spam folders and that any spam filtering software they may 
have does not restrict their ability to receive emails from the system. 
 
  More detailed instructions on DAB E-File for CRD cases can be found by 
clicking the CRD E- File Procedures link on the File New Appeal Screen 
for CRD appeals. 
 
If you are unable to use DAB E-file 
 
Parties are required to use DAB E-file unless they receive a waiver. If you cannot  file your appeal electronically, you may mail your hearing request, along with a 
request for waiver of the electronic filing requirement and an explanation of why 
you cannot use DAB E-file, to: Department of Health and Human Services, 
Departmental Appeals Board, Civil Remedies Division, Mail Stop 6132, Attn: 
CMS Enrollment Appeal, 330 Independence Avenue, S.W., Cohen Building, 
Room G-644, Washington, D.C. 20201. 
 
Appeal rights can be found 42 C.F.R. part 498. The regulation explains the appeal 
rights following the determination by the CMS as to whether such entities meet the 
requirements for enrollment in the Medicare program. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address]  
[Call Center Telephone Number] 
 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[MAC Name] 
 
J. Favorable Reconsideration Request Model Letter in Response to a 
Reactivation Effective Date Determination 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [Day], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Reconsideration Request] 
[Address] (Address from which the Reconsideration Request was sent)  
[City], [State] [Zip Code] 
 
Re: Reconsideration Request Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the Reconsideration Request]: 
 
This letter is in response to the reconsideration request received by [MAC Name]  related to a reactivation effective date determination. The initial determination 
letter was dated [Month] [DD], [YYYY] and the reconsideration request was 
received by [MAC Name] on [Month] [DD], [YYYY]; therefore, this 
reconsideration request is considered timely. (if the reconsideration request is 
untimely, but good cause has been found to accept the reconsideration request, use 
the following [This reconsideration request was not timely submitted, but a good 
cause waiver has been granted.]) The following decision is based on the Social 
Security Act (Act), Medicare regulations, the CMS manual instructions, the 
Medicare enrollment record, and any information received before this decision 
was rendered. 
 
EFFECTIVE DATE REGULATION(S): 
 
42 C.F.R.  424.520(a-d) (Other effective date regulations may be included) 
 
OTHER APPLICABLE AUTHORITIES: 
 
42 C.F.R.  424.540 (Other applicable regulations for MPIM sections may be 
included) 
(Ex: Medicare Program Integrity Manual (MPIM) chapter 10, section 10.XX) 
 
EXHIBITS: 
 
Exhibit 1: (Ex.: CMS-855I Medicare enrollment application, signed and certified 
by John Smith on [Month] [DD], [YYYY].) 
Exhibit 2: (Ex: Copy of an email chain between John Smith and Jane Doe, dated 
[Month] [DD], [YYYY], requesting additional informed needed to process the 
revalidation application to completion for John Smith to Jane Doe. 
 
(In this section list each document submitted by the provider or supplier. Each 
exhibit shall include the date, if provided, as well as a brief description of the 
document. You shall also include all other documentation not submitted by the 
provider that the hearing officer reviewed in making the decision, e.g., enrollment 
applications, development letters, etc.) 
 
BACKGROUND: 
 
The documentation related to the matter for [Provider/Supplier Name] has been 
reviewed and the decision has been made in accordance with the applicable 
Medicare rules, policies, and program instructions. 
 
(Summarize the facts underlying the case which led up to the submission of the 
reconsideration request.) 
 
RECONSIDERATION ANALYSIS: 
 
(A reconsideration request reviews whether or not an error was made at the time 
the initial determination was implemented. This section should summarize the  statements made by the provider or supplier in its reconsideration request. Then 
conduct analysis of the arguments based on the applicable regulations and sub-
regulations, MPIM. This section shall not reference a reconsideration decision 
without explaining how and why you came to that decision.) 
 
DECISION: 
 
(A short conclusory restatement.) 
 
(Ex.: On [Month] [DD], [YYYY], John Smiths revalidation application was 
approved with a gap in his billing privileges from [Month] [DD], [YYYY] to 
[Month] [DD], [YYYY]. However, as indicated above, [MAC Name] has 
determined that the reactivation effective should be [Month] [DD], [YYYY]. As a 
result of the change in the reactivation effective date, the gap in John Smiths 
Medicare billing privileges has been eliminated.) 
 
This decision is a FAVORABLE DECISION. To effectuate this decision, [MAC 
name] [will modify/has modified] the reactivation effective date for 
[Provider/Supplier Name]. 
 
You must resubmit any claims that were denied or not previously submitted due to 
the former gap in your Medicare billing privileges. 
 
(If additional information is needed from the provider or supplier in order to 
reactivate the enrollment, the MAC shall state what information is needed 
from the provider or supplier in this reconsideration decision. MACs shall 
state that the requested information/documentation must be received within 
30 calendar days of the date of this decision letter.) 
 
FURTHER APPEAL RIGHTS - ADMINISTRATIVE LAW JUDGE (ALJ): 
 
If you are satisfied with this decision, you do not need to take further action. If you 
believe that this determination is not correct, you may request ALJ review for the 
reconsideration portion of this decision letter. To request ALJ review, you must 
file your appeal with the Civil Remedies Division of the Departmental Appeals 
Board within 60 calendar days after the date of receipt of this decision. 
 
How to file a hearing request 
 
You can file your appeal electronically at the Departmental Appeals Board 
Electronic Filing System Web site (DAB E-File) at https://dab.efile.hhs.gov/. 
 
To file a new appeal using DAB E-File, you first need to register a new account 
by: 
 
1. Clicking Register on the DAB E-File home page; 
2. Entering the information requested on the Register New Account form; and 
3. Clicking Register Account at the bottom of the form. If you have more than one  representative, each representative must register separately to use DAB E-File on 
your behalf. 
 
The e-mail address and password provided during registration must be entered on 
the login screen at https://dab.efile.hhs.gov/user_sessions/new to access DAB E-
File. A registered users access to DAB E-File is restricted to the appeals for 
which he or she is a party or authorized representative. 
 
Once registered, you may file your appeal by logging in and: 
 
  Clicking the File New Appeal link on the Manage Existing Appeals screen, 
and then clicking Civil Remedies Division on the File New Appeal screen; 
and 
 
  Entering and uploading the requested information and documents on the 
File New Appeal  Civil Remedies Division form. 
 
All documents must be submitted in PDF form. 
 
What you must include in a hearing request for ALJ review 
 
At minimum, the Civil Remedies Division (CRD) requires a party to file the 
following: 
  A signed request for hearing that: 
  Identifies the specific issues and the findings of fact and 
o
conclusions of law with which the party disagrees; and 
  Specifies the basis for contending that the findings and conclusions 
o
are incorrect; 
  The underlying notice letter from CMS that sets forth the action taken and 
the partys appeal rights. 
 
In addition, the following identifying information is required with all ALJ hearing 
requests: 
 
  Your legal business name 
  Your Medicare PTAN (if applicable) 
  Tax Identification Number (TIN) or Employer Identification Number (EIN) 
  A copy of the Hearing Officer or the CMS Regional Office (RO) decision 
 
The procedures for ALJ review can be found at Title 42 of the Code of Federal 
Regulations, sections 498.40  498.79. 
 
Guidelines for Using DAB E-file 
 
  Any document, including a request for hearing, will be deemed to have 
been filed on a given day if it is uploaded to DAB E-File on or before 
11:59 p.m. ET of that day.   
  A party that files a request for hearing via DAB E-File will be deemed to 
have consented to accept electronic service of appeal-related documents 
that CMS files, or CRD issues on behalf of the ALJ, via DAB E-File. 
Correspondingly, CMS will also be deemed to have consented to electronic 
service. 
 
  Parties are responsible for ensuring that DAB E-file email notifications do 
not go to their spam folders and that any spam filtering software they may 
have does not restrict their ability to receive emails from the system. 
 
  More detailed instructions on DAB E-File for CRD cases can be found by 
clicking the CRD E- File Procedures link on the File New Appeal Screen 
for CRD appeals. 
 
If you are unable to use DAB E-file 
 
Parties are required to use DAB E-file unless they receive a waiver. If you cannot 
file your appeal electronically, you may mail your hearing request, along with a 
request for waiver of the electronic filing requirement and an explanation of why 
you cannot use DAB E-file, to: Department of Health and Human Services, 
Departmental Appeals Board, Civil Remedies Division, Mail Stop 6132, Attn: 
CMS Enrollment Appeal, 330 Independence Avenue, S.W., Cohen Building, 
Room G-644, Washington, D.C. 20201. 
 
Appeal rights can be found 42 C.F.R. part 498. The regulation explains the appeal 
rights following the determination by the CMS as to whether such entities meet the 
requirements for enrollment in the Medicare program. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address]  
[Call Center Telephone Number] 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[MAC Name] 
 
K. Favorable Reconsideration Request Model Letter in Response to an 
Effective Date of Participation Determination (Non-Revalidation) 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to  send via fax if a valid fax number is available). 
 
[Month] [Day], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Reconsideration Request] 
[Address] (Address from which the Reconsideration Request was sent)  
[City], [State] [Zip Code] 
 
Re: Reconsideration Request Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the Reconsideration Request]: 
 
This letter is in response to the reconsideration request received by [MAC Name] 
in response to a determination of the effective date of participation in the Medicare 
program. The initial determination letter was dated [Month] [DD], [YYYY] and 
the reconsideration request was received by [MAC Name] on [Month] [DD], 
[YYYY]; therefore, this reconsideration request is considered timely. (if the 
reconsideration request is untimely, but good cause has been found to accept the 
reconsideration request, use the following [This reconsideration request was not 
timely submitted, but a good cause waiver has been granted.]) The following 
decision is based on the Social Security Act (Act), Medicare regulations, the CMS 
manual instructions, the Medicare enrollment record, and any information received 
before this decision was rendered. 
 
EFFECTIVE DATE REGULATION(S): 
 
42 C.F.R.  424.520(a-d) 
 
OTHER APPLICABLE AUTHORITIES: 
 
42 C.F.R.  
(Ex: Medicare Program Integrity Manual (MPIM) chapter 10, section 10.XX) 
 
EXHIBITS: 
 
Exhibit 1: (Ex.: CMS-855I Medicare enrollment application, signed and certified 
by John Smith on [Month] [DD], [YYYY].) 
Exhibit 2: (Ex: Copy of an email chain between John Smith and Jane Doe, dated 
[Month] [DD], [YYYY], submitting the requested development documentation for 
John Smith to Jane Doe. 
 
(In this section list each document submitted by the provider or supplier. Each  exhibit should include the date, as well as a brief description of the document. You 
shall also include all other documentation not submitted by the provider that the 
hearing officer reviewed in making the decision, e.g., enrollment applications, 
development letters, etc.) 
 
BACKGROUND: 
 
The documentation related to the matter for [Provider/Supplier Name] has been 
reviewed and the decision has been made in accordance with the applicable 
Medicare rules, policies, and program instructions. 
 
(Summarize the facts underlying the case which led up to the determination of the 
effective date.) 
 
RECONSIDERATION ANALYSIS: 
 
(A reconsideration request reviews whether or not an error was made at the time the 
initial determination was implemented. This section should summarize the 
statements made by the provider or supplier in its reconsideration request. Then 
conduct analysis of the arguments based on the applicable regulations and sub-
regulations, MPIM. This section shall not reference a reconsideration decision 
without explaining how and why you came to that decision.) 
 
DECISION: 
 
(A short conclusory restatement.) 
 
(On [Month] [DD], [YYYY], John Smith submitted an initial enrollment 
application, which was subsequently rejected for failure to timely respond to a 
development request for additional information/documentation. As part of his 
reconsideration request, John Smith submitted an email receipt showing that he 
timely responded to the development request. As a result, [MAC Name] will 
modify John Smiths Medicare effective date to [Month] [DD], [YYYY].) 
 
This decision is a FAVORABLE DECISION. To effectuate this decision, [MAC 
name] [will modify/has modified] the enrollment effective date to [Month] [DD], 
[YYYY]. 
 
(If additional information is needed from the provider or supplier in order to 
reactivate the enrollment, the MAC shall state what information is needed from the 
provider or supplier in this reconsideration decision. MACs shall state that the 
requested information/documentation must be received within 30 calendar days of 
the date of this decision letter.) 
 
FURTHER APPEAL RIGHTS - ADMINISTRATIVE LAW JUDGE (ALJ): 
 
If you are satisfied with this decision, you do not need to take further action. If you 
believe that this determination is not correct, you may request ALJ review for the  reconsideration portion of this decision letter. To request ALJ review, you must 
file your appeal with the Civil Remedies Division of the Departmental Appeals 
Board within 60 calendar days after the date of receipt of this decision. 
 
How to file a hearing request 
 
You can file your appeal electronically at the Departmental Appeals Board 
Electronic Filing System Web site (DAB E-File) at https://dab.efile.hhs.gov/. 
 
To file a new appeal using DAB E-File, you first need to register a new account 
by: 
 
1. Clicking Register on the DAB E-File home page; 
2. Entering the information requested on the Register New Account form; and 
3. Clicking Register Account at the bottom of the form. If you have more than one 
representative, each representative must register separately to use DAB E-File on 
your behalf. 
 
The e-mail address and password provided during registration must be entered on 
the login screen at https://dab.efile.hhs.gov/user_sessions/new to access DAB E-
File. A registered users access to DAB E-File is restricted to the appeals for 
which he or she is a party or authorized representative. 
 
Once registered, you may file your appeal by logging in and: 
 
  Clicking the File New Appeal link on the Manage Existing Appeals screen, 
and then clicking Civil Remedies Division on the File New Appeal screen; 
and 
 
  Entering and uploading the requested information and documents on the 
File New Appeal  Civil Remedies Division form. 
 
All documents must be submitted in PDF form. 
 
What you must include in a hearing request for ALJ review 
 
At minimum, the Civil Remedies Division (CRD) requires a party to file the 
following: 
  A signed request for hearing that: 
  Identifies the specific issues and the findings of fact and 
o
conclusions of law with which the party disagrees; and 
  Specifies the basis for contending that the findings and conclusions 
o
are incorrect; 
  The underlying notice letter from CMS that sets forth the action taken and 
the partys appeal rights. 
 
In addition, the following identifying information is required with all ALJ hearing 
requests:   
  Your legal business name 
  Your Medicare PTAN (if applicable) 
  Tax Identification Number (TIN) or Employer Identification Number (EIN) 
  A copy of the Hearing Officer or the CMS Regional Office (RO) decision 
 
The procedures for ALJ review can be found at Title 42 of the Code of Federal 
Regulations, sections 498.40  498.79. 
 
Guidelines for Using DAB E-file 
 
  Any document, including a request for hearing, will be deemed to have 
been filed on a given day if it is uploaded to DAB E-File on or before 
11:59 p.m. ET of that day. 
 
  A party that files a request for hearing via DAB E-File will be deemed to 
have consented to accept electronic service of appeal-related documents 
that CMS files, or CRD issues on behalf of the ALJ, via DAB E-File. 
Correspondingly, CMS will also be deemed to have consented to electronic 
service. 
 
  Parties are responsible for ensuring that DAB E-file email notifications do 
not go to their spam folders and that any spam filtering software they may 
have does not restrict their ability to receive emails from the system. 
 
  More detailed instructions on DAB E-File for CRD cases can be found by 
clicking the CRD E- File Procedures link on the File New Appeal Screen 
for CRD appeals. 
 
If you are unable to use DAB E-file 
 
Parties are required to use DAB E-file unless they receive a waiver. If you cannot 
file your appeal electronically, you may mail your hearing request, along with a 
request for waiver of the electronic filing requirement and an explanation of why 
you cannot use DAB E-file, to: Department of Health and Human Services, 
Departmental Appeals Board, Civil Remedies Division, Mail Stop 6132, Attn: 
CMS Enrollment Appeal, 330 Independence Avenue, S.W., Cohen Building, 
Room G-644, Washington, D.C. 20201. 
 
Appeal rights can be found 42 C.F.R. part 498. The regulation explains the appeal 
rights following the determination by the CMS as to whether such entities meet the 
requirements for enrollment in the Medicare program. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address]   [Call Center Telephone Number] 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[MAC Name] 
 
L. Favorable Reconsideration Request Model Letter for Revocation 
Determination 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [Day], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Reconsideration Request] 
[Address] (Address from which the Reconsideration Request was sent)  
[City], [State] [Zip Code] 
 
Re: Reconsideration Request Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Person(s) who submitted the Reconsideration Request]: 
 
This letter is in response to the reconsideration request received by [MAC Name] 
based on a revocation of Medicare billing privileges. The initial determination 
letter was dated [Month] [DD], [YYYY] and the reconsideration request was 
received by [MAC Name] on [Month] [DD], [YYYY]; therefore, this appeal is 
considered timely. (if the reconsideration request is untimely, but good cause has 
been found to accept the reconsideration request, use the following [This 
reconsideration request was not timely submitted, but a good cause waiver has 
been granted.]) The following decision is based on the Social Security Act (Act), 
Medicare regulations, the CMS manual instructions, the Medicare enrollment 
record, and any information received before this decision was rendered. 
 
REVOCATION REASON(S): 
 
42 C.F.R.  424.535(a)(revocation reason 1-22) 
42 C.F.R.  424.535(a)(revocation reason 1-22) 
 
OTHER APPLICABLE AUTHORITIES: 
 
42 C.F.R.   (Ex: Medicare Program Integrity Manual chapter 10, section 10.XX) 
 
EXHIBITS: 
 
Exhibit 1: (Ex.: Reconsideration request, signed by Jane Doe, dated [Month] [DD] 
[YYYY].) 
Exhibit 2: (Ex: Copy of a medical license for Jane Doe from the Wisconsin 
Medical Board, effective [Month] [DD], [YYYY].) 
(In this section list each document submitted by the provider or supplier. Each 
exhibit should include the date, as well as a brief description of the document. You 
shall also include all other documentation not submitted by the provider that the 
hearing officer reviewed in making the decision, e.g., enrollment applications, 
development letters, etc.) 
 
BACKGROUND: 
 
The documentation related to the matter for [Provider/Supplier Name] has been 
reviewed and the decision has been made in accordance with the applicable 
Medicare rules, policies, and program instructions. 
 
(Summarize the facts underlying the case which led up to the submission of the 
reconsideration request.) 
 
RECONSIDERATION ANALYSIS: 
 
(The hearing officer needs to check to determine if a CAP was also submitted and 
approved for this provider or supplier. If so, the reconsideration decision should 
only address the remaining authorities and use the following sentence, [MAC 
Name] has reviewed and/or approved the CAP submitted on [Month] [DD], 
[YYYY] in a decision dated [Month] [DD], [YYYY]. 
Therefore, this decision will only address the remaining revocation reason(s) 42 
C.F.R.  424.535(a)(revocation reason 1- 22).) 
 
(If the CAP resolves the revocation in its entirety, the applicable moot model letter 
should be issued in response to the reconsideration request instead of this decision 
template.) 
 
(A reconsideration request reviews whether or not an error was made at the time 
the initial determination was implemented. This section should summarize the 
statements made by the provider or supplier in its reconsideration request. Then 
conduct analysis of the provider or supplier arguments based on the applicable 
regulations and sub-regulations (MPIM). This section shall not reference a 
reconsideration decision without explaining how and why you came to that 
decision.) 
 
DECISION: 
 
(A short conclusory restatement.)   
(Ex: On [Month] [DD], [YYYY], Jane Does medical license was temporarily 
suspended by the Wisconsin medical board based on allegations of malpractice. 
However, on [Month] [DD] [YYYY], the Wisconsin medical board issued an 
order reversing the license suspension back to its implementation date based on the 
outcome of a hearing. As a result, [MAC Name] is overturning the revocation of 
Jane Does Medicare billing privileges as it relates to 42 C.F.R. 
 424.535(a)(1). 
 
This decision is a FAVORABLE DECISION. To effectuate this decision, [MAC 
name] [will reinstate/has reinstated] your Medicare billing privileges, effective 
[Month] [DD], [YYYY]. 
 
(The reinstatement date is based on chapter 10 of the MPIM and the date of the 
providers or suppliers revocation or the date the providers or suppliers license 
was reinstated if the revocation involves a licensure issue.) 
 
(If additional information is needed from the provider or supplier in order to 
reactivate the enrollment, the MAC shall state what information is needed from the 
provider or supplier in this reconsideration decision. MACs shall state that the 
requested information/documentation must be received within 30 calendar days of 
the date of this decision letter.) 
 
FURTHER APPEAL RIGHTS - ADMINISTRATIVE LAW JUDGE (ALJ): 
 
If you are satisfied with this decision, you do not need to take further action. If you 
believe that this determination is not correct, you may request ALJ review for the 
reconsideration portion of this decision letter. To request ALJ review, you must 
file your appeal with the Civil Remedies Division of the Departmental Appeals 
Board within 60 calendar days after the date of receipt of this decision. 
 
How to file a hearing request 
 
You can file your appeal electronically at the Departmental Appeals Board 
Electronic Filing System Web site (DAB E-File) at https://dab.efile.hhs.gov/. 
 
To file a new appeal using DAB E-File, you first need to register a new account 
by: 
 
1. Clicking Register on the DAB E-File home page; 
2. Entering the information requested on the Register New Account form; and 
3. Clicking Register Account at the bottom of the form. If you have more than one 
representative, each representative must register separately to use DAB E-File on 
your behalf. 
 
The e-mail address and password provided during registration must be entered on 
the login screen at https://dab.efile.hhs.gov/user_sessions/new to access DAB E- File. A registered users access to DAB E-File is restricted to the appeals for 
which he or she is a party or authorized representative. 
 
Once registered, you may file your appeal by logging in and: 
 
  Clicking the File New Appeal link on the Manage Existing Appeals screen, 
and then clicking Civil Remedies Division on the File New Appeal screen; 
and 
 
  Entering and uploading the requested information and documents on the 
File New Appeal  Civil Remedies Division form. 
 
All documents must be submitted in PDF form. 
 
What you must include in a hearing request for ALJ review 
 
At minimum, the Civil Remedies Division (CRD) requires a party to file the 
following: 
  A signed request for hearing that: 
  Identifies the specific issues and the findings of fact and 
o
conclusions of law with which the party disagrees; and 
  Specifies the basis for contending that the findings and conclusions 
o
are incorrect; 
  The underlying notice letter from CMS that sets forth the action taken and 
the partys appeal rights. 
 
In addition, the following identifying information is required with all ALJ hearing 
requests: 
 
  Your legal business name 
  Your Medicare PTAN (if applicable) 
  Tax Identification Number (TIN) or Employer Identification Number (EIN) 
  A copy of the Hearing Officer or the CMS Regional Office (RO) decision 
 
The procedures for ALJ review can be found at Title 42 of the Code of Federal 
Regulations, sections 498.40  498.79. 
 
Guidelines for Using DAB E-file 
 
  Any document, including a request for hearing, will be deemed to have 
been filed on a given day if it is uploaded to DAB E-File on or before 
11:59 p.m. ET of that day. 
 
  A party that files a request for hearing via DAB E-File will be deemed to 
have consented to accept electronic service of appeal-related documents 
that CMS files, or CRD issues on behalf of the ALJ, via DAB E-File. 
Correspondingly, CMS will also be deemed to have consented to electronic  service. 
 
  Parties are responsible for ensuring that DAB E-file email notifications do 
not go to their spam folders and that any spam filtering software they may 
have does not restrict their ability to receive emails from the system. 
 
  More detailed instructions on DAB E-File for CRD cases can be found by 
clicking the CRD E- File Procedures link on the File New Appeal Screen 
for CRD appeals. 
 
If you are unable to use DAB E-file 
 
Parties are required to use DAB E-file unless they receive a waiver. If you cannot 
file your appeal electronically, you may mail your hearing request, along with a 
request for waiver of the electronic filing requirement and an explanation of why 
you cannot use DAB E-file, to: Department of Health and Human Services, 
Departmental Appeals Board, Civil Remedies Division, Mail Stop 6132, Attn: 
CMS Enrollment Appeal, 330 Independence Avenue, S.W., Cohen Building, 
Room G-644, Washington, D.C. 20201. 
 
Appeal rights can be found 42 C.F.R. part 498. The regulation explains the appeal 
rights following the determination by the CMS as to whether such entities meet the 
requirements for enrollment in the Medicare program. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address]  
[Call Center Telephone Number] 
 
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
M. Unfavorable Reconsideration Request Model Letter in Response to an 
Enrollment Denial 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [Day], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name]  Attn: [Signer/Submitter of Reconsideration Request] 
[Address] (Address from which the Reconsideration Request was sent)  
[City], [State] [Zip Code] 
 
Re: Reconsideration Request Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Person(s) who submitted the Reconsideration Request]: 
 
This letter is in response to the reconsideration request received by [MAC Name] 
based on an enrollment denial. The initial determination letter was dated [Month] 
[DD], [YYYY] and the reconsideration request was received by [MAC Name] on 
[Month] [DD], [YYYY]; therefore, this appeal is considered timely. (if the 
reconsideration request is untimely, but good cause has been found to accept the 
reconsideration request, use the following [This reconsideration request was not 
timely submitted, but a good cause waiver has been granted.]) The following 
decision is based on the Social Security Act (Act), Medicare regulations, the CMS 
manual instructions, the Medicare enrollment record, and any information received 
before this decision was rendered. 
 
DENIAL REASON(S): 
 
42 C.F.R.  424.530(a)(denial reason 1-14) 
42 C.F.R.  424.530(a)(denial reason 1-14) 
 
OTHER APPLICABLE AUTHORITIES: 
 
42 C.F.R.  
(Ex: Medicare Program Integrity Manual chapter 10, section 10.XX) 
 
EXHIBITS: 
 
Exhibit 1: (Ex.: Reconsideration request, signed by Jane Doe, dated [Month] [DD] 
[YYYY].) 
Exhibit 2: (Ex: Copy of a medical license for Jane Doe from the Wisconsin 
Medical Board, effective [Month] [DD], [YYYY].) 
(In this section list each document submitted by the provider or supplier. Each 
exhibit should include the date, as well as a brief description of the document. You 
shall also include all other documentation not submitted by the provider that the 
hearing officer reviewed in making the decision, e.g., enrollment applications, 
development letters, etc.) 
 
BACKGROUND: 
 
The documentation related to the matter for [Provider/Supplier Name] has been  reviewed and the decision has been made in accordance with the applicable 
Medicare rules, policies, and program instructions. 
 
[Summarize the facts underlying the case which led up to the submission of the 
reconsideration request.] 
 
RECONSIDERATION ANALYSIS: 
 
(The hearing officer needs to check to determine if a CAP was also submitted and 
approved for this provider or supplier. If so, the reconsideration decision should 
only address the remaining authorities and use the following sentence, [MAC 
Name] has approved the CAP submitted on [Month] [DD], [YYYY] in a decision 
dated [Month] [DD], [YYYY]. Therefore, this decision will only address the 
remaining denial reason(s) 42 C.F.R.  424.530(a)(denial reason 1-14).) 
 
(If the CAP resolves the denial in its entirety, the applicable moot model letter 
should be issued in response to the reconsideration request instead of this decision 
template.) 
 
(A reconsideration request reviews whether or not an error was made at the time the 
initial determination was implemented. This section should summarize the 
statements made by the provider or supplier in its reconsideration request. Then 
conduct analysis of the arguments based on the applicable regulations and sub-
regulations (MPIM). This section shall not reference a reconsideration decision 
without explaining how and why you came to that decision.) 
 
DECISION: 
 
(A short conclusory restatement.) 
 
(Ex: On [Month] [DD], [YYYY], Jane Does medical license was temporarily 
suspended by the Wisconsin medical board based on allegations of malpractice. 
Jane Doe did not submit any documentation to demonstrate that her medical 
license was not suspended. In addition, [MAC Name] has confirmed that Jane 
Does medical license remains suspended. As a result, [MAC Name] upholds the 
denial of Jane Does Medicare enrollment application as it relates to 42 C.F.R.  
424.530(a)(1).) 
 
This decision is an UNFAVORABLE DECISION. [MAC name] concludes that 
there was no error made in the denial of your Medicare enrollment. As a result, the 
denial of your Medicare enrollment is upheld. 
 
FURTHER APPEAL RIGHTS - ADMINISTRATIVE LAW JUDGE (ALJ): 
 
If you are satisfied with this decision, you do not need to take further action. If you 
believe that this determination is not correct, you may request ALJ review for the 
reconsideration portion of this decision letter. To request ALJ review, you must 
file your appeal with the Civil Remedies Division of the Departmental Appeals  Board within 60 calendar days after the date of receipt of this decision. 
 
How to file a hearing request 
 
You can file your appeal electronically at the Departmental Appeals Board 
Electronic Filing System Web site (DAB E-File) at https://dab.efile.hhs.gov/. 
 
To file a new appeal using DAB E-File, you first need to register a new account 
by: 
 
1. Clicking Register on the DAB E-File home page; 
2. Entering the information requested on the Register New Account form; and 
3. Clicking Register Account at the bottom of the form. If you have more than one 
representative, each representative must register separately to use DAB E-File on 
your behalf. 
 
The e-mail address and password provided during registration must be entered on 
the login screen at https://dab.efile.hhs.gov/user_sessions/new to access DAB E-
File. A registered users access to DAB E-File is restricted to the appeals for 
which he or she is a party or authorized representative. 
 
Once registered, you may file your appeal by logging in and: 
 
  Clicking the File New Appeal link on the Manage Existing Appeals screen, 
and then clicking Civil Remedies Division on the File New Appeal screen; 
and 
 
  Entering and uploading the requested information and documents on the 
File New Appeal  Civil Remedies Division form. 
 
All documents must be submitted in PDF form. 
 
What you must include in a hearing request for ALJ review 
 
At minimum, the Civil Remedies Division (CRD) requires a party to file the 
following: 
 
  A signed request for hearing that: 
 
  Identifies the specific issues and the findings of fact and 
o
conclusions of law with which the party disagrees; and 
  Specifies the basis for contending that the findings and conclusions 
o
are incorrect; 
  The underlying notice letter from CMS that sets forth the action taken and 
the partys appeal rights. 
 
In addition, the following identifying information is required with all ALJ hearing 
requests:   
  Your legal business name 
  Your Medicare PTAN (if applicable) 
  Tax Identification Number (TIN) or Employer Identification Number (EIN) 
  A copy of the Hearing Officer or the CMS Regional Office (RO) decision 
 
The procedures for ALJ review can be found at Title 42 of the Code of Federal 
Regulations, sections 498.40  498.79. 
 
Guidelines for Using DAB E-file 
 
  Any document, including a request for hearing, will be deemed to have 
been filed on a given day if it is uploaded to DAB E-File on or before 
11:59 p.m. ET of that day. 
 
  A party that files a request for hearing via DAB E-File will be deemed to 
have consented to accept electronic service of appeal-related documents 
that CMS files, or CRD issues on behalf of the ALJ, via DAB E-File. 
Correspondingly, CMS will also be deemed to have consented to electronic 
service. 
 
  Parties are responsible for ensuring that DAB E-file email notifications do 
not go to their spam folders and that any spam filtering software they may 
have does not restrict their ability to receive emails from the system. 
 
  More detailed instructions on DAB E-File for CRD cases can be found by 
clicking the CRD E- File Procedures link on the File New Appeal Screen 
for CRD appeals. 
 
If you are unable to use DAB E-file 
 
Parties are required to use DAB E-file unless they receive a waiver. If you cannot 
file your appeal electronically, you may mail your hearing request, along with a 
request for waiver of the electronic filing requirement and an explanation of why 
you cannot use DAB E-file, to: Department of Health and Human Services, 
Departmental Appeals Board, Civil Remedies Division, Mail Stop 6132, Attn: 
CMS Enrollment Appeal, 330 Independence Avenue, S.W., Cohen Building, 
Room G-644, Washington, D.C. 20201. 
 
Appeal rights can be found 42 C.F.R. part 498. The regulation explains the appeal 
rights following the determination by the CMS as to whether such entities meet the 
requirements for enrollment in the Medicare program. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address]   [Call Center Telephone Number] 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
 [Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
N. Unfavorable Reconsideration Request Model Letter in Response to a 
Reactivation Effective Date Determination 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [Day], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Reconsideration Request] 
[Address] (Address from which the Reconsideration Request was sent)  
[City], [State] [Zip Code] 
 
Re: Reconsideration Request Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the Reconsideration Request]: 
 
This letter is in response to the reconsideration request received by [MAC Name] 
in response to a reactivation effective date determination. The initial determination 
letter was dated [Month] [DD], [YYYY] and the reconsideration request was 
received by [MAC Name] on [Month] [DD], [YYYY]; therefore, this appeal is 
considered timely. (if the reconsideration request is untimely, but good cause has 
been found to accept the reconsideration request, use the following [This 
reconsideration request was not timely submitted, but a good cause waiver has 
been granted.]) The following decision is based on the Social Security Act (Act), 
Medicare regulations, the CMS manual instructions, the Medicare enrollment 
record, and any information received before this decision was rendered. 
 
EFFECTIVE DATE REGULATION(S): 
 
42 C.F.R.  424.520(a-d) (Other effective date regulations may be included) 
 
OTHER APPLICABLE AUTHORITIES: 
 
42 C.F.R.  424.540 (Other applicable regulations for MPIM sections may be  included) 
(Ex: Medicare Program Integrity Manual (MPIM) chapter 10, section 10.XX) 
 
EXHIBITS: 
 
Exhibit 1: (Ex.: CMS-855I Medicare enrollment application, signed and certified 
by John Smith on [Month] [DD], [YYYY].) 
Exhibit 2: (Ex: Copy of an email chain between John Smith and Jane Doe, dated 
[Month] [DD], [YYYY], submitting the requested development documentation for 
John Smith to Jane Doe.) 
 
(In this section list each document submitted by the provider or supplier. Each 
exhibit should include the date, as well as a brief description of the document. You 
shall also include all other documentation not submitted by the provider that the 
hearing officer reviewed in making the decision, e.g., enrollment applications, 
development letters, etc.) 
 
BACKGROUND: 
 
The documentation related to the matter for [Provider/Supplier Name] has been 
reviewed and the decision has been made in accordance with the applicable 
Medicare rules, policies, and program instructions. 
 
(Summarize the facts underlying the case which led up to the submission of the 
reconsideration request.) 
 
RECONSIDERATION ANALYSIS: 
 
(A reconsideration request reviews whether or not an error was made at the time the 
initial determination was implemented. This section should summarize the 
statements made by the provider or supplier in its reconsideration request. Then 
conduct analysis of the arguments based on the applicable regulations and sub-
regulations, MPIM. This section shall not reference a reconsideration decision 
without explaining how and why you came to that decision.) 
 
DECISION: 
 
(A short conclusory restatement.) 
 
(On [Month] [DD], [YYYY], John Smiths Medicare enrollment was deactivated 
for failing to timely respond to a revalidation request. On [Month] [DD], [YYYY], 
John Smith submitted a revalidation application, which was processed and 
approved. Per the MPIM, Ch. 10, Section 10.4(K), John Smiths Medicare 
enrollment was reactivated, but with a gap in his Medicare billing privileges from 
[Month] [DD], [YYYY] to [Month] [DD], [YYYY]. John Smiths reconsideration 
request did not demonstrate an error in the determination of his reactivation 
effective date.) 
  This decision is an UNFAVORABLE DECISION. [MAC name] concludes that 
no error was made in the determination of a reactivation effective date resulting in a 
gap in your Medicare billing privileges. As a result, your reactivation effective 
date will remain [Month] [DD] [YYYY]. 
 
FURTHER APPEAL RIGHTS - ADMINISTRATIVE LAW JUDGE (ALJ): 
 
If you are satisfied with this decision, you do not need to take further action. If you 
believe that this determination is not correct, you may request ALJ review for the 
reconsideration portion of this decision letter. To request ALJ review, you must 
file your appeal with the Civil Remedies Division of the Departmental Appeals 
Board within 60 calendar days after the date of receipt of this decision. 
 
How to file a hearing request 
 
You can file your appeal electronically at the Departmental Appeals Board 
Electronic Filing System Web site (DAB E-File) at https://dab.efile.hhs.gov/. 
 
To file a new appeal using DAB E-File, you first need to register a new account 
by: 
 
1. Clicking Register on the DAB E-File home page; 
2. Entering the information requested on the Register New Account form; and 
3. Clicking Register Account at the bottom of the form. If you have more than one 
representative, each representative must register separately to use DAB E-File on 
your behalf. 
 
The e-mail address and password provided during registration must be entered on 
the login screen at https://dab.efile.hhs.gov/user_sessions/new to access DAB E-
File. A registered users access to DAB E-File is restricted to the appeals for 
which he or she is a party or authorized representative. 
 
Once registered, you may file your appeal by logging in and: 
 
  Clicking the File New Appeal link on the Manage Existing Appeals screen, 
and then clicking Civil Remedies Division on the File New Appeal screen; 
and 
 
  Entering and uploading the requested information and documents on the 
File New Appeal  Civil Remedies Division form. 
 
All documents must be submitted in PDF form. 
 
What you must include in a hearing request for ALJ review 
 
At minimum, the Civil Remedies Division (CRD) requires a party to file the 
following: 
  A signed request for hearing that:    Identifies the specific issues and the findings of fact and 
o
conclusions of law with which the party disagrees; and 
  Specifies the basis for contending that the findings and conclusions 
o
are incorrect; 
  The underlying notice letter from CMS that sets forth the action taken and 
the partys appeal rights. 
 
In addition, the following identifying information is required with all ALJ hearing 
requests: 
 
  Your legal business name 
  Your Medicare PTAN (if applicable) 
  Tax Identification Number (TIN) or Employer Identification Number (EIN) 
  A copy of the Hearing Officer or the CMS Regional Office (RO) decision 
 
The procedures for ALJ review can be found at Title 42 of the Code of Federal 
Regulations, sections 498.40  498.79. 
 
Guidelines for Using DAB E-file 
 
  Any document, including a request for hearing, will be deemed to have 
been filed on a given day if it is uploaded to DAB E-File on or before 
11:59 p.m. ET of that day. 
 
  A party that files a request for hearing via DAB E-File will be deemed to 
have consented to accept electronic service of appeal-related documents 
that CMS files, or CRD issues on behalf of the ALJ, via DAB E-File. 
Correspondingly, CMS will also be deemed to have consented to electronic 
service. 
 
  Parties are responsible for ensuring that DAB E-file email notifications do 
not go to their spam folders and that any spam filtering software they may 
have does not restrict their ability to receive emails from the system. 
 
  More detailed instructions on DAB E-File for CRD cases can be found by 
clicking the CRD E- File Procedures link on the File New Appeal Screen 
for CRD appeals. 
 
If you are unable to use DAB E-file 
 
Parties are required to use DAB E-file unless they receive a waiver. If you cannot 
file your appeal electronically, you may mail your hearing request, along with a 
request for waiver of the electronic filing requirement and an explanation of why 
you cannot use DAB E-file, to: Department of Health and Human Services, 
Departmental Appeals Board, Civil Remedies Division, Mail Stop 6132, Attn: 
CMS Enrollment Appeal, 330 Independence Avenue, S.W., Cohen Building, 
Room G-644, Washington, D.C. 20201.   
Appeal rights can be found 42 C.F.R. part 498. The regulation explains the appeal 
rights following the determination by the CMS as to whether such entities meet the 
requirements for enrollment in the Medicare program. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address]  
[Call Center Telephone Number] 
 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
 [Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
O. Unfavorable Reconsideration Request Model Letter in Response to an 
Effective Date of Participation Determination (Non-Revalidation) 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to 
send via fax if a valid fax number is available). 
 
[Month] [Day], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Reconsideration Request] 
[Address] (Address from which the Reconsideration Request was sent)  
[City], [State] [Zip Code] 
 
Re: Reconsideration Request Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Person(s) who submitted the Reconsideration Request]: 
 
This letter is in response to the reconsideration request received by [MAC Name] 
based on an effective date of enrollment determination. The initial determination 
letter was dated [Month] [DD], [YYYY] and the reconsideration request was 
received by [MAC Name] on [Month] [DD], [YYYY]; therefore, this appeal is 
considered timely. (if the reconsideration request is untimely, but good cause has 
been found to accept the reconsideration request, use the following [This 
reconsideration request was not timely submitted, but a good cause waiver has 
been granted.]) The following decision is based on the Social Security Act (Act),  Medicare regulations, the CMS manual instructions, the Medicare enrollment 
record, and any information received before this decision was rendered. 
 
EFFECTIVE DATE REGULATION(S): 
 
42 C.F.R.  424.520(a-d) 
 
OTHER APPLICABLE AUTHORITIES: 
 
42 C.F.R.  
(Ex: Medicare Program Integrity Manual chapter 10, section 10.XX) 
 
EXHIBITS: 
 
Exhibit 1: (Ex.: CMS-855I Medicare enrollment application, signed and certified 
by John Smith on [Month] [DD], [YYYY].) 
Exhibit 2: (Ex: Copy of an email chain between John Smith and Jane Doe, dated 
[Month] [DD], [YYYY], submitting the requested development documentation for 
John Smith to Jane Doe.) 
 
(In this section list each document submitted by the provider or supplier. Each 
exhibit should include the date, as well as a brief description of the document. You 
shall also include all other documentation not submitted by the provider that the 
hearing officer reviewed in making the decision, e.g., enrollment applications, 
development letters, etc.) 
 
BACKGROUND: 
 
The documentation related to the matter for [Provider/Supplier Name] has been 
reviewed and the decision has been made in accordance with the applicable 
Medicare rules, policies, and program instructions. 
 
(Summarize the facts underlying the case which led up to the submission of the 
reconsideration request.) 
 
RECONSIDERATION ANALYSIS: 
 
(A reconsideration request reviews whether or not an error was made at the time the 
initial determination was implemented. This section should summarize the 
statements made by the provider or supplier in its reconsideration request. Then 
conduct analysis of the arguments based on the applicable regulations and sub-
regulations (MPIM). This section shall not reference a reconsideration decision 
without explaining how and why you came to that decision.) 
 
DECISION: 
 
(A short conclusory restatement.) 
  (On [Month] [DD], [YYYY], John Smith submitted an initial Medicare enrollment 
application. On [Month] [DD], [YYYY], [MAC Name] sent a development 
request to John Smith for additional documentation/information to continue 
processing his enrollment application. 
 
However, John Smith did not submit the requested documentation within 30 days. 
As a result, [MAC Name] properly rejected John Smiths Medicare enrollment 
application received on [Month] [DD] [YYYY]. On [Month] [DD] [YYYY], John 
Smith submitted another Medicare enrollment application, which was processed 
and subsequently approved with an effective date of [Month] [DD], [YYYY] in 
accordance with 42 C.F.R.  424.520. 
 
This decision is an UNFAVORABLE DECISION. [MAC name] concludes that 
no error was made in the determination of your effective date of participation in 
the Medicare program. As a result, the effective date of participation will remain 
the same. 
 
FURTHER APPEAL RIGHTS - ADMINISTRATIVE LAW JUDGE (ALJ): 
 
If you are satisfied with this decision, you do not need to take further action. If you 
believe that this determination is not correct, you may request ALJ review for the 
reconsideration portion of this decision letter. To request ALJ review, you must 
file your appeal with the Civil Remedies Division of the Departmental Appeals 
Board within 60 calendar days after the date of receipt of this decision. 
 
How to file a hearing request 
 
You can file your appeal electronically at the Departmental Appeals Board 
Electronic Filing System Web site (DAB E-File) at https://dab.efile.hhs.gov/. 
 
To file a new appeal using DAB E-File, you first need to register a new account 
by: 
 
1. Clicking Register on the DAB E-File home page; 
2. Entering the information requested on the Register New Account form; and 
3. Clicking Register Account at the bottom of the form. If you have more than one 
representative, each representative must register separately to use DAB E-File on 
your behalf. 
 
The e-mail address and password provided during registration must be entered on 
the login screen at https://dab.efile.hhs.gov/user_sessions/new to access DAB E-
File. A registered users access to DAB E-File is restricted to the appeals for 
which he or she is a party or authorized representative. 
 
Once registered, you may file your appeal by logging in and: 
 
  Clicking the File New Appeal link on the Manage Existing Appeals screen, 
and then clicking Civil Remedies Division on the File New Appeal screen;  and 
 
  Entering and uploading the requested information and documents on the 
File New Appeal  Civil Remedies Division form. 
 
All documents must be submitted in PDF form. 
 
What you must include in a hearing request for ALJ review 
 
At minimum, the Civil Remedies Division (CRD) requires a party to file the 
following: 
  A signed request for hearing that: 
  Identifies the specific issues and the findings of fact and 
o
conclusions of law with which the party disagrees; and 
  Specifies the basis for contending that the findings and conclusions 
o
are incorrect; 
  The underlying notice letter from CMS that sets forth the action taken and 
the partys appeal rights. 
 
In addition, the following identifying information is required with all ALJ hearing 
requests: 
 
  Your legal business name 
  Your Medicare PTAN (if applicable) 
  Tax Identification Number (TIN) or Employer Identification Number (EIN) 
  A copy of the Hearing Officer or the CMS Regional Office (RO) decision 
 
The procedures for ALJ review can be found at Title 42 of the Code of Federal 
Regulations, sections 498.40  498.79. 
 
Guidelines for Using DAB E-file 
 
  Any document, including a request for hearing, will be deemed to have 
been filed on a given day if it is uploaded to DAB E-File on or before 
11:59 p.m. ET of that day. 
 
  A party that files a request for hearing via DAB E-File will be deemed to 
have consented to accept electronic service of appeal-related documents 
that CMS files, or CRD issues on behalf of the ALJ, via DAB E-File. 
Correspondingly, CMS will also be deemed to have consented to electronic 
service. 
 
  Parties are responsible for ensuring that DAB E-file email notifications do 
not go to their spam folders and that any spam filtering software they may 
have does not restrict their ability to receive emails from the system. 
 
  More detailed instructions on DAB E-File for CRD cases can be found by  clicking the CRD E- File Procedures link on the File New Appeal Screen 
for CRD appeals. 
 
If you are unable to use DAB E-file 
 
Parties are required to use DAB E-file unless they receive a waiver. If you cannot 
file your appeal electronically, you may mail your hearing request, along with a 
request for waiver of the electronic filing requirement and an explanation of why 
you cannot use DAB E-file, to: Department of Health and Human Services, 
Departmental Appeals Board, Civil Remedies Division, Mail Stop 6132, Attn: 
CMS Enrollment Appeal, 330 Independence Avenue, S.W., Cohen Building, 
Room G-644, Washington, D.C. 20201. 
 
Appeal rights can be found 42 C.F.R. part 498. The regulation explains the appeal 
rights following the determination by the CMS as to whether such entities meet the 
requirements for enrollment in the Medicare program. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address]  
[Call Center Telephone Number] 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
 [Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
 
P. Unfavorable Reconsideration Request Model Letter for Revocation Determination 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to send via fax if 
a valid fax number is available). 
 
[Month] [Day], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Reconsideration Request] 
[Address] (Address from which the Reconsideration Request was sent)  
[City], [State] [Zip Code] 
 
Re: Reconsideration Request Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
  Dear [Person(s) who submitted the Reconsideration Request]: 
 
This letter is in response to the reconsideration request received by [MAC Name] based on a 
revocation of Medicare billing privileges. The initial determination letter was dated [Month] 
[DD], [YYYY] and the reconsideration request was received by [MAC Name] on [Month] [DD], 
[YYYY]; therefore, this appeal is considered timely. (if the reconsideration request is untimely, 
but good cause has been found to accept the reconsideration request, use the following [This 
reconsideration request was not timely submitted, but a good cause waiver has been granted.]) 
The following decision is based on the Social Security Act (Act), Medicare regulations, the CMS 
manual instructions, the Medicare enrollment record, and any information received before this 
decision was rendered. 
 
REVOCATION REASON(S): 
 
42 C.F.R.  424.535(a)(revocation reason 1-22) 
42 C.F.R.  424.535(a)(revocation reason 1-22) 
 
OTHER APPLICABLE AUTHORITIES: 
 
42 C.F.R.  
(Ex: Medicare Program Integrity Manual chapter 10, section 10.XX) 
 
EXHIBITS: 
 
Exhibit 1: (Ex.: Reconsideration request, signed by Jane Doe, dated [Month] [DD] [YYYY].) 
Exhibit 2: (Ex: Copy of a medical license for Jane Doe from the Wisconsin Medical Board, 
effective [Month] [DD], [YYYY].) 
 
(In this section list each document submitted by the provider or supplier. Each exhibit should 
include the date, as well as a brief description of the document. You shall also include all other 
documentation not submitted by the provider that the hearing officer reviewed in making the 
decision, e.g., enrollment applications, development letters, etc.) 
 
BACKGROUND: 
 
The documentation related to the matter for [Provider/Supplier Name] has been reviewed and the 
decision has been made in accordance with the applicable Medicare rules, policies, and program 
instructions. 
 
(Summarize the facts underlying the case which led up to the submission of the reconsideration 
request.) 
 
RECONSIDERATION ANALYSIS: 
 
(The hearing officer needs to check to determine if a CAP was also submitted and approved for 
this provider or supplier. If so, the reconsideration decision should only address the remaining 
authorities and use the following sentence, [MAC Name] has denied or approved the CAP 
submitted on [Month] [DD], [YYYY] in a decision dated [Month] [DD], [YYYY]. Therefore,  this decision will only address the remaining revocation reason(s) 42 C.F.R.  
424.535(a)(revocation reason 1-22).) 
 
(If the CAP resolves the revocation in its entirety, the applicable moot model letter should be 
issued in response to the reconsideration request instead of this decision template.) 
 
(A reconsideration request reviews whether or not an error was made at the time the initial 
determination was implemented. This section should summarize the statements made by the 
provider or supplier in its reconsideration request. Then conduct analysis of the arguments based 
on the applicable regulations and sub-regulations (MPIM). This section shall not reference a 
reconsideration decision without explaining how and why you came to that decision.) 
 
DECISION: 
 
(A short conclusory restatement.) 
 
(On [Month] [DD], [YYYY], Jane Does medical license was suspended by the Wisconsin 
Medical Board. Jane Doe has not submitted evidence to demonstrate that the suspension of her 
medical license was rescinded. In addition, [MAC Name] has confirmed that Jane Does medical 
license remains suspended. As a result, [MAC Name] upholds the revocation of Jane Does 
Medicare enrollment application under 42 C.F.R.  424.535(a)(1).) 
 
This decision is an UNFAVORABLE DECISION. [MAC name] concludes that there was no 
error made in the implementation of a revocation. As a result, the revocation of your Medicare 
billing privileges is upheld. 
 
FURTHER APPEAL RIGHTS - ADMINISTRATIVE LAW JUDGE (ALJ): 
 
If you are satisfied with this decision, you do not need to take further action. If you believe that 
this determination is not correct, you may request ALJ review for the reconsideration portion of 
this decision letter. To request ALJ review, you must file your appeal with the Civil Remedies 
Division of the Departmental Appeals Board within 60 calendar days after the date of receipt of 
this decision. 
 
How to file a hearing request 
 
You can file your appeal electronically at the Departmental Appeals Board 
Electronic Filing System Web site (DAB E-File) at https://dab.efile.hhs.gov/. 
 
To file a new appeal using DAB E-File, you first need to register a new account 
by: 
 
1. Clicking Register on the DAB E-File home page; 
2. Entering the information requested on the Register New Account form; and 
3. Clicking Register Account at the bottom of the form. If you have more than one 
representative, each representative must register separately to use DAB E-File on 
your behalf. 
  The e-mail address and password provided during registration must be entered on 
the login screen at https://dab.efile.hhs.gov/user_sessions/new to access DAB E-
File. A registered users access to DAB E-File is restricted to the appeals for 
which he or she is a party or authorized representative. 
 
Once registered, you may file your appeal by logging in and: 
 
  Clicking the File New Appeal link on the Manage Existing Appeals screen, 
and then clicking Civil Remedies Division on the File New Appeal screen; 
and 
 
  Entering and uploading the requested information and documents on the 
File New Appeal  Civil Remedies Division form. 
 
All documents must be submitted in PDF form. 
 
What you must include in a hearing request for ALJ review 
 
At minimum, the Civil Remedies Division (CRD) requires a party to file the 
following: 
 
  A signed request for hearing that: 
 
  Identifies the specific issues and the findings of fact and 
o
conclusions of law with which the party disagrees; and 
  Specifies the basis for contending that the findings and conclusions 
o
are incorrect; 
  The underlying notice letter from CMS that sets forth the action taken and 
the partys appeal rights. 
 
In addition, the following identifying information is required with all ALJ hearing 
requests: 
 
  Your legal business name 
  Your Medicare PTAN (if applicable) 
  Tax Identification Number (TIN) or Employer Identification Number (EIN) 
  A copy of the Hearing Officer or the CMS Regional Office (RO) decision 
 
The procedures for ALJ review can be found at Title 42 of the Code of Federal 
Regulations, sections 498.40  498.79. 
 
Guidelines for Using DAB E-file 
 
  Any document, including a request for hearing, will be deemed to have 
been filed on a given day if it is uploaded to DAB E-File on or before 
11:59 p.m. ET of that day. 
    A party that files a request for hearing via DAB E-File will be deemed to 
have consented to accept electronic service of appeal-related documents 
that CMS files, or CRD issues on behalf of the ALJ, via DAB E-File. 
Correspondingly, CMS will also be deemed to have consented to electronic 
service. 
 
  Parties are responsible for ensuring that DAB E-file email notifications do 
not go to their spam folders and that any spam filtering software they may 
have does not restrict their ability to receive emails from the system. 
 
  More detailed instructions on DAB E-File for CRD cases can be found by 
clicking the CRD E- File Procedures link on the File New Appeal Screen 
for CRD appeals. 
 
If you are unable to use DAB E-file 
 
Parties are required to use DAB E-file unless they receive a waiver. If you cannot 
file your appeal electronically, you may mail your hearing request, along with a 
request for waiver of the electronic filing requirement and an explanation of why 
you cannot use DAB E-file, to: Department of Health and Human Services, 
Departmental Appeals Board, Civil Remedies Division, Mail Stop 6132, Attn: 
CMS Enrollment Appeal, 330 Independence Avenue, S.W., Cohen Building, 
Room G-644, Washington, D.C. 20201. 
 
Appeal rights can be found 42 C.F.R. part 498. The regulation explains the appeal 
rights following the determination by the CMS as to whether such entities meet the 
requirements for enrollment in the Medicare program. 
 
If you have any further questions, please forward your inquiries to [MAC Appeal 
Receipt Email Address] or mail it to the following address: 
 
[MAC Appeal Receipt Address]  
[Call Center Telephone Number] 
 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer]  
[Position of Hearing Officer]  
[MAC Name] 
 
Q. Reconsideration Further Information Required for Development Model Letter 
 
(To be sent by hard-copy mail and email if email address is provided. Optional to send via fax if 
a valid fax number is available). 
  To: [Email address provided by the person who submitted the Reconsideration.]  
Subject: Medicare Provider Enrollment Reconsideration re: [Provider/Supplier Name]  
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Reconsideration] (If submitted on behalf of an organization or group) 
[Address] (Address from which the Reconsideration was sent) 
[City], [State] [Zip Code] 
 
Re: Reconsideration Decision 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (Internal Tracking) 
 
Dear [Name of the person(s) who submitted the Reconsideration]: 
 
On [Month] [DD]. [YYYY], [MAC Name] issued a reconsideration decision. As stated in the 
[Month] [DD], [YYYY] reconsideration decision letter, the approval of [Provider/Supplier 
Name]s Medicare enrollment is contingent upon the submission of [list required 
documentation]. Please send the required documentation within 30 calendar days to: 
 
[MAC Reconsideration Receipt Address] [MAC Reconsideration Receipt Email Address] [MAC 
Reconsideration Receipt Fax Number] 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM]. 
 
Sincerely, 
[Signature of Hearing Officer] (May be electronic) [Name of Hearing Officer] 
[Position of Hearing Officer]  
[MAC Name] 
10.7.12  Deactivation Model Letter 
(Rev. 11859; Issued: 02-16-23; Effective: 03-17-23; Implementation: 03-17-23) 
(To be sent by hard-copy mail, and via email if email address is listed in the provider/supplier 
correspondence mailing address on the enrollment record. Optional to send via fax if a valid fax 
number is available.) 
 
[Month] [DD], [YYYY]  
 
[Provider/Supplier Name] (as it appears in PECOS)  
[Address]  
[City], [State] [Zip Code]  
 
Re: Deactivation of Medicare billing privileges  
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)   NPI: [XXXXXXXXXX]  
PTAN: [XXXXX]  
Reference Number: [XXXX] (Internal Tracking)  
 
Dear [Provider/Supplier Name]:  
 
Your Medicare billing privileges are being deactivated effective [Month] [DD], [YYYY] 
pursuant to:  
 
DEACTIVATION REASON:  
 
  42 C.F.R.  424.540(a)[1-8]  
 
[Specific reason for the deactivation of the provider/suppliers Medicare billing privileges.]  
 
(If the deactivation is under 424.540(a)(1), an example narrative may include:  
 
[Contractor Name] has reviewed your Medicare billing data and found that you have not 
submitted any claims since January 1, 2017, which is more than twelve calendar months from the 
date of this letter.)  
 
(If the deactivation is under 424.540(a)(2), an example narrative may include:  
 
[Contractor Name] has been informed that John Smith is deceased as of January 1, 2017. Your 
Medicare enrollment application, signed and certified on November 1, 2016, identifies John 
Smith as a 5% or greater owner. [Contractor Name] has not received a Medicare enrollment 
application reporting this change in ownership.)  
 
REBUTTAL RIGHTS: 
 
If you believe that this determination is not correct, you may rebut the deactivation as indicated 
in 42 C.F.R.  424.545(b). The rebuttal must be received by this office in writing within 15 
calendar days of the date of this letter. The rebuttal must state the issues or findings of fact with 
which you disagree and the reasons for disagreement. You may submit additional information 
with the rebuttal that you believe may have a bearing on the decision. You must submit all 
information that you would like to be considered in conjunction with the rebuttal. This includes 
any application(s) to update your enrollment, if necessary. You may only submit one rebuttal in 
response to this deactivation of your Medicare enrollment.  
 
The rebuttal must be signed and dated by the individual provider/supplier, the authorized or 
delegated official, or a legal representative. (Delete next sentence if letter is related to a 
DMEPOS suppliers enrollment.) [Please be advised that authorized or delegated officials for 
groups cannot sign and submit a rebuttal on behalf of a reassigned provider/supplier without the 
provider/supplier submitting a signed statement authorizing that individual from the group to act 
on his/her/their behalf.] 
  If the provider/supplier wishes to appoint a legal representative that is not an attorney to sign the 
rebuttal, the provider/supplier must include with the rebuttal a written notice authorizing the 
legal representative to act on the provider/suppliers behalf. The notice should be signed by the 
provider/supplier.  
 
If the provider/supplier has an attorney sign the rebuttal, the rebuttal must include a statement 
from the attorney that he/she/they have the authority to represent the provider/supplier.  
 
If you wish to receive communication regarding your rebuttal via email, please include a valid 
email address in your rebuttal submission.  
 
The rebuttal should be sent to the following:  
[Contractor Rebuttal Receipt Address]  
[Contractor Rebuttal Receipt Email Address]  
[Contractor Rebuttal Receipt Fax Number]  
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 AM/PM ET/CT/MT/PT] and [x:00 AM/PM ET/CT/MT/PT].  
 
Sincerely,  
 
[Name] [Title] [Company] 
 
10.7.13  Rebuttal Model Letters  
(Rev. 11637; Issued: 10-07-22; Effective: 12-09-22; Implementation: 12-09-22) 
 
Instruction 
 
For the following model letters, all text within parentheses is intended as instruction/explanation 
and should be deleted before the letter is finalized and sent to the provider or supplier. All text 
within brackets requires the contractor to fill in the appropriate text. All letters shall be saved in 
PDF format. 
 
A.  Rebuttal Signature Development Model Letter 
 
(To be sent by hard-copy mail, and via email if email address is provided with the rebuttal 
submission, and email address listed in the provider/supplier correspondence mailing address on 
the enrollment application or enrollment record if different from the email address on the rebuttal 
submission. Optional to send via fax if a valid fax number is available.) 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Rebuttal] (If submitted on behalf of an organization or group) 
[Address] (Address from which the rebuttal was sent) 
[City], [State] [Zip Code]   
Re: Rebuttal Submission 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS) 
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the rebuttal]: 
 
We are in receipt of your rebuttal submission on behalf of [Provider/Supplier], received on 
[Month] [DD], [YYYY].  
 
(If the submission is not properly signed, use the following.) Your submission is not 
appropriately signed, as required in the Medicare Program Integrity Manual, Ch. 10, Section 
10.4(M). [Contractor Name] requests that you submit a rebuttal properly signed by the individual 
provider, supplier, the authorized or delegated official, or a legal representative. (Delete next 
sentence if letter is related to a DMEPOS suppliers enrollment.) [Please be advised that 
authorized or delegated officials for groups cannot sign and submit a rebuttal on behalf of a 
reassigned provider/supplier without the provider/supplier submitting a signed statement 
authorizing that individual from the group to act on his/her/their behalf.] 
 
Your properly signed submission must be received within 15 calendar days of the date of this 
notice. If you do not timely respond to this request, [Contractor Name] may dismiss your rebuttal 
submission. 
 
(If the submission is missing a statement by the attorney, use the following.) Your submission is 
missing an attorney statement that he or she has the authority to represent the provider or 
supplier. [Contractor Name] requests that you submit a rebuttal that includes an attorney 
statement that he/she/they have the authority to represent the provider or supplier within 15 
calendar days of the date of this notice. If you do not timely respond to this request, [Contractor 
Name] may dismiss your rebuttal submission. 
 
(If the submission is missing a signed written notice from the provider/supplier authorizing the 
legal representative to act on his/her/their/its behalf, use the following.) Your submission is 
missing a written notice of the appointment of a representative signed by the provider or 
supplier. Please be advised that authorized or delegated officials for groups cannot sign and 
submit a rebuttal on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her/their 
behalf. [Contractor Name] requests that you submit written notice of the appointment of a 
representative that is properly signed by the provider or supplier within 15 calendar days of the 
date of this notice. If you do not timely respond to this request, [Contractor Name] may dismiss 
your rebuttal submission. 
 
Please send the required documentation to: 
 
[Contractor Rebuttal Receipt Address] 
[Contractor Rebuttal Receipt Email Address] 
Fax: [Contractor Rebuttal Receipt Fax Number]   
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 a.m./p.m ET/CT/MT/PT] and [x:00 a.m./p.m ET/CT/MT/PT]. 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
B.  Rebuttal Further Information Required Development Model Letter 
 
(To be sent by hard-copy mail, and via email if email address is provided with the rebuttal 
submission, and email address listed in the provider/supplier correspondence mailing address on 
the enrollment application or enrollment record if different from the email address on the rebuttal 
submission. Optional to send via fax if a valid fax number is available.) 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Rebuttal] (If submitted on behalf of an organization or group) 
[Address] (Address from which the rebuttal was sent) 
[City], [State] [Zip Code] 
 
Re: Rebuttal Submission 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS) 
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (Optional) 
 
Dear [Name of the person(s) who submitted the rebuttal]: 
 
On [Month] [DD]. [YYYY], [Contractor Name] issued a favorable rebuttal determination, 
reversing the deactivation of [Provider/Supplier Name]s Medicare billing privileges. As stated 
in the [Month] [DD], [YYYY] determination letter, the reactivation of [Provider/Supplier 
Name]s Medicare enrollment is contingent upon the submission of [list required 
documentation]. Please send the required documentation to: 
 
[Contractor Rebuttal Receipt Address] 
[Contractor Rebuttal Receipt Email Address] 
Fax: [Contractor Rebuttal Receipt Fax Number] 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 a.m./p.m ET/CT/MT/PT] and [x:00 a.m./p.m ET/CT/MT/PT]. 
 
Sincerely,   
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
C.  Rebuttal Moot Model Letter  
 
(To be sent by hard-copy mail, and via email if email address is provided with the rebuttal 
submission, and email address listed in the provider/supplier correspondence mailing address on 
the enrollment application or enrollment record if different from the email address on the rebuttal 
submission. Optional to send via fax if a valid fax number is available.) 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Rebuttal] (If submitted on behalf of an organization or group) 
[Address] (Address from which the rebuttal was sent) 
[City], [State] [Zip Code] 
 
Re: Rebuttal Submission 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS) 
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the rebuttal]: 
 
This letter is in response to the rebuttal submission, on behalf of [Provider/Supplier], received on 
[Month] [DD], [YYYY]. On [Month] [DD], [YYYY], [Contractor Name] approved an 
application to reactivate [Provider/Supplier]s Medicare billing privileges without a gap. 
Therefore, the issue set forth in the rebuttal submission is no longer actionable. As a result, this 
issue is moot and a determination will not be made in regards to the rebuttal submission. 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 a.m./p.m ET/CT/MT/PT] and [x:00 a.m./p.m ET/CT/MT/PT]. 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
D.  Rebuttal Facts or Issues and Reasons for Disagreement Development Model Letter 
(To be sent by hard-copy mail, and via email if email address is provided with the rebuttal 
submission, and email address listed in the provider/supplier correspondence mailing address on  the enrollment application or enrollment record if different from the email address on the rebuttal 
submission. Optional to send via fax if a valid fax number is available.) 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name]  
Attn: [Signer/Submitter of Rebuttal] 
[Address] (Address from which the Rebuttal was sent)  
[City], [State] [Zip Code] 
 
Re: Rebuttal Submission 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)  
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
 
Dear [Name of the person(s) who submitted the Rebuttal]: 
 
We are in receipt of your rebuttal submission on behalf of [Provider/Supplier Name], received on 
[Month] [DD], [YYYY]. 
 
As stated in the deactivation letter dated [Month] [DD], [YYYY], to be accepted and reviewed, 
your rebuttal must state the facts or issues identified in the deactivation letter with which you 
disagree and your reasons for disagreement. The rebuttal received on [Month] [DD], [YYYY] does 
not clearly identify the facts or issues with which you disagree and your reasons for disagreement. 
[Contractor Name] is granting you an additional 15 calendar days from the date of this notification 
letter to submit a proper rebuttal that clearly identifies the facts or issues with which you disagree 
and your reasons for disagreement. This revised rebuttal submission must be received within 15 
calendar days of the date of this notice. If you do not timely respond to this request, [Contractor 
Name] may dismiss your rebuttal submission. 
 
Please send the required documentation to: 
 
[Contractor Rebuttal Receipt Address] 
[Contractor Rebuttal Receipt Email Address] 
Fax: [Contractor Rebuttal Receipt Fax Number] 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 a.m./p.m ET/CT/MT/PT] and [x:00 a.m./p.m ET/CT/MT/PT]. 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name]   
E.  Rebuttal Withdrawn Model Letter 
 
(To be sent by hard-copy mail, and via email if email address is provided with the rebuttal 
submission, and email address listed in the provider/supplier correspondence mailing address on 
the enrollment application or enrollment record if different from the email address on the rebuttal 
submission. Optional to send via fax if a valid fax number is available.) 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Rebuttal] (If submitted on behalf of an organization or group) 
[Address] (Address from which the rebuttal was sent) 
[City], [State] [Zip Code] 
 
Re: Rebuttal Submission 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS) 
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the rebuttal]: 
 
We are in receipt of your written withdrawal request in regards to your rebuttal received on 
[Month] [DD], [YYYY], submitted on behalf of [Provider/Supplier Name]. [Contractor Name] 
has not yet issued a rebuttal determination. Therefore, [Contractor Name] considers the rebuttal 
to be withdrawn. As a result, a determination will not be issued in response to the rebuttal and 
[Provider/Supplier Name]s Medicare billing privileges will remain deactivated. 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 a.m./p.m ET/CT/MT/PT] and [x:00 a.m./p.m ET/CT/MT/PT]. 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
F.  Rebuttal Receipt Acknowledgement Model Letter 
 
(To be sent by hard-copy mail, and via email if email address is provided with the rebuttal 
submission, and email address listed in the provider/supplier correspondence mailing address on 
the enrollment application or enrollment record if different from the email address on the rebuttal 
submission. Optional to send via fax if a valid fax number is available.) 
 
[Month] [DD], [YYYY] 
  [Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Rebuttal] (If submitted on behalf of an organization or group) 
[Address] (Address from which the rebuttal was sent) 
[City], [State] [Zip Code] 
 
Re: Rebuttal Submission 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS) 
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the rebuttal]: 
 
We are in receipt of your rebuttal on behalf of [Provider/Supplier Name]. Please be advised that 
[Contractor Name] has made an interim determination to maintain the deactivation of your 
Medicare billing privileges. However, [Contractor Name] will further review the information and 
documentation submitted in the rebuttal and will render a final determination regarding the 
deactivation of your Medicare billing privileges within 30 days of the date of receipt. 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 a.m./p.m ET/CT/MT/PT] and [x:00 a.m./p.m ET/CT/MT/PT]. 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
G.  Final Rebuttal Decision Email Template 
 
(To be sent by hard-copy mail, and via email if email address is provided with the rebuttal 
submission, and email address listed in the provider/supplier correspondence mailing address on 
the enrollment application or enrollment record if different from the email address on the rebuttal 
submission. Optional to send via fax if a valid fax number is available.) 
 
To: [Email address provided by the person who submitted the rebuttal and email address listed in 
the provider/supplier correspondence mailing address on the enrollment application if different 
from the email address on the rebuttal submission.] 
 
Subject: Medicare Provider Enrollment Rebuttal re: [Provider/Supplier Name] 
 
Dear [Name of the person(s) who submitted the rebuttal]: 
 
Please see the attached determination regarding your rebuttal, submitted on behalf of 
[Provider/Supplier Name].  
  If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 a.m./p.m ET/CT/MT/PT] and [x:00 a.m./p.m ET/CT/MT/PT]. 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
H.  Rebuttal Dismissal Model Letters  
 
1.  Untimely Rebuttal Dismissal Model Letter 
 
(To be sent by hard-copy mail, and via email if email address is provided with the rebuttal 
submission, and email address listed in the provider/supplier correspondence mailing address on 
the enrollment application or enrollment record if different from the email address on the rebuttal 
submission. Optional to send via fax if a valid fax number is available.) 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Rebuttal] (If submitted on behalf of an organization or group) 
[Address] (Address from which the rebuttal was sent) 
[City], [State] [Zip Code] 
 
Re: Rebuttal Submission 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS) 
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the rebuttal]: 
 
This letter is in response to the rebuttal received by [Contractor Name], based on the letter 
deactivating [Provider/Supplier Name]s Medicare billing privileges dated [Month] [DD], 
[YYYY]. 
 
[Contractor Name] is unable to accept your rebuttal as it was not timely submitted. The 
deactivation letter was dated [Month] [DD], [YYYY]. A rebuttal must be received within 15 
calendar days of the date of the [Month] [DD], [YYYY] deactivation letter. Your rebuttal was 
not received until [Month] [DD], [YYYY], which is beyond the applicable submission time 
frame. [Provider/Supplier/Legal Representative/Representative] failed to show good cause for 
the late request. Therefore, [Contractor Name] is unable to render a determination in this matter 
and [Provider/Supplier]s Medicare billing privileges will remain deactivated. 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 a.m./p.m ET/CT/MT/PT] and [x:00 a.m./p.m ET/CT/MT/PT].   
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
2.  Improper Signature Rebuttal Dismissal Model Letter 
 
(To be sent by hard-copy mail, and via email if email address is provided with the rebuttal 
submission, and email address listed in the provider/supplier correspondence mailing address on 
the enrollment application or enrollment record if different from the email address on the rebuttal 
submission. Optional to send via fax if a valid fax number is available.) 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Rebuttal]  
[Address](Address from which the rebuttal was sent) 
[City], [State] [Zip Code] 
 
Re: Rebuttal Submission 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS) 
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the rebuttal]: 
 
This letter is in response to the rebuttal received by [Contractor Name], based on the letter 
deactivating [Provider/Supplier Name]s Medicare billing privileges dated [Month] [DD], 
[YYYY]. 
 
[Contractor Name] is unable to accept your rebuttal as it was not signed by an authorized or 
delegated official currently on file in your Medicare enrollment, the individual provider or 
supplier, a legal representative, or did not contain the required statement of representation from 
an attorney or signed written notice appointing a non-attorney legal representative.  Please be 
advised that authorized or delegated officials for groups cannot sign and submit a rebuttal on 
behalf of a reassigned provider/supplier without the provider/supplier submitting a signed 
statement authorizing that individual from the group to act on his/her/their behalf. The signature 
requirement is stated in the [Month] [DD], [YYYY] deactivation letter. Additionally, in a letter 
dated [Month] [DD], [YYYY], [Contractor Name] requested that you provide a properly signed 
submission and permitted an additional 15-calendar days to submit your response. 
 
(If no response received, use this language: [To date, [Contractor Name] has not received a 
response. As a result, [Contractor Name] is dismissing your rebuttal and no decision will be 
rendered.])   
(If response received after 15 calendar days, use this language: [While [Contractor Name] 
received a response, it was not timely received within 15-calendar days. As a result, [Contractor 
Name] is dismissing your rebuttal and no decision will be rendered.]) 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 a.m./p.m ET/CT/MT/PT] and [x:00 a.m./p.m ET/CT/MT/PT]. 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
3.  No Rebuttal Rights Rebuttal Dismissal Model Letter 
 
(To be sent by hard-copy mail, and via email if email address is provided with the rebuttal 
submission, and email address listed in the provider/supplier correspondence mailing address on 
the enrollment application or enrollment record if different from the email address on the rebuttal 
submission. Optional to send via fax if a valid fax number is available.) 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Rebuttal] (If submitted on behalf of an organization or group) 
[Address](Address from which the rebuttal was sent) 
[City], [State] [Zip Code] 
 
Re: Rebuttal Submission 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS) 
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the rebuttal]: 
 
This letter is in response to the rebuttal received by [Contractor Name], submitted on behalf of 
[Provider/Supplier Name]. 
 
[Contractor Name] is unable to accept your rebuttal submission because the action taken in 
regards to your Medicare billing privileges does not afford the opportunity for a rebuttal. Under 
42 C.F.R.  424.546, only a provider or supplier whose Medicare billing privileges are 
deactivated may file a rebuttal in accordance with 42 C.F.R.  405.374. As a result, [Contractor 
Name] is dismissing your rebuttal and no decision will be rendered. 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 a.m./p.m ET/MT/CT/PT] and [x:00 a.m./p.m ET/MT/CT/PT].   
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
4.  More than One Submission Rebuttal Dismissal Model Letter 
 
(To be sent by hard-copy mail, and via email if email address is provided with the rebuttal 
submission, and email address listed in the provider/supplier correspondence mailing address on 
the enrollment application or enrollment record if different from the email address on the rebuttal 
submission. Optional to send via fax if a valid fax number is available.) 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Rebuttal]  
[Address](Address from which the rebuttal was sent) 
[City], [State] [Zip Code] 
 
Re: Rebuttal Submission 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS) 
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the rebuttal]: 
 
This letter is in response to the rebuttal submitted on behalf of [Provider/Supplier Name], based 
on the deactivation letter dated [Month] [DD], [YYYY]. 
 
[Contractor Name] previously received a rebuttal for [Provider/Supplier Name] on [Month] 
[DD], [YYYY]. Per Chapter 10 of the Medicare Program Integrity Manual, only one rebuttal 
request may be submitted per deactivation. Therefore, [Contractor Name] is unable to accept 
your additional rebuttal[s] received on [Month] [DD], [YYYY]. As a result, [Contractor Name] 
is dismissing your rebuttal and no decision will be rendered. 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 a.m./p.m ET/MT/CT/PT] and [x:00 a.m./p.m ET/MT/CT/PT]. 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name]   
5.  No Specification of Why the Provider/Supplier Disagrees with Enrollment Deactivation 
and Reasons for Disagreement Rebuttal Dismissal Model Letter 
 
(To be sent by hard-copy mail, and via email if email address is provided with the rebuttal 
submission, and email address listed in the provider/supplier correspondence mailing address on 
the enrollment application or enrollment record if different from the email address on the rebuttal 
submission. Optional to send via fax if a valid fax number is available.) 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name]  
Attn: [Signer/Submitter of Rebuttal] 
[Address] (Address from which the Rebuttal was sent)  
[City], [State] [Zip Code] 
 
 
Re: Rebuttal Submission 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS) 
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the Rebuttal]: 
 
This letter is in response to the rebuttal submitted on behalf of [Provider/Supplier Name] based on 
the deactivation letter, dated [Month] [DD], [YYYY]. 
 
[Contractor Name] is unable to accept your rebuttal as it does not specify the facts or issues 
identified in the deactivation letter with which you disagree and your reasons for disagreement. 
The requirement to identify the facts or issues with which you disagree and your reasons for 
disagreement was stated in the deactivation letter, dated [Month] [DD], [YYYY], as well as in 42 
C.F.R.  424.546(b), and in Chapter 10 of the Medicare Program Integrity Manual. Additionally, 
in a letter dated [Month] [DD], [YYYY], [Contractor Name] requested that you identify the facts 
or issues identified in the deactivation letter with which you disagree and your reasons for 
disagreement and permitted an additional 15-calendar days to submit your response.  
 
(If no response received, use this language: [To date, [Contractor Name] has not received a 
response. As a result, [Contractor Name] is dismissing your rebuttal and no decision will be 
rendered.]) 
 
(If response received after 15 calendar days, use this language: [While [Contractor Name] 
received a response, it was not timely received within 15-calendar days. As a result, [Contractor 
Name] is dismissing your rebuttal and no decision will be rendered.]) 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 a.m./p.m ET/MT/CT/PT] and [x:00 a.m./p.m ET/MT/CT/PT].   
Sincerely, 
 
 
[Signature of Hearing Officer] (May be electronic)  
[Name of Hearing Officer]  
[Position of Hearing Officer] 
[Contractor Name] 
 
I.  Rebuttal Not Actionable Model Letter (Moot) 
 
(To be sent by hard-copy mail, and via email if email address is provided with the rebuttal 
submission, and email address listed in the provider/supplier correspondence mailing address on 
the enrollment application or enrollment record if different from the email address on the rebuttal 
submission. Optional to send via fax if a valid fax number is available.) 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Rebuttal]  
[Address] (Address from which the rebuttal was sent) 
[City], [State] [Zip Code] 
 
Re: Rebuttal Submission 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS) 
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the person(s) who submitted the rebuttal]: 
 
This letter is in response to the rebuttal received by [Contractor Name], concerning the 
deactivation of [Provider/Supplier Name]s Medicare billing privileges, effective [Month] [DD], 
[YYYY]. 
 
On [Month] [DD], [YYYY], [Contractor Name] reopened the deactivation for [Provider/Supplier 
Name] and issued a revised initial determination. This revised initial determination rendered the 
issue set forth in your rebuttal no longer actionable. For your convenience a copy of the revised 
initial determination is attached. Accordingly, the issue addressed in your rebuttal is now moot, 
and we are unable to render a determination on the matter.  
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 a.m./p.m ET/MT/CT/PT] and [x:00 a.m./p.m ET/MT/CT/PT]. 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer]  [Position of Hearing Officer] 
[Contractor Name] 
 
(The contractor shall include PDF copy of the letter that rendered the rebuttal moot (e.g. the 
revised initial determination).) 
 
J.  Favorable Rebuttal Model Letter 
 
(To be sent by hard-copy mail, and via email if email address is provided with the rebuttal 
submission, and email address listed in the provider/supplier correspondence mailing address on 
the enrollment application or enrollment record if different from the email address on the rebuttal 
submission. Optional to send via fax if a valid fax number is available.) 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Rebuttal]  
[Address] (Address from which the Rebuttal was sent) 
[City], [State] [Zip Code] 
 
Re: Rebuttal Determination 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS) 
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Name of the Person(s) who submitted the rebuttal]: 
 
This letter is in response to the rebuttal received by [Contractor Name] based on the deactivation 
of [Provider/Supplier Name]s Medicare billing privileges. (If the rebuttal was timely, use the 
following.) [The deactivation letter was dated [Month] [DD], [YYYY] and [Contractor Name] 
received the rebuttal on [Month] [DD], [YYYY]; therefore, this rebuttal is considered timely.] (If 
the rebuttal is untimely, but good cause has been found to accept the rebuttal, use the following.) 
[The deactivation letter was dated [Month] [DD], [YYYY] and [Contractor Name] received the 
rebuttal on [Month] [DD], [YYYY]. This rebuttal was not timely submitted, but a good cause 
waiver has been granted.]) [Contractor Name] based the following determination on the Social 
Security Act (Act), Medicare regulations, the CMS manual instructions, the Medicare enrollment 
record, and any information received before this decision was rendered.   
 
DEACTIVATION REASON:  
 
  42 C.F.R.  424.540(a)([1-8]) 
 
OTHER APPLICABLE AUTHORIT[Y/IES]: (list any authorities cited in analysis) 
 
  42 C.F.R.  424.546 
  Medicare Program Integrity Manual (MPIM) chapter 10.XX (If applicable).    (Ex.: If deactivation based non-compliance, list supplier standards) 
  (Ex.: If deactivation based on failure to report, list regulation that requires reporting) 
 
EXHIBITS:  
 
  Exhibit 1: (Example: Rebuttal letter to CMS, signed by John Smith, Administrator for Home 
Healthcare Services, LLC, dated January 1, 2018);  
  Exhibit 2: (Example: Letter from [Contractor Name] to Home Healthcare Services, LLC, 
dated December 1, 2017, deactivating Home Healthcare Services, LLCs Medicare billing 
privileges pursuant to 42 C.F.R.  424.540(a)(3)). 
 
(In this section list each document submitted by the provider or supplier. Each exhibit shall 
include the date, as well as a brief description of the document. The contractor shall also include 
other documentation not submitted by the provider or supplier that the hearing officer reviewed 
in making the determination, e.g., enrollment applications, development letters, etc.) 
 
BACKGROUND: 
 
[Contractor Name] has reviewed the documentation related to the matter for [Provider/Supplier 
Name] and made the determination in accordance with the applicable Medicare rules, policies 
and program instructions. 
 
(Summarize the facts underlying the case which led up to the submission of the rebuttal.)  
 
REBUTTAL ANALYSIS: 
 
(A rebuttal reviews whether or not an error was made in the implementation of the deactivation 
of the providers or suppliers Medicare billing privileges. This section shall summarize the 
statements made by the provider or supplier in its rebuttal, then provide an analysis of the 
arguments based on the applicable regulations and sub-regulations, such as the MPIM. Any 
regulation or sub-regulatory guidance that is referenced in this section shall also be listed in 
Other Applicable Authorities. It is insufficient to state a rebuttal determination without 
explaining how and why the determination was made.) 
 
DECISION: 
 
(A short conclusory restatement.)  
 
(Example: On [Month] [DD], [YYYY], [Contractor Name] received a revalidation application 
for Home Healthcare Services, LLC. On [Month] [DD], [YYYY], [Contractor Name] rejected 
Home Healthcare Services, LLCs revalidation application prior to 90 calendar days from the 
date of the revalidation request letter. As a result, [Contractor Name] finds that the deactivation 
of Home Healthcare Services, LLCs Medicare billing privileges was not appropriately 
implemented based on the information available.) 
 
This is a FAVORABLE DETERMINATION. To effectuate this determination, [Contractor 
name] will reinstate [Provider/Supplier Name]s Medicare billing privileges.    
(If additional information is needed from the provider or supplier in order to reactivate the 
enrollment, the Contractor shall state what information is needed from the provider or 
supplier in this rebuttal determination. Contractors shall state that the requested 
information/documentation must be received within 30 calendar days of the date of this 
determination letter) 
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00 a.m./p.m  ET/MT/CT/PT] and [x:00 a.m./p.m  ET/MT/CT/PT]. 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
K.  Unfavorable Rebuttal Model Letter 
 
(To be sent by hard-copy mail, and via email if email address is provided with the rebuttal 
submission, and email address listed in the provider/supplier correspondence mailing address on 
the enrollment application or enrollment record if different from the email address on the rebuttal 
submission. Optional to send via fax if a valid fax number is available.) 
 
[Month] [DD], [YYYY] 
 
[Provider/Supplier/Attorney/Firm Name] 
Attn: [Signer/Submitter of Rebuttal]  
[Address] (Address from which the Rebuttal was sent) 
[City], [State] [Zip Code] 
 
Re: Rebuttal Determination 
Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS) 
NPI: [XXXXXXXXXX] 
PTAN: [XXXXX] 
Reference Number: [XXXX] (optional) 
 
Dear [Person(s) who submitted the rebuttal]: 
 
This letter is in response to the rebuttal received by [Contractor Name] based on the deactivation 
of [Provider/Supplier Name]s Medicare billing privileges. (If the rebuttal was timely, use the 
following.) [The deactivation letter was dated [Month] [DD], [YYYY] and [Contractor Name] 
received the rebuttal on [Month] [DD], [YYYY]; therefore, this rebuttal is considered timely.] (If 
the rebuttal is untimely, but good cause has been found to accept the rebuttal, use the following.) 
[The deactivation letter was dated [Month] [DD], [YYYY] and [Contractor Name] received the 
rebuttal on [Month] [DD], [YYYY]. This rebuttal was not timely submitted, but a good cause 
waiver has been granted.]) [Contractor Name] based the following determination is based on the  Social Security Act (Act), Medicare regulations, the CMS manual instructions, the Medicare 
enrollment record, and any information received before this decision was rendered. 
 
DEACTIVATION REASON:  
 
  42 C.F.R.  424.540(a)([1-8]) 
 
OTHER APPLICABLE AUTHORIT[Y/IES]: (list any authorities cited in analysis) 
 
  42 C.F.R.  424.546 
  Medicare Program Integrity Manual chapter 10.XX (If applicable) 
  (Ex.: If deactivation based non-compliance, list supplier standards) 
  (Ex.: If deactivation based on failure to report, list regulation that requires reporting) 
 
EXHIBITS: 
 
  Exhibit 1: (Example: Rebuttal letter to CMS, signed by John Smith, Administrator for Home 
Healthcare Services, LLC, dated January 1, 2018);  
  Exhibit 2: (Example: Letter from [Contractor Name] to Home Healthcare Services, LLC, 
dated December 1, 2017, deactivating Home Healthcare Services, LLCs Medicare billing 
privileges pursuant to 42 C.F.R.  424.540(a)(3)). 
 
(In this section list each document submitted by the provider or supplier. Each exhibit shall 
include the date, as well as a brief description of the document. The Contractor shall also include 
other documentation not submitted by the provider or supplier that the hearing officer reviewed 
in making the determination, e.g., enrollment applications, development letters, etc.) 
 
BACKGROUND: 
 
[Contractor Name] has reviewed the documentation related to the matter for [Provider/Supplier 
Name] and made the determination in accordance with the applicable Medicare rules, policies, 
and program instructions.  
 
(Summarize the facts underlying the case which led up to the submission of the rebuttal.) 
 
REBUTTAL ANALYSIS: 
 
(A rebuttal reviews whether or not an error was made in the implementation of the deactivation 
of the providers or suppliers Medicare billing privileges. This section shall summarize the 
statements made by the provider or supplier in its rebuttal, then provide an analysis of the 
arguments based on the applicable regulations and sub-regulations, such as the MPIM. Any 
regulation or sub-regulatory guidance that is referenced in this section shall also be listed in 
Other Applicable Authorities. It is insufficient to state a rebuttal determination without 
explaining how and why the determination was made.) 
 
DECISION: 
  (A short conclusory restatement.) 
 
(Example: On [Month] [DD], [YYYY], [Contractor Name] received a revalidation application 
for Home Healthcare Services, LLC. On [Month] [DD], [YYYY], [Contractor Name] sent a 
development request to continue processing Home Healthcare Services, LLCs revalidation 
application. Home Healthcare Services, LLC did not timely respond to [Contractor Name]s 
development request. As a result, [Contractor Name] properly rejected Home Healthcare 
Services, LLCs revalidation application. Therefore, [Contractor Name] finds that the 
deactivation of Home Healthcare Services, LLCs Medicare enrollment under 42 C.F.R.  
424.540(a)([1-8]) was appropriately implemented.) 
 
This is an UNFAVORABLE DETERMINATION. [Contractor name] concludes that there was 
no error made in the deactivation of [Provider/Supplier Name]s Medicare billing privileges. As 
a result, [Provider/Supplier Name]s Medicare billing privileges will remain deactivated.  
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00  a.m./p.m  ET/MT/CT/PT] and [x:00  a.m./p.m  ET/MT/CT/PT]. 
 
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
10.7.14  Model Opt-out Letters 
(Rev. 11637; Issued:10-07-22; Effective:12-09-22; Implementation:12-09-22) 
 
The Contractors shall use the model letters in this section to respond to eligible practitioners 
opt-out affidavits, request additional documentation, approve opt out affidavits and acknowledge 
the cancelation or early termination of an opt-out. The Contractors shall not use these model 
letters to respond to Medicare enrollment applications or other correspondence. The Contractors 
may issue the Model Opt-out Development Letter via fax, e-mail or mail to the eligible 
practitioner. 
 
A. Opt-out Affidavit Development Letter 
 
MACs shall use the following letter to request missing information from an eligible practitioner 
that wishes to opt-out of Medicare. This letter should be sent only one time and include a request 
for all missing information. The MAC may select the response type, either via mail, fax or email. 
[month] [day], [year]  
[Eligible Practitioner Name]  
[Address]   [City] ST [Zip]  
Reference: Case/Control Number  
Dear [Eligible Practitioner]:  
[Insert MAC] requires the following information to complete the processing of your Medicare 
opt-out affidavit:  
[Specify information needed]  
Submit the requested information within 30 calendar days of the postmark date of this letter 
[to the address listed below, via fax to (###-###-####), or via email to (enter PE analysts 
email address here)]. We may reject your opt-out affidavit if you do not furnish the requested 
information within this timeframe. 
[Name of MAC]  
[Address]  
[City], [ST] [Zip]  
 
Attach a copy of this letter with your revised opt-out affidavit.  
For questions concerning this letter, contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM ] .  
Sincerely,  
 
[Name]  
[Title]  
[Company] 
 
B. Opt-out Rejection Letter 
 
In the event that an eligible practitioner does not respond timely or does not respond with needed 
information to complete an opt-out affidavit, the MACs shall issue this rejection letter. 
[month] [day], [year]  
[Eligible Practitioner Name]  
[Address]  
[City] ST [Zip]  
Reference: Case/Control Number   Dear Eligible Practitioner Name:  
[Insert MAC] is rejecting your Medicare opt-out affidavit, received on [insert date], for the 
following reason(s):  
[List all reasons for rejection:]  
To resubmit your opt-out affidavit include all information needed to process your opt-out 
request. Additional information on submitting a complete opt-out affidavit can be found at: 
[enter MAC website address].  
Return the completed opt-out affidavit to:  
[Name of MAC] 
[Address]  
[City], [ST] [Zip]  
For questions concerning this letter, contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM].  
Sincerely, 
[Name] 
[Title] 
[Company] 
 
C. Opt-out Return Letters  
 
Opt-out affidavits should only be returned for the following reasons:  
1. The eligible practitioner requesting to opt-out of Medicare is not appropriately licensed by the 
state,  
2. The practitioner is a specialty that is ineligible to opt-out (e.g., Chiropractic Medicine,  
Physical Therapy, Occupational Therapy, etc.),  
3. The opt-out affidavit is filed with an incorrect MAC,   
4. The eligible practitioner decides not to opt out of Medicare while their opt-out affidavit is still 
in process, but not yet approved by the MAC, 
5. The eligible practitioner submits a cancellation request too late (within 30 days of the auto-
renewal date or after the auto-renewal date), this return letter provides appeal rights, or 
6. The eligible practitioner submits a cancellation request more than 90 days prior to the auto-
renewal date. 
 
MACs shall issue the specific letter for the return reason. 
1.  Opt-out Return Letter  Unlicensed Eligible Practitioner    
[month] [day], [year]  
[Eligible Practitioner Name]  
[Address]  
[City] ST [Zip]  
Reference: Case/Control Number  
Dear [Eligible Practitioner Name]:  
[Insert MAC] is returning your Medicare opt-out affidavit, submitted on [insert date], as you are 
not licensed by the state for the specialty type you indicated on your opt-out affidavit. 
For questions concerning this letter, contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM].  
Sincerely,  
[Name]  
[Title]  
[Company] 
 
2.  Opt-out Return Letter  Ineligible Practitioner  
 
[month] [day], [year]  
[Eligible Practitioner Name]  
 
[Address] 
 
[City] ST [Zip]  
 
Reference: Case/Control Number  
 
Dear [Eligible Practitioner Name]:  
 
[Insert MAC] is returning your Medicare opt-out affidavit, submitted on [insert date], because 
you indicated a specialty that is ineligible to opt-out (e.g., Chiropractic Medicine, Physical 
Therapy, Occupational Therapy, etc.) of Medicare. 
 
For questions concerning this letter, contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM].  
  Sincerely,  
 
[Name]  
[Title]  
[Company] 
 
 
3.  Opt-out Return Letter  Submitted to Incorrect MAC 
 
[month] [day], [year]  
[Eligible Practitioner Name] 
 [Address] 
 [City] ST [Zip]  
Reference: Case/Control Number  
Dear [Eligible Practitioner Name]:  
[Insert MAC] is returning your Medicare opt-out affidavit, submitted on [insert date], because 
your opt-out affidavit was filed with an incorrect Medicare Administrative Contractor for the 
state that you are located in. Your affidavit should be resubmitted to the appropriate contractor 
for processing. 
 
For questions concerning this letter, contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM].  
Sincerely,  
[Name]  
[Title]  
[Company] 
 
 
4.  Opt-out Return Letter  Withdraw of Affidavit During Processing 
 
[month] [day], [year]  
[Eligible Practitioner Name]  
[Address]   [City] ST [Zip]  
Reference: Case/Control Number  
Dear [Eligible Practitioner Name]:  
[Insert MAC] is returning your Medicare opt-out affidavit, submitted on [insert date], because 
you have decided to withdraw your opt-out affidavit while it is still in process. 
 
For questions concerning this letter, contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM].  
Sincerely,  
[Name]  
[Title]  
[Company] 
 
5.  Opt-out Return Letter  Late Cancellation Request 
 
[Month] [DD], [YYYY]  
 
[Eligible Practitioner Name]  
[Address from which opt-out was sent]  
[City], [ST] [Zip]  
 
Reference: [Case/Control Number] (optional) 
NPI: [xxxxxxxxxx] 
 
Dear [Eligible Practitioner Name]:  
 
[Contractor Name] is returning your written request to cancel the automatic renewal of your 
Medicare opt-out status, submitted on [Month] [DD], [YYYY], as it was (choose appropriate 
language) [not submitted at least 30 days prior to the end of your current opt-out period/received 
after the opt-out period automatically renews]. 
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the implementation of the initial determination. (Optional 
Coversheet sentence) [To facilitate the processing of your reconsideration request, please utilize 
and include the attached coversheet [also found at [[insert web address for coversheet]] with your 
submission.] 
  Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that 
o
he/she/they have the authority to represent the provider or supplier is sufficient to 
accept this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on 
his/her/their behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
Failure to submit a reconsideration request is deemed a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to: (Insert correct address based on whether the 
contractor or CMS is responsible for handling the reconsideration.) 
 
[Contractor Name]  OR  Centers for Medicare & Medicaid Services 
[Address]  Provider Enrollment & Oversight Group 
[City], [ST] [Zip]  ATTN: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop: AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: ([Contractor email] or ProviderEnrollmentAppeals@cms.hhs.gov). 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].    
Sincerely,  
 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
6.  Opt-out Return Letter  Cancellation Request Submitted Too Early 
 
[Month] [DD], [YYYY]  
 
[Eligible Practitioner Name]  
[Address from which opt-out was sent]  
[City], [ST] [Zip]  
 
Reference: [Case/Control Number] (optional) 
NPI: [xxxxxxxxxx] 
 
 
Dear [Eligible Practitioner Name]: 
 
[Contractor Name] is returning your written request to cancel the automatic renewal your 
Medicare opt-out status, submitted on [Month] [DD], [YYYY], as it was submitted at more than 
90 days prior to the end of your current opt-out period. 
 
Please submit your cancellation request no later than 30 days prior to the end of your current opt-
out period to avoid auto-renewal of your opt-out status. Your autorenewal date is: [Month] [DD], 
[YYYY]. 
 
For questions concerning this letter, contact our office at [phone number] between the hours of 
[x:00 AM/PM] and [x:00 AM/PM]. 
 
Sincerely,  
 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
D. Opt-out Affidavit Approval Letters 
 
The Contractors shall issue an Opt-out Affidavit Approval model letter when approving an opt-
out affidavit and PECOS has been updated with the affidavit information. The approval letter 
shall be issued for the following reasons:   
1. Approved Opt-Out, Eligible Practitioner May Order & Refer 
2. Approved Opt-Out, Eligible Practitioner May Not Order & Refer (OIG Exclusion) 
3. Approved Opt-Out, Eligible Practitioner May Not Order & Refer (Ineligible Specialty) 
4. Approved Opt-Out, Eligible Practitioner May Not Order & Refer (Did Not Elect to Order 
& Refer) 
5. Approved Opt-Out, Eligible Practitioner May Not Order & Refer (Eligible Practitioner 
Does Not Have an NPI) 
6. Approved Opt-Out, Eligible Practitioner May Not Order & Refer (Eligible Practitioner has 
Revoked Billing Privileges) 
7. Approved Opt-Out Change of Information 
 
The Opt-out approval letter shall include:  
 
  The eligible practitioners personal information:  
  Name,  
o
  Address,  
o
  NPI,  
o
  Specialty, and  
o
  Eligibility to order and refer.  
o
 
  The eligible practitioners opt-out effective date. 
 
  The date that the eligible practitioner can submit a request to cancel their opt-out affidavit 
(at least 30 days prior to the end-date of their current opt-out period).  
 
  The date the eligible practitioner can terminate his/her/their opt-out early (if they are 
eligible to so, no later than 90 days after the effective date) of the eligible practitioners 
initial 2-year opt-out period. 
 
  Should the eligible practitioner opt-out a subsequent time after cancelling, contractors 
shall remove the paragraph noting Since you are opting out for the very first time... 
since this statement no longer applies. 
 
1.  Opt-out Affidavit Approval Letter  Eligible Practitioner Approved to Order & Refer 
 
[Month] [DD], [YYYY]  
 
[Eligible Practitioner Name]  
[Address from which opt-out was sent]  
[City], [ST] [Zip]  
 
Reference: [Case/Control Number] (optional) 
 
Dear [Eligible Practitioner Name]:  
 
[Contractor Name] approved your Medicare opt-out affidavit.    
Opt-out Affidavit Information:  
 
Eligible Practitioner Name:  [Name] 
Address on File:  [Address, City, State, Zip] 
National Provider Identifier (NPI):  [NPI] 
Specialty:  [Specialty] 
Ordering and Referring:  You are eligible to Order and Refer 
Effective Date:  [Effective date] 
 
Your opt-out will automatically renew every 2 years.   
Since you are opting out for the very first time, you have a one-time, 90-day period to change 
your mind about opting out.  If you decide to terminate during this 90-day period, you must 
submit your request, in writing, no later than [Month] [DD], [YYYY].  After this 90-day period 
ends, you can only cancel the opt-out at the end of a 2 year opt-out period. If you were unable to 
submit a termination request, you may appeal after the 90-day period ends. Please follow the 
Right to Submit a Reconsideration Request sections below. 
To cancel opt-out, you must submit a cancellation request at least 30 days prior to the end of the 
opt-out period.  For example, if you decide you want to cancel your opt-out at the end of this opt-
out period, you must submit your cancellation request before [Month] [DD], [YYYY]. 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the implementation of the initial determination. (Optional 
Coversheet sentence) [To facilitate the processing of your reconsideration request, please utilize 
and include the attached coversheet [also found at [[insert web address for coversheet]] with your 
submission.] 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or 
emailed to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
 If the authorized representative is an attorney, the attorneys statement that he/she/they 
o
have the authority to represent the provider or supplier is sufficient to accept this 
individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request.   Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier submitting 
a signed statement authorizing that individual from the group to act on his/her/their behalf. 
 
Providers and suppliers may: 
 
 Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing 
Officer to consider during the reconsideration or, if necessary, an Administrative Law 
Judge (ALJ) to consider during a hearing, you must submit that information with your 
request for reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be 
submitted.   
 Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
Failure to submit a reconsideration request is deemed a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to: (Insert correct address and email address based on 
whether the contractor or CMS is responsible for handling the reconsideration.) 
 
[Contractor Name]  OR  Centers for Medicare & Medicaid Services 
[Address]  Provider Enrollment & Oversight Group 
[City], [ST] [Zip]  ATTN: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop: AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: ([Contractor email] or ProviderEnrollmentAppeals@cms.hhs.gov). 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
2.  Opt-out Affidavit Approval Letter  Eligible Practitioner May Not Order & Refer 
(Excluded by the OIG) 
 
[Month] [DD], [YYYY]  
 
[Eligible Practitioner Name]   [Address from which opt-out was sent]  
[City], [ST] [Zip]  
 
Reference: [Case/Control Number] (optional) 
 
Dear [Eligible Practitioner Name]:  
 
[Insert Contractor] approved your Medicare opt-out affidavit.  
 
Opt-out Affidavit Information:  
 
Eligible Practitioner Name:  [Name] 
Address on File:  [Address, City, State, Zip] 
National Provider Identifier (NPI):  [NPI] 
Specialty:  [Specialty] 
Ordering and Referring:  You are not eligible to Order and Refer* 
Effective Date:  [Effective date] 
 
* You have been excluded by the OIG (and even if you have or have not obtained a waiver 
according to 42 C.F.R.  1001.1901(c)), you may opt-out of Medicare, but you are not permitted 
to order and refer items and services to Medicare beneficiaries 
 
Your opt-out will automatically renew every 2 years.   
Since you are opting out for the very first time, you have a one-time, 90 day period to change 
your mind about opting out.  If you decide to terminate during this 90 day period, you must 
submit your request, in writing, no later than [Month] [DD], [YYYY].  After this 90 day period 
ends, you can only cancel the opt-out at the end of a 2 year opt-out period. If you were unable to 
submit a termination request, you may appeal after the 90 day period ends. Please follow the 
Right to Submit a Reconsideration Request sections below. 
To cancel opt-out, you must submit a cancellation request at least 30 days prior to the end of the 
opt-out period.  For example, if you decide you want to cancel your opt-out at the end of this opt-
out period, you must submit your cancellation request before [Month] [DD], [YYYY]. 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the implementation of the initial determination. (Optional 
Coversheet sentence) [To facilitate the processing of your reconsideration request, please utilize 
and include the attached coversheet [also found at [[insert web address for coversheet]] with your 
submission.] 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.      State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that 
o
he/she/they have the authority to represent the provider or supplier is sufficient to 
accept this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on 
his/her/their behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
Failure to submit a reconsideration request is deemed a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to: (Insert correct address based on whether the 
contractor or CMS is responsible for handling the reconsideration.) 
 
[Contractor Name]  OR  Centers for Medicare & Medicaid Services 
[Address]  Provider Enrollment & Oversight Group 
[City], [ST] [Zip]  ATTN: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop: AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: ([Contractor email] or ProviderEnrollmentAppeals@cms.hhs.gov). 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
[Signature of Hearing Officer] (May be electronic)  [Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
3.  Opt-out Affidavit Approval Letter  Eligible Practitioner May Not Order & Refer 
(Ineligible Specialty) 
 
[Month] [DD], [YYYY]  
 
[Eligible Practitioner Name]  
[Address from which opt-out was sent]  
[City], [ST] [Zip]  
 
Reference: [Case/Control Number] (optional) 
 
Dear [Eligible Practitioner Name]:  
 
[Insert Contractor] approved your Medicare opt-out affidavit.  
 
Opt-out Affidavit Information:  
 
Eligible Practitioner Name:  [Name]   
Address on File:  [Address, City, State, Zip]   
National Provider Identifier (NPI):  [NPI]   
Specialty:  [Specialty]   
Ordering and Referring:  You are not eligible to Order and Refer*   
Effective Date:  [Effective date]   
 
* You may opt-out of Medicare, but you are not permitted to order and refer items and services 
to Medicare beneficiaries, as your specialty is ineligible to order and refer. 
 
Your opt-out will automatically renew every 2 years.   
Since you are opting out for the very first time, you have a one-time, 90 day period to change 
your mind about opting out. If you decide to terminate during this 90 day period, you must 
submit your request, in writing, no later than [Month] [DD], [YYYY]. After this 90 day period 
ends, you can only cancel the opt-out at the end of a 2 year opt-out period. If you were unable to 
submit a termination request, you may appeal after the 90 day period ends. Please follow the 
Right to Submit a Reconsideration Request section below. 
To cancel opt-out, you must submit a cancellation request at least 30 days prior to the end of the 
opt-out period.  For example, if you decide you want to cancel your opt-out at the end of this opt-
out period, you must submit your cancellation request before [Month] [DD], [YYYY]. 
Right to Submit a Reconsideration Request: 
  You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the implementation of the initial determination. (Optional 
Coversheet sentence) [To facilitate the processing of your reconsideration request, please utilize 
and include the attached coversheet [also found at [[insert web address for coversheet]] with your 
submission.] 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that 
o
he/she/they have the authority to represent the provider or supplier is sufficient to 
accept this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on 
his/her/their behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
Failure to submit a reconsideration request is deemed a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to: (Insert correct address based on whether the 
contractor or CMS is responsible for handling the reconsideration.) 
 
[Contractor Name]  OR  Centers for Medicare & Medicaid Services 
[Address]  Provider Enrollment & Oversight Group 
[City], [ST] [Zip]  ATTN: Division of Provider Enrollment Appeals 
7500 Security Boulevard  Mailstop: AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: ([Contractor email] or ProviderEnrollmentAppeals@cms.hhs.gov). 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
4.  Opt-out Affidavit Approval Letter  Eligible Practitioner May Not Order & Refer (Did 
Not Elect to Order and Refer) 
 
[Month] [DD], [YYYY]  
 
[Eligible Practitioner Name]  
[Address from which opt-out was sent]  
[City], [ST] [Zip]  
 
Reference: [Case/Control Number] (optional) 
 
Dear [Eligible Practitioner Name]:  
 
[Insert Contractor] approved your Medicare opt-out affidavit.  
 
Opt-out Affidavit Information:  
 
Eligible Practitioner Name:  [Name] 
Address on File:  [Address, City, State, Zip] 
National Provider Identifier (NPI):  [NPI] 
Specialty:  [Specialty] 
Ordering and Referring:  You are not eligible to Order and Refer* 
Effective Date:  [Effective date] 
* You may opt-out of Medicare, but you are not permitted to order and refer items and services 
to Medicare beneficiaries as you did not elect to be and ordering and referring practitioner on 
your opt-out affidavit. 
 
Your opt-out will automatically renew every 2 years.   
Since you are opting out for the very first time, you have a one-time, 90 day period to change 
your mind about opting out.  If you decide to terminate during this 90 day period, you must 
submit your request, in writing, no later than [Month] [DD], [YYYY].  After this 90 day period 
ends, you can only cancel the opt-out at the end of a 2 year opt-out period. If you were unable to  submit a termination request, you may appeal after the 90 day period ends. Please follow the 
Right to Submit a Reconsideration Request section below. 
To cancel opt-out, you must submit a cancellation request at least 30 days prior to the end of the 
opt-out period.  For example, if you decide you want to cancel your opt-out at the end of this opt-
out period, you must submit your cancellation request before [Month] [DD], [YYYY]. 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the implementation of the initial determination. (Optional 
Coversheet sentence) [To facilitate the processing of your reconsideration request, please utilize 
and include the attached coversheet [also found at [[insert web address for coversheet]] with your 
submission.] 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that 
o
he/she/they have the authority to represent the provider or supplier is sufficient to 
accept this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on 
his/her/their behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
  Failure to submit a reconsideration request is deemed a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to: (Insert correct address based on whether the 
contractor or CMS is responsible for handling the reconsideration.) 
 
[Contractor Name]  OR  Centers for Medicare & Medicaid Services 
[Address]  Provider Enrollment & Oversight Group 
[City], [ST] [Zip]  ATTN: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop: AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: ([Contractor email] or ProviderEnrollmentAppeals@cms.hhs.gov). 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name]  
 
5.  Opt-out Affidavit Approval Letter  Eligible Practitioner May Not Order & Refer 
(Eligible Practitioner Does Not Have an NPI) 
 
[Month] [DD], [YYYY]  
 
[Eligible Practitioner Name]  
[Address from which opt-out was sent]  
[City], [ST] [Zip]  
 
Reference: [Case/Control Number] (optional) 
 
Dear [Eligible Practitioner Name]:  
 
[Insert Contractor] approved your Medicare opt-out affidavit.  
 
Eligible Practitioner Name:  [Name]   
Address on File:  [Address, City, State, Zip]   
National Provider Identifier (NPI):  [Not Provided]   
Specialty:  [Specialty]   
 
Ordering and Referring:  You are not eligible to Order and Refer* 
 
Effective Date:  [Effective date] 
  * You may opt-out of Medicare, but you are not permitted to order and refer items and services 
to Medicare beneficiaries, as you have not obtained an NPI. 
 
Opt-out Affidavit Information:  
 
Your opt-out will automatically renew every 2 years.   
Since you are opting out for the very first time, you have a one-time, 90 day period to change 
your mind about opting out.  If you decide to terminate during this 90 day period, you must 
submit your request, in writing, no later than [Month] [DD], [YYYY].  After this 90 day period 
ends, you can only cancel the opt-out at the end of a 2 year opt-out period. If you were unable to 
submit a termination request, you may appeal after the 90 day period ends. Please follow the 
Right to Submit a Reconsideration Request section below. 
To cancel opt-out, you must submit a cancellation request at least 30 days prior to the end of the 
opt-out period.  For example, if you decide you want to cancel your opt-out at the end of this opt-
out period, you must submit your cancellation request before [Month] [DD], [YYYY]. 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the implementation of the initial determination. (Optional 
Coversheet sentence) [To facilitate the processing of your reconsideration request, please utilize 
and include the attached coversheet [also found at [[insert web address for coversheet]] with your 
submission.] 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that 
o
he/she/they have the authority to represent the provider or supplier is sufficient to 
accept this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on 
his/her/their behalf. 
 
Providers and suppliers may: 
    Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
Failure to submit a reconsideration request is deemed a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to: (Insert correct address based on whether the 
contractor or CMS is responsible for handling the reconsideration.) 
 
[Contractor Name]  OR  Centers for Medicare & Medicaid Services 
[Address]  Provider Enrollment & Oversight Group 
[City], [ST] [Zip]  ATTN: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop: AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: ([Contractor email] or ProviderEnrollmentAppeals@cms.hhs.gov). 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name]  
 
6.  Opt-out Affidavit Approval Letter  Eligible Practitioner May Not Order & Refer 
(Eligible Practitioner Has Revoked Billing Privileges) 
 
[Month] [DD], [YYYY]  
 
[Eligible Practitioner Name]  
[Address from which opt-out was sent]  
[City], [ST] [Zip]  
 
Reference: [Case/Control Number] (optional) 
 
Dear [Eligible Practitioner Name]:  
  [Insert Contractor] approved your Medicare opt-out affidavit.  
 
Opt-out Affidavit Information:  
 
Eligible Practitioner Name:  [Name] 
Address on File:  [Address, City, State, Zip] 
National Provider Identifier (NPI):  [NPI] 
Specialty:  [Specialty] 
Ordering and Referring:  You are not eligible to Order and Refer* 
Effective Date:  [Effective date] 
* Your billing privileges have been revoked, you may opt-out of Medicare, but you are not 
permitted to order and refer items and services to Medicare beneficiaries 
 
Your opt-out will automatically renew every 2 years.   
Since you are opting out for the very first time, you have a one-time, 90 day period to change 
your mind about opting out.  If you decide to terminate during this 90 day period, you must 
submit your request, in writing, no later than [Month] [DD], [YYYY].  After this 90 day period 
ends, you can only cancel the opt-out at the end of a 2 year opt-out period. If you were unable to 
submit a termination request, you may appeal after the 90 day period ends. Please follow the 
Right to Submit a Reconsideration Request section below. 
To cancel opt-out, you must submit a cancellation request at least 30 days prior to the end of the 
opt-out period.  For example, if you decide you want to cancel your opt-out at the end of this opt-
out period, you must submit your cancellation request before [Month] [DD], [YYYY]. 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the implementation of the initial determination. (Optional 
Coversheet sentence) [To facilitate the processing of your reconsideration request, please utilize 
and include the attached coversheet [also found at [[insert web address for coversheet]] with your 
submission.] 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that 
o
he/she/they have the authority to represent the provider or supplier is sufficient to 
accept this individual as the representative.     If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on 
his/her/their behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
Failure to submit a reconsideration request is deemed a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to: (Insert correct address based on whether the 
contractor or CMS is responsible for handling the reconsideration.) 
 
[Contractor Name]  OR  Centers for Medicare & Medicaid Services 
[Address]  Provider Enrollment & Oversight Group 
[City], [ST] [Zip]  ATTN: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop: AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: ([Contractor email] or ProviderEnrollmentAppeals@cms.hhs.gov). 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
7.  Opt-out Affidavit Approval Letter  Approved Opt-Out Change of Information 
 
[Month] [DD], [YYYY]    
[Eligible Practitioner Name]  
[Address from which opt-out was sent]  
[City], [ST] [Zip]  
 
Reference: [Case/Control Number] (optional) 
 
 
Dear [Eligible Practitioner Name]:  
 
[Insert Contractor] has updated your Medicare opt-out affidavit.  
 
Opt-out Affidavit Information:  
 
Eligible Practitioner Name:  [Name] 
Address on File:  [Address, City, State, Zip] 
National Provider Identifier (NPI):  [NPI] 
Specialty:  [Specialty] 
Ordering and Referring:  You [are/are not] eligible to Order and 
Refer[*] 
Effective Date:  [Effective date] 
Changed Information:   
[* You may opt-out of Medicare, but you are not permitted to order and refer items and services 
to Medicare beneficiaries, as you have {enter reason for inability to order and refer}.] 
 
As a reminder, to cancel opt-out, you must submit a cancellation request at least 30 days prior to 
the end of the opt-out period.  For example, if you decide you want to cancel your opt-out at the 
end of this opt-out period, you must submit your cancellation request before [Month] [DD], 
[YYYY]. 
 
For questions concerning this letter, contact our office at [phone number] between the hours of 
[x:00  a.m./p.m  ET/MT/CT/PT] and [x:00  a.m./p.m ET/MT/CT/PT].  
 
 
Sincerely,  
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name] 
 
E.  Opt-out Renewal Alert Letter 
 
The Contractors shall issue the following letter, informing the eligible practitioner that the opt-
out is due to be automatically renewed.  
[Month] [DD], [YYYY]    
[Eligible Practitioner Name]  
[Address from which opt-out was sent]  
[City], [ST] [Zip]  
 
Reference: [Case/Control Number] (optional) 
NPI: [xxxxxxxxxx] 
 
Dear [Eligible Practitioner Name]: 
 
We are writing to inform you that your opt-out will be automatically renewed for a new 2 year 
opt-out period, on [Month] [DD], [YYYY].  
 
To cancel your opt-out in the future, you will need to submit a cancellation request at least 30 
days prior to the end of your opt-out period, which is [Month] [DD], [YYYY]. 
 
If your intention is to cancel your opt-out, but fail to submit a cancellation notice to us, please 
see the Right to Submit a Reconsideration Request section of this letter below. 
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the implementation of the initial determination. (Optional 
Coversheet sentence) [To facilitate the processing of your reconsideration request, please utilize 
and include the attached coversheet [also found at [[insert web address for coversheet]] with your 
submission.] 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that 
o
he/she/they have the authority to represent the provider or supplier is sufficient to 
accept this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on 
his/her/their behalf. 
 
Providers and suppliers may:   
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
Failure to submit a reconsideration request is deemed a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to: (Insert correct address based on whether the 
contractor or CMS is responsible for handling the reconsideration.) 
 
[Contractor Name]  OR  Centers for Medicare & Medicaid Services 
[Address]  Provider Enrollment & Oversight Group 
[City], [ST] [Zip]  ATTN: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop: AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: ([Contractor email] or ProviderEnrollmentAppeals@cms.hhs.gov). 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name]  
F.  Opt-out Affidavit Termination Letter 
 
If an eligible practitioner timely terminates his/her/their initial opt-out, the Contractors shall 
acknowledge this action by using this model letter. If the eligible practitioner requests a 
cancellation, the Contractors shall indicate the date of the cancellation and remove the following 
paragraph regarding termination. If the eligible practitioner terminates the opt-out, the 
Contractors shall remove the cancellation language. 
[Month] [DD], [YYYY]  
 
[Eligible Practitioner Name]  
[Address from which request was sent]   [City], [ST] [Zip]  
 
Reference: [Case/Control Number] (optional) 
NPI: [xxxxxxxxxx] 
 
 
Dear [Eligible Practitioner Name]:  
 
[Insert Contractor] completed your request to terminate your Medicare opt-out affidavit.  
 
Want to enroll as a Medicare billing provider or for the sole purpose of ordering and referring?  
Submit the appropriate Provider Enrollment Chain and Ownership System (PECOS) application 
or paper CMS-855 form.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the implementation of the initial determination. (Optional 
Coversheet sentence) [To facilitate the processing of your reconsideration request, please utilize 
and include the attached coversheet [also found at [[insert web address for coversheet]] with your 
submission.] 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that 
o
he/she/they have the authority to represent the provider or supplier is sufficient to 
accept this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on 
his/her/their behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for  reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
Failure to submit a reconsideration request is deemed a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to: (Insert correct address based on whether the 
contractor or CMS is responsible for handling the reconsideration.) 
 
[Contractor Name]  OR  Centers for Medicare & Medicaid Services 
[Address]  Provider Enrollment & Oversight Group 
[City], [ST] [Zip]  ATTN: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop: AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: ([Contractor email] or ProviderEnrollmentAppeals@cms.hhs.gov). 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely,  
 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name]  
G.  Opt-out Affidavit Cancellation Letter 
If an eligible practitioner timely submits an opt-out cancellation request, the Contractors shall 
 acknowledge this action by using this model letter.  
[Month] [DD], [YYYY]  
 
[Eligible Practitioner Name]  
[Address from which request was sent]  
[City], [ST] [Zip]  
 
Reference: [Case/Control Number] (optional) 
NPI: [xxxxxxxxxx] 
 
Dear [Eligible Practitioner Name]:  
 
[Contractor Name] completed your request to cancel your Medicare opt-out affidavit.    
Your opt-out status will be canceled effective [Month] [DD], [YYYY].  
 
Want to enroll as a Medicare billing provider or for the sole purpose of ordering of referring?  
Submit the appropriate Provider Enrollment Chain and Ownership System (PECOS) application 
or paper CMS-855 form.  
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the implementation of the initial determination. (Optional 
Coversheet sentence) [To facilitate the processing of your reconsideration request, please utilize 
and include the attached coversheet [also found at [[insert web address for coversheet]] with your 
submission.] 
 
Reconsideration requests must: 
 
  Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below.   
  State the issues or findings of fact with which you disagree and the reasons for 
disagreement.   
  Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative.  
  If the authorized representative is an attorney, the attorneys statement that 
o
he/she/they have the authority to represent the provider or supplier is sufficient to 
accept this individual as the representative.  
  If the authorized representative is not an attorney, the individual provider, supplier, or 
o
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
  Authorized or delegated officials for groups cannot sign and submit a reconsideration 
o
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on 
his/her/their behalf. 
 
Providers and suppliers may: 
 
  Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted.   
  Include an email address if you want to receive correspondence regarding your appeal via 
email. 
  Failure to submit a reconsideration request is deemed a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part 
498. 
 
The reconsideration request should be sent to: (Insert correct address based on whether the 
contractor or CMS is responsible for handling the reconsideration.) 
 
[Contractor Name]  OR  Centers for Medicare & Medicaid Services 
[Address]  Provider Enrollment & Oversight Group 
[City], [ST] [Zip]  ATTN: Division of Provider Enrollment Appeals 
7500 Security Boulevard 
Mailstop: AR-19-51 
Baltimore, MD 21244-1850 
 
Or emailed to: ([Contractor email] or ProviderEnrollmentAppeals@cms.hhs.gov). 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information].  
 
Sincerely, 
 
[Signature of Hearing Officer] (May be electronic) 
[Name of Hearing Officer] 
[Position of Hearing Officer] 
[Contractor Name]  
 
10.7.15 Revalidation Notification Letters 
(Rev. 11859; Issued: 02-16-23; Effective: 03-17-23; Implementation: 03-17-23) 
 
A. Revalidation Letter  Non-DMEPOS Supplier 
 
REVALIDATION 
 
[month] [day], [year]  
 
[Provider/Supplier Name] 
[Address]  
[City], [State] [Zip Code] 
 
Dear [Provider/Supplier Name], 
 
Every five years, CMS requires you to revalidate your Medicare enrollment record.  You need to 
update or confirm all the information in your record, including your practice locations and 
reassignments. 
 
We need this from you by [Due date, as Month dd yyyy].  If we dont receive your response by 
then, we may stop your Medicare billing privileges.   
If you are a non-certified provider or supplier, and your enrollment is deactivated, you will 
maintain your original PTAN, however will not be paid for services rendered during the period 
of deactivation.  This will cause a gap in your reimbursement. 
 
What record needs revalidating by [Due date, as Month dd yyyy] 
 
[Name] |  NPI [NPI]  |  PTAN [PTAN]  
Reassignments:   <Only include this title if the record has any reassignments> 
[Legal Business Name] | [dba Name] | Tax ID [Tax ID, mask all but last 4 digits] 
<Repeat for other reassignments> 
 
CMS lists the records that need revalidating at go.cms.gov/MedicareRevalidation. 
 
What you need to do 
 
Revalidate your Medicare enrollment record, through 
https://pecos.cms.hhs.gov/pecos/login.do or [form CMS-855 or Form CMS-20134]. 
 
  Online: PECOS is the fastest option. If you dont know your username or password, PECOS 
offers ways to retrieve them. Our customer service can also help you by phone at 866-484-
8049. 
  Paper: Download the right version of form [CMS-855 or Form CMS-20134] for your 
situation at cms.gov.  We recommend getting proof of receipt for your mailing. Mail to 
[contractor address]. 
If you have a fee due, use PECOS to pay. If you feel you qualify for a hardship waiver, mail us a 
request on practice letterhead with financial statements, application form, and certification. For 
more on fees and exceptions, search cms.gov for CR 7350 or Fee Matrix. 
 
A new Electronic Funds Transfer (EFT) Authorization Form (CMS-588) is only required to be 
submitted as part of your revalidation package if: (1) you have no Form CMS-588 on file with 
Medicare at all; or (2) you are changing any of your existing Form CMS-588 data.   
The current version of the form can be found at http://www.cms.gov/Medicare/CMS-
Forms/CMS-Forms/Downloads/CMS588.pdf. 
 
If you need help 
Visit go.cms.gov/MedicareRevalidation  
Call [contractor phone #] or visit [contractorsite.com] for more options.  
 
Sincerely,  
[Name] 
[Title] 
[Company] 
 
B.  Revalidation Letter  DMEPOS Supplier   
REVALIDATION 
 
[month] [day], [year] 
[Provider/Supplier Name] 
[Address] 
[City], [State] [Zip Code] 
 
Dear [Provider/Supplier Name], 
 
Every three years, CMS requires you to revalidate your Medicare enrollment record.  You need 
to update or confirm all the information in your record, including your practice location. 
 
We need this from you by [Due date, as Month dd yyyy].  If we do not receive your 
response by then, we may stop your Medicare billing privileges. 
 
If you are a non-certified provider or supplier and your enrollment is deactivated, you will  
maintain your original PTAN.  However, you will not be paid for services rendered during the  
period of deactivation. This will cause a gap in your reimbursement. 
 
What record needs revalidating by [Due date, as Month dd yyyy] 
[Name] | NPI [NPI] | PTAN [PTAN] 
[Legal Business Name] | [dba Name] | Tax ID [Tax ID, mask all but last 4 digits] 
 
The CMS lists the records that need revalidating at go.cms.gov/MedicareRevalidation. 
 
What you need to do 
 
Revalidate your Medicare enrollment record, through 
https://pecos.cms.hhs.gov/pecos/login.do or [Form CMS-855S or Form CMS-20134]. 
 
  Online: PECOS is the fastest option. If you do not know your username or password, 
PECOS offers ways to retrieve them. Our customer service can also help you by 
phone at 866-484-8049. 
 
  Paper: Download the right version of form [CMS-855S] for 
your situation at cms.gov. We recommend getting proof of receipt for your mailing. 
Mail to [contractor address]. 
 
If you have a fee due, use PECOS to pay. If you feel you qualify for a hardship waiver, 
mail us a request on practice letterhead with financial statements, application form, and 
certification. For more on fees and exceptions, search cms.gov for CR 7350 or Fee 
Matrix. 
 
A new Electronic Funds Transfer (EFT) Authorization Form (CMS-588) is only 
required to be submitted as part of your revalidation package if: (1) you have no Form 
CMS-588 on file with Medicare at all; or (2) you are changing any of your existing 
Form CMS-588 data.   
The current version of the form can be found at 
http://www.cms.gov/Medicare/CMSForms/CMS-Forms/Downloads/CMS588.pdf. 
 
If you need help 
 
Visit go.cms.gov/MedicareRevalidation 
Call [contractor phone #] or visit [contractorsite.com] for more options. 
 
Sincerely, 
[Name] 
[Title] 
[Company] 
 
C. Revalidation Letter  CHOW Scenario Only 
 
[month] [day], [year]  
 
 
PROVIDER/SUPPLIER NAME           NPI: 
ADDRESS 1, ADDRESS 2          PTAN: 
CITY STATE ZIP CODE 
 
Dear Provider/Supplier Name: 
 
 
 
 
 
 
THIS IS A PROSPECTIVE PROVIDER ENROLLMENT REVALIDATION REQUEST 
 
IMMEDIATELY SUBMIT AN UPDATED 
PROVIDER ENROLLMENT PAPER APPLICATION 855 FORM TO VALIDATE YOUR 
ENROLLMENT INFORMATION 
 
In accordance with Section 6401 (a) of the Patient Protection and Affordable Care Act, all 
new and existing providers must be reevaluated under the new screening guidelines.  
Medicare requires all enrolled providers and suppliers to revalidate their enrollment information 
every five years (reference 42 CFR 424.515). To ensure compliance with these requirements, 
existing regulations at 42 CFR 424.515(d) provide that the Centers for Medicare & Medicaid 
Services (CMS) is permitted to conduct off-cycle revalidations for certain program integrity 
purposes.  Upon the CMS request to revalidate its enrollment, the provider/supplier has 60 days 
from the post mark date of this letter to submit complete enrollment information. 
 
You previously submitted a change of ownership (CHOW) application that is currently being 
reviewed by the State Agency.  Since your application has not been finalized, please validate that  we have the most current information on file.  Any updated information received since your 
initial submission will be forwarded to the State Agency for their final determination. 
  
Providers and suppliers can validate their provider enrollment information using the paper 
application form.  To validate by paper, download the appropriate and current CMS-855 
Medicare Enrollment application from the CMS Web site at 
https://www.cms.gov/MedicareProviderSupEnroll/.  Mail your completed application and all 
required supporting documentation to the [insert contractor name], at the address below. 
 
[Insert application return address] 
 
A new Electronic Funds Transfer (EFT) Authorization Form (CMS-588) is only required to be 
submitted as part of your revalidation package if (1) you have no Form CMS-588 on file with 
Medicare at all; or (2) you are changing any of your existing Form CMS-588 data.   
The current version of the form can be found at http://www.cms.gov/Medicare/CMS-
Forms/CMS-Forms/Downloads/CMS588.pdf.  
 
If additional time is required to complete the validation applications, you may request one 60-
day extension, which will be added onto the initial 60 days given to respond to the request.  The 
request may be submitted in writing from the individual provider, the Authorized or Delegated 
Official of the organization or the contact person and addressed to the MAC(s).  The request 
should include justification of why a 60-day extension is needed.  The request may also be made 
by contacting your MAC(s), via phone. 
 
Physicians, non-physician practitioners and physician and non-physician practitioner 
organizations must report a change of ownership, any adverse legal action, or a change of 
practice location to the MAC within 30 days.  All other changes must be reported within 90 days.  
For most but not all other providers and suppliers, changes of ownership or control, including 
changes in authorized official(s) must be reported within 30 days; all other changes to enrollment 
information must be made within 90 days. 
 
Failure to submit complete enrollment application(s) and all supporting documentation within 60 
calendar days of the postmark date of this letter may result in your Medicare billing privileges 
being deactivated and your CHOW not being processed.  We strongly recommend you mail your 
documents using a method that allows for proof of receipt. 
 
If you have any questions regarding this letter, please call [contractor telephone number will be 
inserted here] between the hours of [contractor telephone hours will be inserted here] or visit our 
Web site at [insert Web site] for additional information regarding the enrollment process or the 
[insert application type]. 
 
 
Sincerely,  
[Your Name] 
[Title] 
 
D.  Large Group Revalidation Notification Letter 
  [month] [day], [year]  
 
PROVIDER/SUPPLIER GROUP NAME           NPI:  
ADDRESS 1, ADDRESS 2               PTAN:  
CITY STATE ZIP CODE  
 
Dear Provider/Supplier Group Name: 
 
 
THIS IS NOT A PROVIDER ENROLLMENT REVALIDATION REQUEST 
 
 
This is to inform you that a number of physicians and/or non-physician practitioners reassigning 
all or some of their benefits to your group have been selected for revalidation.  For your 
convenience, a list of those individuals is attached.  A revalidation notice will be sent to the 
physician or non-physician practitioner within the next seven months.  They will need to respond 
by the revalidation due date provided for each provider.  It is the responsibility of the physician 
and/or non-physician practitioner to revalidate all their Medicare enrollment information and not 
just that associated with the reassignment to your group practice. 
 
In accordance with Section 6401 (a) of the Patient Protection and Affordable Care Act, all new 
and existing providers must be reevaluated under the new screening guidelines. Medicare 
requires all enrolled providers and suppliers to revalidate their enrollment information every five 
years (reference 42 CFR 424.515).  To ensure compliance with these requirements, existing 
regulations at 42 CFR 424.515(d) provide that the Centers for Medicare & Medicaid Services 
(CMS) is permitted to conduct off-cycle revalidations for certain program integrity purposes. 
 
Physicians and non-physician practitioners can revalidate by using either Internet-based PECOS 
or submitting a paper CMS-855 enrollment application.  Failure to submit a complete 
revalidation application and all supporting documentation within 60 calendar days may result in 
the physician or non-physician practitioners Medicare billing privileges being deactivated.  As 
such, your group will no longer be reimbursed for services rendered by the physician or non-
physician practitioner. 
 
If you have any questions regarding this letter, please call [contractor telephone number will be 
inserted here] between the hours of [contractor telephone hours will be inserted here] or visit our 
Web site at [insert Web site] for additional information regarding the revalidation process. 
 
 
 
Sincerely,  
 
[Your Name]  
[Title] 
 
E.  Revalidation Pend Letter 
  PAYMENT HOLD 
 
[month] [day], [year]  
 
[Provider/Supplier Name] 
[Address]  
[City], [State] [Zip Code] 
 
Dear [Provider/Supplier Name], 
 
We are holding all payments on your Medicare claims, because you havent revalidated your 
enrollment record with us.  This does not affect your Medicare participation agreement, or any of 
its conditions. 
Every [three or five years], CMS requires you to revalidate your Medicare enrollment record 
information. You need to update or confirm all the information in your record, including your 
practice locations and reassignments.  
 
Failure to respond to this notice will result in a possible deactivation of your Medicare 
enrollment. If you are a non-certified provider or supplier, and your enrollment is deactivated, 
you will maintain your original PTAN, however will not be paid for services rendered during the 
period of deactivation.  This will cause a gap in your reimbursement. 
 
What record needs revalidating 
 
[Name] |  NPI [NPI]  |  PTAN [PTAN]  
Reassignments: 
[Legal Business Name] | [dba Name] | Tax ID [Tax ID, mask all but last 4 digits]   
<Repeat for other reassignments> 
 
CMS lists the records that need revalidating at go.cms.gov/MedicareRevalidation. 
 
How to resume your payments 
 
Revalidate your Medicare enrollment record, through 
https://pecos.cms.hhs.gov/pecos/login.do or [form CMS-855 or Form CMS-20134].  
 
  Online: PECOS is the fastest option. If you dont know your username or password, PECOS 
offers ways to retrieve them. Our customer service can also help you by phone at 866-484-
8049. 
  Paper: Download the right version of [form CMS-855 or Form CMS-20134] for your 
situation at cms.gov.  We recommend getting proof of receipt for your mailing. Mail to 
[contractor address]. 
If you have a fee due, use PECOS to pay. If you feel you qualify for a hardship waiver, mail us a 
request on practice letterhead with financial statements, application form, and certification. 
  If you need help 
 
Visit go.cms.gov/MedicareRevalidation  
Call [contractor phone #] or visit [contractorsite.com] for more options. 
 
Sincerely,  
[Name] 
[Title] 
[Company] 
 
F.  Revalidation Deactivation Letter 
 
STOPPING BILLING PRIVILEGES 
 
[month] [day], [year]  
 
[Provider/Supplier Name] 
[Address]  
[City], [State] [Zip Code] 
 
 
Dear [Provider/Supplier Name], 
 
Your Medicare billing privileges are being deactivated effective [Month] [DD], [YYYY], 
pursuant to 42 C.F.R.  424.540(a)(3) because you have not timely revalidated your enrollment 
record with us, or your revalidation application has been rejected because you did not timely 
respond to our requests for more information. We will not pay any claims after this date.  
 
Every five years [three for DMEPOS suppliers], CMS requires you to revalidate your Medicare 
enrollment record.  
 
What record needs revalidating  
   
[Name] |  NPI [NPI]  |  PTAN [PTAN]  
Reassignments: 
[Legal Business Name] | [dba Name] | Tax ID [Tax ID, mask all but last 4 digits]   
<Repeat for other reassignments>  
 
CMS lists the records that need revalidating at https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidations.html.  
 
Rebuttal Rights:  
 
If you believe that this determination is not correct, you may rebut the deactivation as indicated 
in 42 C.F.R.  424.546. The rebuttal must be received in writing within 15 calendar days of the 
date of this letter. The rebuttal must state the issues or findings of fact with which you disagree 
and the reasons for disagreement. You may submit additional information with the rebuttal that  you believe may have a bearing on the decision. You must submit all information that you would 
like to be considered in conjunction with the rebuttal. This includes any application(s) to update 
your enrollment, if necessary. You may only submit one rebuttal in response to this deactivation 
of your Medicare enrollment.  
 
The rebuttal must be signed and dated by the individual provider/supplier, the authorized or 
delegated official, or a legal representative. (Delete next sentence if letter is related to a 
DMEPOS suppliers enrollment.) Authorized or delegated officials for groups cannot sign and 
submit a rebuttal on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her/their 
behalf. 
 
If the provider/supplier wishes to appoint a legal representative that is not an attorney to sign the 
rebuttal, the provider/supplier must include with the rebuttal a written notice authorizing the 
legal representative to act on the providers or suppliers behalf. The notice should be signed by 
the provider/supplier.  
 
If the provider/supplier has an attorney sign the rebuttal, the rebuttal must include a statement 
from the attorney that he/she has the authority to represent the provider/supplier.  
 
If you wish to receive communication regarding your rebuttal via email, please include a valid 
email address in your rebuttal request.  
 
The rebuttal should be sent to the following:  
 
[Contractor Rebuttal Receipt Address]  
[Contractor Rebuttal Receipt Email Address]  
[Contractor Rebuttal Receipt Fax Number]  
 
If you have any questions, please contact our office at [phone number] between the hours of 
[x:00  a.m./p.m  ET/MT/CT/PT] and [x:00  a.m./p.m ET/MT/CT/PT].  
 
How to recover your billing privileges  
 
Revalidate your Medicare enrollment record, through PECOS.cms.hhs.gov, or [Form CMS-855 
or Form CMS-20134].  
 
  Online: PECOS is the fastest option. If you dont know your username or password, 
PECOS offers ways to retrieve them. Our customer service can also help you by phone at 
866-484-8049.  
 
  Paper: Download the right version of [form CMS-855 or Form CMS-20134] for your 
situation at cms.gov. We recommend getting proof of receipt for your mailing. Mail to 
[contractor address].  
 
If you have a fee due, use PECOS to pay. If you feel you deserve a hardship waiver, mail us a 
request on practice letterhead with financial statements, application form, and certification.    
If you are a non-certified provider or supplier, and your enrollment is deactivated, you will 
maintain your original PTAN, however will not be paid for services rendered during the period 
of deactivation. This will cause a gap in your reimbursement.  
 
If you need help Visit https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/MedicareProviderSupEnroll/Revalidations.html.  
 
Call [contractor telephone number] or visit [contractorsite.com] for more options.  
 
Sincerely,  
 
[Name] 
[Title] 
[Company] 
 
G.  Revalidation Past-Due Group Member Letter 
 
REVALIDATION | Past-Due Group Member 
 
[month] [day], [year]  
 
[Provider/Supplier Name] 
[Address]  
[City], [State] [Zip Code] 
 
 
Dear [Provider/Supplier Name], 
 
Every five years, CMS requires providers to revalidate their Medicare enrollment records.  You 
have not revalidated by the requested due date of [revalidation due date]. 
 
You need to update or confirm all the information in your record, including your practice 
locations and reassignments.  If you are a non-certified provider or supplier, and your enrollment 
is deactivated, you will maintain your original PTAN, however will not be paid for services 
rendered during the period of deactivation.  This will cause a gap in your reimbursement. 
 
If multiple records below need to be revalidated, please coordinate with the appropriate parties to 
provide only one response. 
 
What record needs revalidating 
 
[Name] |  NPI [NPI]  |  PTAN [PTAN]  
Reassignments:   <Only include this title if the record has any reassignments> 
[Legal Business Name] | [dba Name] | Tax ID [Tax ID, mask all but last 4 digits]   
<Repeat for other reassignments> 
 
CMS lists the records that need revalidating at go.cms.gov/MedicareRevalidation.   
What your group member needs to do 
 
Revalidate their Medicare enrollment record, through 
https://pecos.cms.hhs.gov/pecos/login.do. or [form CMS-855 or Form CMS-20134]. 
 
  Online: PECOS is the fastest option. If they dont know their username or password, PECOS 
offers ways to retrieve them. Our customer service can also help by phone at 866-484-8049. 
  Paper: Download the right version of [form CMS-855 or Form CMS-20134] for their 
situation at cms.gov. We recommend getting proof of receipt for this mailing. Mail to 
[contractor address]. 
 
If your group member needs help 
Visit go.cms.gov/MedicareRevalidation  
Call [contractor phone #] or visit [contractorsite.com] for more options.  
 
Sincerely,  
[Name] 
[Title] 
[Company] 
 
H. Model Return Revalidation Letter 
 
RETURN REVALIDATION 
 
[month] [day], [year]  
 
[Provider/Supplier Name] 
[Address]  
[City], [State] [Zip Code] 
 
NPI: [xxxxxxxxxx] 
 
Dear [Provider/Supplier Name], 
 
Your Medicare enrollment application(s) was received on [date]. We are closing this request and 
returning your application(s) for the following reason(s): 
 
  The [Form CMS-855 or Form CMS-20134] application received by 
[PROVIDER/SUPPLIER NAME] was unsolicited.   
  An unsolicited revalidation is one that is received more than seven months prior 
o
to the provider/suppliers due date.  Due dates are established around 5 years from 
the provider/suppliers last successful revalidation or their initial enrollment.  
  To find the provider/suppliers revalidation due date, please go to 
o
http://go.cms.gov/MedicareRevalidation. 
  If you are not due for revalidation in the current seven-month period, you will 
o
find that your due date is listed as TBD (or To Be Determined). This means that  you do not yet have a due date for revalidation within the current seven-month 
period. This list with be updated monthly.   
 
  If your intention is to change information on your Medicare enrollment file, you must 
complete a new Medicare enrollment application(s) and mark change in section 1 of the 
[form CMS-855 or Form CMS-20134].  
 
  Please address the above issues as well as sign and date the new certification statement 
page on your resubmitted application(s).  
Providers and suppliers can apply to enroll in the Medicare program using one of the following 
two methods:  
 
1. Internet-based Provider Enrollment, Chain and Organization System (PECOS). Go to: 
https://pecos.cms.hhs.gov/pecos/login.do. 
 
2. Paper application process: Download and complete the Medicare enrollment application(s) at 
http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/MedicareProviderSupEnroll/EnrollmentApplications.html.  
 
If you need help 
Visit http://go.cms.gov/MedicareRevalidation, or 
Call2 [contractor phone #] or visit [contractorsite.com] for more options. 
 
Sincerely,  
[Name] 
[Title] 
[Company] 
 
10.7.16  Model Letters for Claims Against Surety Bonds 
(Rev. 10524; Issued: 12-17-20; Effective: 11-13-20; Implementation: 11-13-20) 
 
When making a claim against a surety bond in accordance with section 10.2.5(A)(2)(o)(ii) of this 
chapter, the contractor shall use the applicable model letter below: 
 
A. Letter for Overpayments  Supplier is Still Enrolled in Medicare 
 
Date 
 
Surety Name 
Surety Address  
 
RE:    Supplier Legal Business Name 
  Supplier DBA Name (if any)   
Supplier Address 
  Supplier National Provider Identifier (NPI) 
  Dear Surety: 
 
(Supplier legal business name) is currently enrolled in the Medicare program as a supplier of 
durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).  As a condition of 
its Medicare enrollment, (Supplier) is required  under Federal regulations at 42 C.F.R. 
424.57(d) - to maintain a surety bond in an amount of no less than $50,000.  In accordance with 
this provision, (Supplier) has a $________ surety bond with your company.  
 
Consistent with 42 C.F.R. 424.57(d)(5)(i)(A), the surety must pay CMS - upon receiving 
written notice from CMS containing sufficient evidence as defined in the Program Integrity 
Manual, CMS Pub. 100-08, 10.2.5(A)(3)(b) - the amount of any unpaid claim for which the 
DMEPOS supplier is responsible, up to the full penal amount of the bond.  An unpaid claim is 
defined in 42 C.F.R. 424.57(a) as an overpayment made by the Medicare program to the 
DMEPOS supplier for which the DMEPOS supplier is responsible. 
 
CMS has determined that (Supplier) has incurred an overpayment in the amount of (insert dollar 
amount) for (insert a service or services, as applicable) performed on (insert date(s) of 
service).  This determination was made based on specific information about the overpayment, 
which is included in the attachments to this letter. 
 
CMS has been unable to recover the full overpayment from (Supplier) using its existing 
recoupment procedures.  (Supplier)  has repaid (insert none or only $_____) of the 
overpayment amount.  Consistent with 42 C.F.R. 424.57(d)(5)(i)(A), therefore, CMS requests 
that (Surety) make payment to CMS in the amount of (insert applicable amount) no later than 30 
days from the date of this letter.  Payment shall be made via check or money order and sent to 
the following address: 
 
 
Contractor Name 
Address 
City, State and Postal ZIP Code 
 
 
The payee shall be (insert DME MAC), which is CMSs Durable Medical Equipment Medicare 
Administrative Contractor for (Supplier)s location. 
 
Failure to make the requested payment in a timely manner may result in referrals to the United 
States Department of Justice for collection action, and/or the United States Department of the 
Treasury for revocation of [surety names] authority to provide federal bonds. 
 
Should you have any questions about this letter, please do not hesitate to contact _______ at 
__________.  (The contractor shall identify a specific individual who the surety can contact if 
questions arise.) 
 
 
Sincerely,  
(Name and title) 
   
cc:   Supplier Name 
 
 
B. Letter for Overpayments - Supplier is No Longer Enrolled in Medicare  
 
Date 
 
Surety Name 
Surety Address 
 
RE:  Former Supplier Legal Business Name 
  Former Supplier DBA Name (if any) 
  Former Supplier Address 
  Former Supplier NPI 
 
Dear Surety: 
 
(Former Supplier legal business name) was enrolled in the Medicare program as a supplier of 
durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) until (insert effective 
date of termination/revocation).  As a condition of its Medicare enrollment, (Former Supplier) 
was required  under Federal regulations at 42 C.F.R. 424.57(d) - to maintain a surety bond in 
an amount of no less than $50,000.  In accordance with this provision, (Former Supplier) 
obtained a $__________ surety bond with your company. 
 
Consistent with 42 C.F.R. 424.57(d)(5)(i)(A), the surety must pay CMS  upon receiving 
written notice from CMS containing sufficient evidence to establish the suretys liability under 
the bond  the amount of any unpaid claim for which the DMEPOS supplier is responsible, up to 
the full penal amount of the bond.  An unpaid claim is defined in 42 C.F.R. 424.57(a) as an 
overpayment made by the Medicare program to the DMEPOS supplier for which the DMEPOS 
supplier is responsible. 
 
CMS has determined that (Supplier) incurred an overpayment in the amount of (insert dollar 
amount) for (insert a service or services, as applicable) performed on (insert date(s) of 
service).  This determination was made based on specific information about the overpayment, 
which is included in the attachments to this letter. 
 
CMS has been unable to recover the full overpayment from (Former Supplier) using its existing 
recoupment procedures.  (Former Supplier) has repaid (insert none or only $_____) of the 
overpayment amount. 
 
(Former Suppliers) surety bond coverage with your company ended on (insert date).  However, 
consistent with 42 C.F.R. 424.57(d)(5)(iii), the surety is liable for unpaid claims that: 
 
  CMS assessed against the supplier based on overpayments that took place during the 
term of the bond or rider, and  
    Were assessed by CMS during the 2 years following the date that the supplier failed 
to submit a bond or required rider or the date that the suppliers Medicare enrollment 
was terminated, whichever is later. 
 
The overpayment occurred on (insert date), which was within the period of (Former Supplier)s 
surety bond coverage with your company.  Moreover, CMS has made its overpayment 
determination within the 2-year period following the date of the termination of (Former 
Supplier)s Medicare enrollment.  Consistent with 42 C.F.R. 424.57(d)(5)(i)(A), therefore, 
CMS requests that (Surety) make payment to CMS in the amount of (insert applicable amount) 
no later than 30 days from the date of this letter.  Payment shall be made via check or money 
order and sent to the following address: 
 
Contractor Name 
Address 
City, State and Postal ZIP Code 
 
The payee shall be (insert DME MAC), which is CMSs Durable Medical Equipment Medicare 
Administrative Contractor for (Supplier)s location. 
 
Failure to make the requested payment in a timely manner may result in referrals to the United 
States Department of Justice for collection action, and/or the United States Department of the 
Treasury for revocation of [surety names] authority to provide federal bonds. 
 
Should you have any questions about this letter, please do not hesitate to contact _______ at 
__________.  (The contractor shall identify a specific individual who the surety can contact if 
questions arise.) 
 
 
Sincerely,  
(Name and title) 
 
 
cc:     Supplier Name 
 
C. Letter for Civil Monetary Penalties and Assessments  Supplier is Still Enrolled in 
Medicare 
 
Date 
 
Surety Name 
Surety Address  
 
 
RE:    Supplier Legal Business Name 
  Supplier DBA Name (if any)  
  Supplier Address 
  Supplier NPI   
Dear Surety: 
 
(Supplier legal business name) is currently enrolled in the Medicare program as a supplier of 
durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).  As a condition of 
its Medicare enrollment, (Supplier) is required  under Federal regulations at 42 C.F.R. 
424.57(d) - to maintain a surety bond in an amount of no less than $50,000.  In accordance with 
this provision, (Supplier) has a $_________ surety bond with your company.  
 
Consistent with 42 C.F.R. 424.57(d)(5)(i)(A), the surety must pay CMS  upon  receiving 
written notice from CMS containing sufficient evidence to establish the suretys liability under 
the bond  the amount of any civil monetary penalty (CMP) and/or assessment for which the 
DMEPOS supplier is responsible, up to the full penal amount of the bond.   (Insert applicable 
language.............. 
 
A CMP is defined in 424.57(a) as a sum that CMS has the authority, as implemented by 
42 C.F.R. 402.1(c) (or the Department of Health and Human Services Office of 
Inspector General (OIG)) has the authority, under section 1128A of the Act or 42 C.F.R. 
Part 1003) to impose on a supplier as a penalty. 
 
            OR 
 
An assessment is defined as a sum certain that CMS or the Department of Health and 
Human Services Office of Inspector General (OIG) may assess against a DMEPOS 
supplier under Titles XI, XVIII or XXI of the Social Security Act.) 
 
(CMS or OIG, as applicable) imposed a (CMP and/or assessment, as applicable) on (Supplier) on 
(date) in the amount of ($ _____).  The (CMP and/or assessment) was imposed because (insert 
explanation, using information furnished by CMS or OIG). 
 
Relevant documentation supporting our determination is attached to this letter.  (Attach copy of 
notice of CMP/assessment that was sent to supplier.) 
 
(CMS or OIG, as applicable) has attempted to recover the amount of the (CMP or assessment) 
from (Supplier) using its existing collection procedures.  (Supplier), however, has repaid (insert 
none or only $_____) of this amount.  Consistent with 42 C.F.R. 424.57(d)(5)(i)(A), 
therefore, CMS requests that (Surety) make payment to CMS in the amount of (insert applicable 
amount) no later than 30 days from the date of this letter.  Payment shall be made via check or 
money order and sent to the following address: 
 
Contractor Name 
Address 
City, State and Postal ZIP Code 
 
The payee shall be the Centers for Medicare and Medicaid Services. 
  Failure to make the requested payment in a timely manner may result in referrals to the United 
States Department of Justice for collection action, and/or the United States Department of the 
Treasury for revocation of [surety names] authority to provide federal bonds. 
 
Should you have any questions about this letter, please do not hesitate to contact _______ at 
__________.  (The contractor shall identify a specific individual who the surety can contact if 
questions arise.) 
 
 
Sincerely,  
(Name and title) 
 
cc:     Supplier Name 
 
D. Letter for Civil Monetary Penalties and Assessments  Supplier is No Longer Enrolled 
in Medicare 
 
Date 
 
Surety Name 
Surety Address  
 
 
 
RE:    Former Supplier Legal Business Name 
  Former Supplier DBA Name (if any) 
  Former Supplier Address 
  Former Supplier NPI 
 
Dear Surety: 
 
(Former Supplier legal business name) was enrolled in Medicare as a supplier of durable medical 
equipment, prosthetics, orthotics and supplies (DMEPOS) until (insert effective date of 
termination/revocation).  As a condition of its Medicare enrollment, (Former Supplier) was 
required  under Federal regulations at 42 C.F.R. 424.57(d) - to maintain a surety bond in an 
amount of no less than $50,000.  In accordance with this provision, (Former Supplier) obtained a 
$_________ surety bond with your company. 
 
Consistent with 42 C.F.R. 424.57(d)(5)(i)(A), the surety must pay CMS  upon  receiving 
written notice from CMS containing sufficient evidence to establish the suretys liability under 
the bond  the amount of any civil monetary penalty (CMP) and/or assessment for which the 
DMEPOS supplier is responsible, up to the full penal amount of the bond.  (Insert applicable 
language.............. 
 
A CMP is defined in 424.57(a) as a sum that CMS has the authority, as implemented by 
42 C.F.R. 402.1(c) (or the Department of Health and Human Services Office of 
Inspector General (OIG) has the authority, under section 1128A of the Act or 42 C.F.R. 
Part 1003)) to impose on a supplier as a penalty.   
            OR 
 
An assessment is defined as a sum certain that CMS or the Department of Health and 
Human Services Office of Inspector General (OIG) may assess against a DMEPOS 
supplier under Titles XI, XVIII or XXI of the Social Security Act.) 
 
(CMS or OIG, as applicable) imposed a (CMP and/or assessment, as applicable) on (Former 
Supplier) on (date) in the amount of ($ _______).  The (CMP and/or assessment) was imposed 
because (insert explanation, using information furnished by CMS or OIG). 
 
Relevant documentation supporting our determination is attached to this letter.  (Attach copy of 
notice of CMP/assessment that was sent to former supplier.) 
 
(CMS or OIG, as applicable) has attempted to recover the amount of the (CMP or assessment) 
from (Former Supplier) using its existing collection procedures.  (Former Supplier), however, 
has repaid (insert none or only $_____) of this amount. 
 
(Former Supplier)s surety bond coverage with your company ended on (insert date).  However, 
consistent with 42 C.F.R. 424.57(d)(5)(iii), the surety is liable for CMPs and/or assessments 
that: 
 
  CMS or OIG imposed  or asserted against the supplier during the term of the bond or 
rider, and  
 
  Were imposed or assessed by CMS during the 2 years following the date that the 
supplier failed to submit a bond or required rider or the date that the suppliers 
Medicare enrollment was terminated, whichever is later. 
 
The (CMP and/or assessment) was based on events that occurred (insert relevant date(s)), which 
was within the period of (Former Suppliers) surety bond coverage with your company.  
Moreover, CMS imposed the (CMP and/or assessment) within the 2-year period following the 
date of the termination of (Former Supplier)s Medicare enrollment.  Consistent with 42 C.F.R. 
424.57(d)(5)(i)(A), therefore, CMS requests that (Surety) make payment to CMS in the amount 
of (insert applicable amount) no later than 30 days from the date of this letter.  Payment shall be 
made via check or money order and sent to the following address: 
 
Contractor Name 
Address 
City, State and Postal ZIP Code 
 
The payee shall be the Centers for Medicare & Medicaid Services. 
 
Failure to make the requested payment in a timely manner may result in referrals to the United 
States Department of Justice for collection action, and/or the United States Department of the 
Treasury for revocation of [surety names] authority to provide federal bonds. 
  Should you have any questions about this letter, please do not hesitate to contact _______ at 
__________.   (The contractor shall identify a specific individual who the surety can contact if 
questions arise.) 
 
 
Sincerely,  
(Name and title) 
 
 
cc:     Supplier Name 
 
E. Surety Non-Payment Letter 
 
Date 
 
Surety Name 
Surety Address  
 
RE:    Supplier Legal Business Name 
  Supplier DBA Name (if any)   
Supplier Address 
  Supplier National Provider Identifier (NPI) 
 
Dear Surety: 
 
Consistent with 42 C.F.R. 424.57(d)(5)(i)(A), we sent you a letter dated (date of letter) 
requesting that you make payment to CMS in the amount of (insert applicable amount) no later 
than 45 days from the date of said letter, a copy of which is attached.  (Attach a copy of the 
demand letter.)  As payment has not been received, this matter may be referred for further action 
to the United States Department of Justice for collection and/or the United States Department of 
the Treasury for revocation of [surety names] authority to provide federal bonds. 
     
Should you have any questions about this letter, please do not hesitate to contact _______ at 
__________.  (The contractor shall identify a specific individual who the surety can contact if 
questions arise.) 
 
 
Sincerely,  
(Name and title) 
 
 
cc:   Supplier Name 
 
10.7.17  Model Identity Theft Prevention Letter  
(Rev. 10611; Issued: 03-19-21; Effective:11-19-20; Implementation: 11-19-20) 
 
[month] [day], [year]    
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
 
Reference # (PTAN #, Enrollment #, Case #, etc.)  
 
Dear [Provider/Supplier Name]:  
 
As a security precaution, we are writing to confirm that you submitted a Medicare enrollment 
application(s) to enroll in or change an existing enrollment at the following address:  
 
[Provider/Supplier Name]  
[Address]  
[City] ST [Zip]  
 
If this application was submitted without your authorization, please contact the Medicare 
contractor that processes your claims immediately. The Medicare Fee-For-Service contact 
information can be found at www.cms.hhs.gov/MedicareProviderSupEnroll.  
 
We will process your application(s) according to The Centers for Medicare & Medicaid (CMS) 
timeliness standards and will contact you if additional information is needed. We will notify you 
once processing is complete.  
 
Please contact our office with any questions at [phone number] between the hours of [x:00 
AM/PM] and [x:00 AM/PM] and refer to your application(s) reference number [Reference 
number]  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
10.7.18 - Model Documentation Request Letter 
(Rev. 10611; Issued: 03-19-21; Effective:11-19-20; Implementation: 11-19-20) 
 
A. Model Language for 424.516(f)(1) Situations  
 
The contractor shall use the model language below if it is requesting documentation from a 
provider or supplier furnishing the items or services addressed in 424.516(f)(1).  
 
Dear Provider/Supplier:  
 
Under 42 CFR 424.516(f)(1), a provider or supplier that furnishes covered ordered items of 
durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), clinical laboratory, 
imaging services, or covered ordered/certified home health services is required to:    
  Maintain documentation for 7 years from the date of service, and  
 
  Upon the request of CMS or a Medicare contractor, provide access to that documentation.  
 
The documentation to be maintained includes written and electronic documents (including the 
National Provider Identifier (NPI) of the physician who ordered/certified the home health 
services and the NPI of the physician - or, when permitted, other eligible professional - who 
ordered items of DMEPOS or clinical laboratory or imaging services) relating to written orders 
and certifications and requests for payments for items of DMEPOS and clinical laboratory, 
imaging, and home health services.  
 
Consistent with 424.516(f)(1), please mail to us copies of the orders for the items or services 
that were furnished to the following beneficiaries on the dates specified:  
 
(Contractors shall insert the beneficiaries names (up to 5 may be listed, unless CMS specifies 
otherwise), appropriate identification information, and the dates on which the provider or 
supplier furnished the items/services in question. The contractor has the discretion to determine 
the cases/services that are included in this documentation request as well as the type(s) of 
documentation to be requested.)  
 
The documentation must be received at the following address no later than 30 calendar days after 
the date of this letter:  
 
(Cite appropriate address)  
 
Failure to timely submit this documentation may result in the revocation of your enrollment 
pursuant to 42 CFR 424.535(a)(10).  
 
 
Please contact our office with any questions at [phone number] between the hours of [x:00 
AM/PM] and [x:00 AM/PM] and refer to your application(s) reference number [Reference 
number]  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
B. Model Language for 424.516(f)(2) Situations  
 
The contractor shall use the model language below if it is requesting documentation from a 
provider or supplier furnishing the items or services addressed in  424.516(f)(2).  
 
Dear Physician/Professional:  
  Under 42 CFR 424.516(f)(2), a physician who orders/certifies home health services and the 
physician - or, when permitted, other eligible professional - who orders items of DMEPOS or 
clinical laboratory or imaging services is required to maintain documentation for 7 years from 
the date of service and to provide access to that documentation pursuant to a CMS or Medicare 
contractor request. The documentation to be maintained includes written and electronic 
documents relating to written orders and certifications and requests for payments for items of 
DMEPOS and clinical laboratory, imaging, and home health services.  
 
Consistent with 424.516(f)(2), please mail to us copies of the orders for items or services that 
you issued for the following beneficiaries on the dates specified:  
 
(Contractors shall insert the beneficiaries names (up to 5 may be listed, unless CMS specifies 
otherwise), appropriate identification information, and the dates on which the orders were made. 
The contractor has the discretion to determine the cases/services that are included in this 
documentation request as well as the type(s) of documentation to be requested.)  
 
The documentation must be received at the following address no later than 30 calendar days after 
the date of this letter:  
 
(Cite appropriate address)  
 
Failure to timely submit this documentation may result in the revocation of your enrollment 
pursuant to 42 CFR 424.535(a)(10). (For individuals enrolled via the Form CMS-855O, the 
contractor shall instead use the following language: Failure to timely submit this documentation 
may result in the revocation of your Form CMS-855O enrollment.) 
 
Please contact our office with any questions at [phone number] between the hours of [x:00 
AM/PM] and [x:00 AM/PM] and refer to your application(s) reference number [Reference 
number]  
 
Sincerely,  
 
[Name]  
[Title]  
[Company]  
 
10.7.19  ESRD Approval Letters  
(Rev. 12100; Issued: 06-29-23; Effective: 07-31-23; Implementation: 07-31-23) 
 
In the ESRD situations described in this section 10.7.19, the letters below shall be used as 
directed in section 10.2.1.3 notwithstanding any other instruction to the contrary in this chapter. 
 
A.  ESRD Service Station/Modality Changes 
 
[Provider/Supplier Name] 
[Address] 
[City, State, Zip]   
Reference # (Application Tracking Number) 
 
Dear [Provider/Supplier], 
   
Your State Agency has notified [insert contractor name] [insert contractor number] that your 
end-stage renal disease (ESRD) facility changed [your approved service modalities and/or 
number of stations.] Therefore, your facility is now approved for a total of [number of in-center 
hemodialysis stations] maintenance stations and the services outlined below: 
 
Medicare Enrollment Information 
 
Legal Business Name (LBN) 
Doing Business As (DBA) 
Provider/Supplier Type 
National Provider Identifier (NPI) 
Provider Transaction Access Number (PTAN) 
Effective Date 
CMS Certification Information 
 
CCN 
Effective Date 
Changed Information  
Effective Date of Change(s) (Include detailed changes or section. Select from list below.) 
 
__In Center Hemodialysis 
__In Center Peritoneal Dialysis  
__In Center Nocturnal Hemodialysis  
__Patient Training and Support for Home Hemodialysis  
__Patient Training and Support for Continuous Ambulatory Peritoneal Dialysis (CAPD)  
__Patient Training and Support for Continuous Cycling Peritoneal Dialysis (CCPD) 
 
You should report to the [State Agency ([SA])] any changes in location, services, or organization 
which might affect your certification status or the status of your ESRD facility. In addition, 
providers must notify CMS when there is a change of ownership. Therefore, you must notify 
your Medicare Administrative Contractor (MAC) and the [SA] promptly if there is a change in 
the legal status of the ownership of this facility. 
 
We look forward to continuing to work with you in the administration of the Medicare program.  
If you have any questions regarding this, please contact [STATE AGENCY NAME], [STATE 
AGENCY EMAIL ADDRESS]. 
 
[Include appropriate MAC signature] 
 
Cc:   State Agency 
        Accrediting Organization (if appropriate) 
 
B.  State Agency Approved Initial    
[Month, Day, Year] 
[Provider/Supplier Name] 
[Address] 
[City, State, Zip] 
 
Reference # (Application Tracking Number) 
 
Dear [Provider/Supplier], 
 
[Insert Contractor name [and Contractor number]] received a response from the Medicare State 
Agency [and Accrediting Organization}]. Your initial enrollment application is approved. 
 
Your unit has been approved as a renal dialysis [facility/center].  This approval is for a total of 
[number] maintenance stations.  Your [facility/center] is approved to provide the following 
services: 
 
[List all that apply--] 
 
  -In Center Hemodialysis 
  -In Center Peritoneal Dialysis 
  -In Center Nocturnal Hemodialysis 
  -Patient Training and Support for Home Hemodialysis  
  -Patient Training and Support for Continuous Ambulatory Peritoneal Dialysis (CAPD)  
  -Patient Training and Support for Continuous Cycling Peritoneal Dialysis (CCPD) 
 
Medicare Enrollment and Provider/Supplier Information 
 
Medicare Enrollment Information 
Legal Business Name (LBN) 
Doing Business As Name 
Primary Practice Location Address 
Provider/Supplier Type 
National Provider Identifier (NPI) 
Provider Transaction Access Number (PTAN) 
Enrollment Effective Date 
 
Please inform the [State Survey Agency/AO] if you wish to relocate your [facility/center], 
change the services that you are currently providing, change the number of approved stations, or 
undergo a change in ownership.   
 
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system. 
Contact our electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number]. 
 
Enroll, make changes, or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov.   
Submit updates and changes to your enrollment information within the timeframes specified at 
42 CFR  424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617. 
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations, at [insert contractors web address] or https://www.cms.gov. 
 
Right to Submit a Reconsideration Request: 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
 Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below. 
 State the issues or findings of fact with which you disagree and the reasons for disagreement. 
 Be signed by the provider or supplier, an authorized or delegated official that has been reported 
within your Medicare enrollment record, or an authorized representative. 
 
o     If the authorized representative is an attorney, the attorneys statement that he or she has 
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative. 
o    If the authorized representative is not an attorney, the individual provider, supplier, or 
authorized or delegated official must file written notice of the appointment of its 
representative with the submission of the reconsideration request. 
o    Authorized or delegated officials for groups cannot sign and submit a reconsideration 
request on behalf of a reassigned provider/supplier without the provider/supplier 
submitting a signed statement authorizing that individual from the group to act on his/her 
behalf. 
 
Providers and suppliers may: 
 
     Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted. 
    Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 CFR Part 
498.   
The reconsideration request should be sent to: 
 
Centers for Medicare & Medicaid Services                         
Provider Enrollment & Oversight Group                               
ATTN: Division of Provider Enrollment Appeals                       
7500 Security Blvd.                                
Mailstop: AR-19-51                              
Baltimore, MD 21244-1850 
 
Or emailed to: ProviderEnrollmentAppeals@cms.hhs.gov 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information]. 
 
Sincerely, 
 
[Name]                                
[Title]                                    
[Company] 
CC: State Agency [and AO, if applicable] 
 
C.  Change of Ownership  
 
[Month, Day, Year] 
 
[Provider/Supplier Name] 
[Address] 
[City, State, Zip] 
  
 
Subject: ESRD Medicare Change of Ownership 
 
Dear Administrator: 
 
[Insert Contractor name [and Contractor number]] has received a response from the State 
Agency. Your change of ownership application is now approved. 
 
[INSERT or CHECK THE APPLICABLE PARAGRAPH]: 
 
__ [Facility status is not changing] 
When an ESRD facility undergoes a change of ownership, the new owner is subject to all of the 
Medicare program terms and conditions that applied to the prior owner.  
 
___ [Changing from free-standing to hospital-based] 
When an ESRD facility undergoes a change of ownership and changes its status from a free-
standing ESRD facility to a hospital-based ESRD center, the existing CCN, formerly known as 
the Medicare Provider/Supplier Number, is automatically terminated and the ESRD center is 
issued a new CCN number that links it to the provider with which it is associated. The new  owner is subject to all of the Medicare program terms and conditions that applied to the prior 
owner. 
 
___ [Changing from hospital-based to free-standing] 
When an ESRD center undergoes a change of ownership and changes its status from a hospital-
based ESRD center to a free-standing ESRD facility, the existing CCN, formerly known as the 
Medicare Provider/Supplier Number, is automatically terminated and the ESRD facility is issued 
a new CCN to indicate the free-standing designation. The new owner is subject to all of the 
Medicare program terms and conditions that applied to the prior owner. Therefore, the CCN of 
[old CCN] is hereby terminated effective [Date of CHOW]. Your facilitys approved CCN is 
provided below.  
 
Your facility has been approved for a total of [number of in-center hemodialysis stations] 
maintenance stations.  Also, your facility is approved to provide the following services: 
 
[CHECK OR INSERT ALL APPLICABLE] 
 
  -In Center Hemodialysis 
  -In Center Peritoneal Dialysis  
  -In Center Nocturnal Hemodialysis  
  -Patient Training and Support for Home Hemodialysis  
-Patient Training and Support for Continuous Ambulatory Peritoneal Dialysis (CAPD)  
  -Patient Training and Support for Continuous Cycling Peritoneal Dialysis (CCPD) 
 
Medicare Enrollment Information 
 
Legal Business Name (LBN) 
Doing Business As Name 
Primary Practice Location Address 
Provider/Supplier Type 
National Provider Identifier (NPI) 
Provider Transaction Access Number (PTAN) 
 
Your PTAN is the authentication element for all inquiries to customer service representatives 
(CSRs), written inquiry units, and the interactive voice response (IVR) system.  Contact our 
electronic data interchange (EDI) department for enrollment and further instructions 
on electronic claims filing at [phone number]. 
 
Enroll, make changes, or view your existing enrollment information by logging into PECOS at 
https://pecos.cms.hhs.gov. 
 
Submit updates and changes to your enrollment information within the timeframes specified at 
42 CFR  424.516. For more information on the reporting requirements, go to Medicare 
Learning Network Article SE1617. 
 
Find additional Medicare program information, including billing, fee schedules, and Medicare 
policies and regulations, at [insert contractors web address] or https://www.cms.gov. 
  Right to Submit a Reconsideration Request 
 
You may request a reconsideration of this determination. This is an independent review 
conducted by a person not involved in the initial determination. (Optional Coversheet sentence 
[To facilitate the processing of your reconsideration request, please utilize and include the 
[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.]) 
 
Reconsideration requests must: 
 
    Be received in writing within 65 calendar days of the date of this letter and mailed or emailed 
to the address below. 
    State the issues or findings of fact with which you disagree and the reasons for 
disagreement. 
    Be signed by the provider or supplier, an authorized or delegated official that has been 
reported within your Medicare enrollment record, or an authorized representative. 
 
o    If the authorized representative is an attorney, the attorneys statement that he or she has 
the authority to represent the provider or supplier is sufficient to accept this individual as 
the representative. 
o    If the authorized representative is not an attorney, the individual provider, supplier,            
or authorized or delegated official must file written notice of the appointment of its 
      representative with the submission of the reconsideration request. 
o    Authorized or delegated officials for groups cannot sign and submit a reconsideration 
request on behalf of a reassigned provider/supplier without the provider/supplier 
 submitting a signed statement authorizing that individual from the group to act on his/her 
behalf. 
 
Providers and suppliers may: 
 
    Submit additional information with the reconsideration that may have a bearing on the 
decision. However, if you have additional information that you would like a Hearing Officer 
to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to 
consider during a hearing, you must submit that information with your request for 
reconsideration. This is your only opportunity to submit information during the 
administrative appeals process unless an ALJ allows additional information to be submitted. 
    Include an email address if you want to receive correspondence regarding your appeal via 
email. 
 
If a reconsideration is not requested, CMS deems this a waiver of all rights to further 
administrative review. More information regarding appeal rights can be found at 42 CFR Part 
498. 
 
The reconsideration request should be sent to: 
 
Centers for Medicare & Medicaid Services 
Provider Enrollment & Oversight Group 
ATTN: Division of Provider Enrollment Appeals 
7500 Security Blvd.  Mailstop: AR-19-51 
Baltimore, MD 21244-1850 
Or emailed to: 
 
ProviderEnrollmentAppeals@cms.hhs.gov 
 
For questions concerning this letter, contact [Insert Contractor] at [contact information]. 
 
Sincerely, 
 
[Name] 
[Title] 
 
[Company] 
CC: State Agency [and AO, if applicable] 
 
     
Transmittals Issued for this Chapter 
 
Rev #  Issue Date  Subject  Impl Date  CR# 
R12209PI  08/17/2023  Tenth General Update to Provider Enrollment  09/17/2023  13308 
Instructions in Chapter 10 of CMS Publication 
(Pub.) 100-08 
R12100PI  06/29/2923  Ninth General Update to Provider Enrollment  07/31/2023  13209 
Instructions in Chapter 10 of CMS Publication 
(Pub.) 100-08 
R11949PI  04/13/2023  Third Policy Change Request (CR) Regarding  06/19/2023  13147 
Implementation of the Provider Enrollment, 
Chain and Ownership System (PECOS) 2.0 
R11891PI  03/09/2023  Second Policy Change Request (CR) Regarding  06/19/2023  13036 
Implementation of the Provider Enrollment, 
Chain and Ownership System (PECOS) 2.0 
R11839PI  02/09/2023  First Policy Change Request Regarding  06/19/2023  12780 
Implementation of the Provider Enrollment, 
Chain and Ownership System (PECOS) 2.0 
R11859PI  02/16/2023  Eighth General Update to Provider Enrollment  03/17/2023  13061 
Instructions in Chapter 10 of CMS Publication 
(Pub.) 100-08 
R11808PI  01/24/2023  Incorporation of Recent Provider Enrollment  01/03/2023  12865 
Regulatory Changes into Chapter 10 of CMS 
Publication (Pub.) 100-08 
R11771PI  12/302022  Internet-Only Manual (IOM) Updates for Nurse  01/31/2023  13029 
Practitioners (NPs) and Clinical Nurse 
Specialists (CNSs) 
R11739PI  12/09/2022  Incorporation of Recent Provider Enrollment  01/03/2023  12865 
Regulatory Changes into Chapter 10 of CMS 
Publication (Pub.) 100-08 - Rescinded and 
replaced by transmittal 11808 
R11701PI  11/10/2022  Incorporation of Recent Provider Enrollment  01/06/2023  12865 
Regulatory Changes into Chapter 10 of CMS 
Publication (Pub.) 100-08- No Longer Sensitive- 
Rescinded and replaced by transmittal 11739 
R11694PI  11/09/2022  Medicare Enrollment of Rural Emergency  10/28/2022  12867 
Hospitals (REHs)  No Longer Sensitive 
R11682PI  11/04/2022  Seventh General Update to Provider Enrollment  12/05/2022  12880 
Instructions in Chapter 10 of CMS Publication 
(Pub.) 100-08 
R11637PI  10/07/2022  Provider Enrollment Appeals and Rebuttals -  12/09/2022  12731 
Revised Instructions and Model Letters  Rev #  Issue Date  Subject  Impl Date  CR# 
  09/15/2022  Medicare Enrollment of Rural Emergency  10/28/2022  12867 
Hospitals (REHs) SENSITIVE and 
CONTROVERSIAL-Rescinded and replaced 
by transmittal 11649 
 
  09/01/2022  Incorporation of Recent Provider Enrollment  01/06/2023  12865 
Regulatory Changes into Chapter 10 of CMS 
Publication (Pub.) 100-08-  SENSITIVE and 
CONTERVERSIAL-Rescinded and replaced 
by transmittal 11701 
 
R11574PI  08/25/2022  Sixth General Update to Provider Enrollment  09/27/2022  12789 
Instructions in Chapter 10 of Publication (Pub.) 
100-08, Program Integrity Manual (PIM) 
R11536PI  08/05/2022  Provider/Supplier Enrollment Adverse Legal  09/06/2022  12235 
Actions 
R11432PI  05/26/2022  Transition of Enrollment and Certification  05/27/2022  12749 
Activities for Various Certified Provider and 
Supplier Types and Transactions 
R11307PI  03/25/2022  Fifth General Update to Provider Enrollment  04/25/2022  12598 
Instructions in Chapter 10 of Publication (Pub.) 
100-08 
 
R11154PI  12/10/2021  Incorporation of Recent Provider Enrollment  01/03/2022  12502 
Regulatory Changes into Chapter 10 of CMS 
Publication (Pub.) 100-08 
 
R11142PI  12/02/2021  Incorporation of Recent Provider Enrollment  01/03/2022  12502 
Regulatory Changes into Chapter 10 of CMS 
Publication (Pub.) 100-08- Rescinded and 
replaced by transmittal 11154 
R11139PI  11/23/2021  Revisions to Certified Provider/Supplier Model  01/03/2022  12368 
Letters and Instructions for Processing Initial 
Skilled Nursing Facility (SNF) Enrollment 
Applications 
R11125PI  11/18/2021  Update to Enrollment Processing Requirements for  01/03/2022  12431 
Certified Provider/Supplier Change of Ownership 
(CHOW) and Change of Information (COI) 
Applications  
 
R11040PI  10/14/2021  Revisions to Certified Provider/Supplier Model  11/18/2021  12431 
Letters and Instructions for Processing Initial 
Skilled Nursing Facility (SNF) Enrollment  Rev #  Issue Date  Subject  Impl Date  CR# 
Applications - Rescinded and replaced by 
transmittal 11139 
R11020PI  10/01/2021  Restructuring of Section 10.4 in Chapter 10 of  10/29/2021  12412 
Publication (Pub.) 100-08 
R10975PI  09/08/2021  Changes of Information Involving Certified  10/08/2021  12386 
Providers and Certified Suppliers 
R10909PI  08/10/2021  Fourth General Update to Chapter 10 of  09/13/2021  12330 
Publication (Pub.) 100-08 
R10868PI  07/14/2021  Third General Update to Chapter 10 of  08/13/2021  12284 
Publication (Pub.) 100-08 
R10828PI  06/11/2021  Provider Enrollment Rebuttal Process -  07/12/2021  12248 
Additional Instructions for Returning 
Applications and Deactivations 
 
R10800PI  05/20/2021  Second General Update to Chapter 10 of  06/22/2021  12162 
Publication (Pub.) 100-08, Program Integrity 
Manual 
R10740PI  05/07/2021  Voluntary Terminations of Enrollment Involving  06/07/2021  12160 
Certified Providers and Certified Suppliers 
R10735PI  04/27/2021  Updates to Medicare Administrative Contractor  05/27/2021  12157 
(MAC) Appeals and Rebuttals Reporting 
R10727PI  04/13/2021  Chapter 15 of Publication (Pub.) 100-08 Manual  02/01/2021  11865 
Redesign  Additional Release of Chapter 10 of 
Pub. 100-08, Modification of the Timeliness 
Standards 
R10723PI  04/08/2021  Implementation of Provider Enrollment  08/10/2020  11551 
Provisions in CMS-6058-FC  Phase 1  
Continued Removal/Moving of Instructions from 
Chapter 15 of Publication (Pub.) 100-08 to 
Chapter 10 of Pub. 100-08 
R10672PI  03/18/2021  First General Update to Chapter 10 of  03/18/2021  12149 
Publication (Pub.) 100-08, Program Integrity 
Manual (PIM) 
R10674PI  03/19/2021  Second Update to Policies on the Enrollment of  01/29/2021  12113 
Opioid Treatment Programs (OTPs) 
R10611PI  03/19/2021  Completion of Removal/Moving of Instructions  11/19/2020  11917 
from Chapter 15 of Publication (Pub.) 100-08 to 
Chapter 10 of Pub. 100-08 
R10560PI  01/20/2021  Second Update to Policies on the Enrollment of  01/29/2021  12113 
Opioid Treatment Programs (OTPs)- Rescinded 
and replaced by transmittal 10674  Rev #  Issue Date  Subject  Impl Date  CR# 
R10524PI  12/17/2020  Chapter 15 of Publication (Pub.) 100-08 Manual  11/13/2020  11700 
Redesign  Additional Release of Chapter 10 
R10467PI  11/13/2020  Update to Chapter 10 of Publication (Pub.) 100- 11/01/2020  11954 
08 - Enrollment Policies for Home Infusion 
Therapy (HIT) Suppliers 
R10481PI  11/18/2020  Update to Policies on the Enrollment of Opioid  11/20/2020  12058 
Treatment Programs (OTPs) 
R10434PI  10/30/2020  Update to Chapter 10 of Publication (Pub.) 100- 11/01/2021  11954 
08 - Enrollment Policies for Home Infusion 
Therapy (HIT) Suppliers  Rescinded and 
Replaced by Transmittal 10467 
R10355PI  09/18/2020  Completion of Removal/Moving of Instructions  11/19/2020  11917 
from Chapter 15 of Publication (Pub.) 100-08 to 
Chapter 10 of Pub. 100-08- Rescinded and 
replaced by transmittal 10611 
R10353PI  09/11/2020  Chapter 15 of Publication (Pub.) 100-08 Manual  02/01/2021  11865 
Redesign  Additional Release of Chapter 10 of 
Pub. 100-08, Modification of the Timeliness 
Standards- Rescinded and Replaced by 
Transmittal 10727 
R10345PI  09/11/2020  Chapter 15 of Publication (Pub.) 100-08 Manual  11/13/2020  11700 
Redesign  Additional Release of Chapter 10- 
Rescinded and replaced by transmittal 10524 
R10239PI  07/28/2020  Implementation of Provider Enrollment  08/10/2020  11551 
Provisions in CMS-6058-FC  Phase 1  
Continued Removal/Moving of Instructions from 
Chapter 15 of Publication (Pub.) 100-08 to 
Chapter 10 of Pub. 100-08- Rescinded and 
replaced by transmittal 10723 
 
R10228PI  07/27/2020  Updates to Chapters 1, 2, 3, 4, 5, 6, 7, 8, 10, 11,  08/27/2020  11884 
and Exhibits of Publication (Pub.) 100-08 
  07/10/2020  Moving Chapter 15 (Medicare Enrollment)  06/16/2020  11546 
Manual Instructions in Publication (Pub.) 100-08 
to Chapter 10 (Medicare Enrollment 
R10146PI  05/22/2020  Implementation of Provider Enrollment  07/24/2020  11551 
Provisions in CMS-6058-FC  Phase 1  
Continued Removal/Moving of Instructions from 
Chapter 15 of Publication (Pub.) 100-08 to 
Chapter 10 of Pub. 100-08 Rescinded and 
replaced by Transmittal 10239 
  Rev #  Issue Date  Subject  Impl Date  CR# 
R10182PI  05/152020  Update to Chapter 10 of Publication (Pub.) 100- 09/16/2020  11375 
08 - Model Letter Templates 
R10138PI  06/15/2020  Moving Chapter 15 (Medicare Enrollment)  06/16/2020  11546 
Manual Instructions in Publication (Pub.) 100-08 
to Chapter 10 (Medicare Enrollment)- Rescinded 
and replaced by Transmittal 10219 
R434PI  09/14/2012  Removal of Remaining Material from Chapter  10/16/2012  8026 
10 of the Program Integrity Manual (PIM) 
R416PI  04/13/2012  General Update to Chapter 15 of the Program  02/27/2012  7698 
Integrity Manual (PIM) Part III 
R405PI  01/26/2012  General Update to Chapter 15 of the Program  02/27/2012  7698 
Integrity Manual (PIM) Part III  Rescinded 
and replaced by Transmittal 416 
R386PI  09/01/2011  Ordering/Referring Providers Who Are Not  04/19/2010  6696 
Enrolled in Medicare 
R363PI  01/14/2011  Clarification for Part A Contractors Including  02/15/2011  7221 
Audit and Claims Intermediaries Notifying Each 
Other via E-mail Upon Processing of the Initial 
Enrollment Application, Change of Information, 
Voluntary Termination, or Any Other CMS-855 
Transaction 
R356PI  09/24/2010  Manual Redesign  10/26/2010  7083 
R354PI  08/27/2010  Manual Redesign  09/28/2010  7016 
R347PI  07/15/2010  Chapter 10 Manual Redesign - Initial release of  07/30/2010  6938 
Chapter 15 
R344PI  06/18/2010  Chapter 10 Manual Redesign - Initial release of  07/05/2011  6938 
Chapter 15 - Rescinded and replaced by 
Transmittal 347 
R339PI  05/21/2010  Cardiac Rehabilitation and Intensive Cardiac  10/04/2010  6850 
Rehabilitation 
R334PI  04/23/2010  Update to Site Verification Process  05/24/2010  6895 
R332PI  03/26/2010  Reporting Changes in Surety Bonds  06/28/2010  6854 
R329PI  03/19/2010  Change in Provider Enrollment Timeliness  06/21/2010  6807 
Standards for Certain Paper Applications 
R328PI  03/19/2010  Ordering/Referring Providers Who Are Not  04/19/2010  6696 
Enrolled in Medicare  Rescinded and replaced 
by Transmittal 386 
R326PI  03/12/2010  Revision of the Internet Only Manual to Remove 06/14/2010  6627 
References to Purchased Diagnostic Test and 
Replace With Language Consistent With the 
Anti-Markup Rule  Rev #  Issue Date  Subject  Impl Date  CR# 
R324PI  02/05/2010  Revisions to Model Approval Letters  03/08/2010  6780 
R323PI  01/29/2010  Verification of Legal Status  03/29/2010  6748 
R322PI  01/15/2010  Durable Medical Equipment (DME MAC) and  7/06/2010  6714 
the National Supplier Clearinghouse (NSC 
MAC) Procedures for Third Party Notification of 
Deceased Durable Medical Equipment, 
Prosthetic, Orthotic and Supplies (DMEPOS) 
Supplier Associates 
R321PI  12/30/2009  Verification of Legal Status Rescinded and  03/29/2010  6748 
replaced by Transmittal 323 
R320PI  12/23/2009  Provider Enrollment Revisions  01/25/2010  6645 
R318PI  12/18/2009  Implementation of Home Health Agency  01/01/2010  6750 
Program Safeguard Provisions - Rescinded 
R316PI  12/04/2009  Administrative Appeals Process for Provider  01/04/2010  6487 
Enrollment 
R315PI  12/04/2009  Provider Enrollment and Veterans  03/08/2010  6735 
Administration (VA) Hospitals 
R314PI  11/27/2009  Clarification of Deactivation Instructions  12/28/2009  6734 
R312PI  11/20/2009  Home Health Agency (HHA) Capitalization  12/21/2009  6732 
Requirements 
R307PI  10/23/2009  Establishing New Practice Locations in a  01/25/2010  6649 
Different State 
R306PI  10/02/2009  Site Verifications  11/02/2009  6639 
R304PI  09/25/2009  Inter-Contractor Communication and Provider  10/26/2009  6642 
Enrollment Revocations 
R300PI  09/01/2009  Compliance Standards for Consignment Closets  03/01/2010  6528 
and Stock and Bill Arrangements - Rescinded 
R299PI  08/28/2009  Updates to Model Rejection, Returned  09/28/2009  6527 
Application, Revalidation, Approval, 
Denial/Revocation Letters and Identity Theft 
Prevention Letter 
R297PI  08/07/2009  Compliance Standards for Consignment Closets  09/08/2009  6528 
and Stock and Bill Arrangements - Rescinded 
and replaced by Transmittal 300 
R296PI  07/10/2009  Provider Enrollment Verification Activities  08/10/2009  6499 
R295PI  06/29/2009  Revision to Certain Instructions Related to  07/27/2009  6491 
Provider Enrollment Deactivations and 
Revocations 
R291PI  06/12/2009  Reassignment and Ambulatory Surgical Centers  10/05/2009  6470 
(ASCs)  Rev #  Issue Date  Subject  Impl Date  CR# 
R289PI  04/15/2009  Incorporation of Physician Fee Schedule  04/01/2009  6310 
Regulatory Changes 
R288PI  04/02/2009  Incorporation of Physician Fee Schedule  04/01/2009  6310 
Regulatory Changes - Rescinded and replaced by 
Transmittal 289 
R287PI  03/27/2009  Surety Bonds for Suppliers of Durable Medical  04/06/2009  6392 
Equipment, Prosthetics, Orthotics and Supplies 
(DMEPOS) 
286PI  03/13/2009  Incorporation of Physician Fee Schedule  04/01/2009  6310 
Regulatory Changes  Rescinded and replaced 
by Transmittal 288 
R284PI  02/20/2009  Model Letter Updates  03/20/2009  6244 
R280PI  12/31/2008  Incorporation of Recent Regulatory Revisions  02/02/2009  6282 
Pertinent to Suppliers of Durable Medical 
Equipment, Prosthetics, Orthotics and Supplies 
(DMEPOS) 
R277PI  12/19/2008  Additional Provider Enrollment Verification and  01/20/2009  6097 
Program Integrity Activities 
R276PI  12/19/2008  Deceased Individuals and the Provider  01/20/2009  6194 
Enrollment Process 
R275PI  12/12/2008  Administrative Appeals for Provider Enrollment  01/12/2009  6248 
R272PI  11/07/2008  Clarification of Provider Enrollment Procedures  12/08/2008  6151 
Involving Certified Suppliers and Providers 
R271PI  10/24/2008  Instructions for the Implementation of the  11/24/2008  6231 
Internet-Based Provider Enrollment, Chain and 
Ownership System (PECOS) 
R269PI  09/19/2008  Incorporation of Recent Regulatory Revisions  10/20/2008  6178 
into Chapter 10 of the Program Integrity Manual 
R266PI  09/05/2008  Model Letters  10/06/2008  6051 
R261PI  06/27/2008  Update to Section 12 of Chapter 10 of the  07/28/2008  6071 
Program Integrity Manual 
R260PI  06/20/2008  Clarification of Chapter 10  07/22/2008  6065 
R251PI  04/11/2008  Administrative Appeals for Provider Enrollment  05/12/2008  5826 
R246PI  03/14/2008  Clarification of Items in Chapter 10  04/14/2008  5952 
R236PI  02/01/2008  Update to Chapter 10  03/03/2008  5892 
R234PI  01/18/2008  Revision to Instructions Relating to Compliance  04/22/2008  5856 
Standards for Independent Diagnostic Testing 
Facilities (IDTFs) 
R233PI  01/18/2008  Update to Chapter 10  02/20/2008  5862  Rev #  Issue Date  Subject  Impl Date  CR# 
R232PI  01/04/2008  Clarification of Standards for Processing CMS- 02/04/2008  5854 
855 Enrollment Applications 
R230PI  12/14/2007  Update to Chapter 10  01/07/2008  5802 
R227PI  11/02/2007  Update to Requirement to Submit National  01/07/2008  5795 
Provider Identifier (NPI) Notification 
R221PI  09/06/2007  Administrative Appeals for Provider Enrollment  10/01/2007  5467 
R219PI  08/17/2007  Nurse Practitioner (NP) Services and Clinical  11/19/2007  5639 
Nurse Specialist (CNS) Services 
R218PI  08/10/2007  Provider Enrollment Manual Update  10/01/2007  5671 
R217PI  07/13/2007  Provider Enrollment Fraud Detection Program  08/13/2007  5633 
for High Risk Areas 
R216PI  07/13/2007  Implementation of New Compliance Standards  10/01/2007  5672 
for Independent Diagnostic Testing Facilities 
(IDTFs) 
R214PI  06/29/2007  Clarification of Provider Enrollment  07/30/2007  5504 
Revocations 
R212PI  06/29/2007  Administrative Appeals for Provider Enrollment  10/01/2007  5467 
- Replaced by Transmittal 221 
R195PI  03/30/2007  General Background Information on Individual  04/30/2007  5503 
Practitioners and Certain Part B Services 
R191PI  03/23/2007  Provider/Supplier Enrollment Approval Letters  05/23/2007  5285 
R190PI  02/23/2007  General Background Information on Certified  04/02/2007  5401 
Providers and Certified Suppliers 
R182PI  01/12/2007  Medicaid State Agencies  03/01/2007  5284 
R175PI  11/24/2006  Division of Provider and Supplier Enrollment  12/26/2006  5340 
Issued Revocations 
R173PI  11/13/2006  Update to Chapter 10-Medicare  11/15/2006  5338 
Provider/Supplier Enrollment 
R158PI  09/15/2006  Provider Enrollment Disenrollment Actions  10/02/2006  5076 
R151PI  07/14/2006  Provider Enrollment Appeals Process  08/14/2006  4354 
R150PI  06/30/2006  Re-issuance of Chapter 10  07/03/2006  5139 
R146PI  04/28/2006  Provider Enrollment Update  05/30/2006  4340 
R137PI  02/10/2006  Provider Enrollment Workload and Timeliness  04/15/2006  4214 
Reports 
R134PI  12/30/2005  Change in Provider Enrollment Timeliness  03/01/2006  4213 
Standards 
R133PI  11/18/2005  Enrolling Indian Health Service (IHS) Facilities  04/03/2006  3845 
as Durable Medical Equipment, Prosthetics, 
Orthotics and Supplies (DMEPOS) Suppliers  Rev #  Issue Date  Subject  Impl Date  CR# 
R132PI  11/18/2005  New Process for Web Maintenance of Provider  12/19/2005  4141 
Enrollment Contractor Contact Information 
R095PI  01/14/2005  Change in Provider Enrollment Appeals Process  02/14/2005  3601 
R088PI  11/26/2004  Timeframes for Processing 855 Enrollment  12/27/2004  3528 
Applications 
R069PI  03/26/2004  Streamlining Enrollment Requirements  04/26/2004  3159 
R060PI  11/28/2003  Establishing an Enrollment Record in PECOS  12/29/2003  2855 
R058PI  11/28/2003  Tracking with PECOS Instead of CROWD  12/10/2003  2939 
R041PI  05/23/2003  General Revision  05/23/2003  2595 
R029PIM  07/24/2002  Enrollment Process for New Medicare  07/26/2002  2114 
Providers/Suppliers 
R007PIM  05/31/2001  Physician Identification and Registration  07/01/2001  1550 
Instructions 
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