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Enrollment

The enrollment activities that a DME supplier must complete in order to receive payment in the Medicare program are outlined on this webpage. All DME suppliers who serve Medicare beneficiaries and meet the supplier standards must register to receive a National Provider Identifier (NPI) This link takes you to an external website.  as well as register with the National Supplier Clearinghouse (NSC).

A supplier is an entity or individual that provides, sells, or rents durable medical equipment, prosthetics, orthotics, or supplies (DMEPOS) to Medicare beneficiaries and meets the supplier standards described on the CMS 855S form.

Section 6401(a) of the Affordable Care Act (ACA) requires the Secretary to impose a fee on each "institutional provider of medical or other items or services and suppliers." The fee is to be used by the Secretary to cover the cost of program integrity efforts including the cost of screening associated with provider enrollment processes, including those under section 1866(j) and section 1128J of the Social Security Act. The application fee is based upon provisions of the ACA this fee will vary from year-to-year based on adjustments made pursuant to the Consumer Price Index for Urban Areas (CPI-U). The application fee is to be imposed on institutional providers that are newly-enrolling, re-enrolling/re-validating, or adding a new practice location - for applications received on and after March 25, 2011.

CMS has defined "institutional provider" to mean any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A, CMS-855B (except physician and non-physician practitioner organizations), or CMS-855S or associated Internet-based PECOS enrollment application.

National Supplier Clearinghouse

The next step is to enroll with the National Supplier Clearinghouse (NSC), which is responsible for enrollment of all suppliers nationwide (including Indian Health Services (IHS) facilities-see Chapter 10). In order to be eligible to submit claims to either of the DME MACs and receive payment for covered services provided to Medicare beneficiaries, the CMS-855S form must be completed. The Medicare enrollment application is used to collect information about the supplier and to secure the necessary documentation to ensure the supplier is qualified and eligible to enroll in the Medicare program. An electronic copy of the current CMS-855S Medicare enrollment application is available on the CMS website. Instructions on how to complete the CMS-855S are located under the Supplier Enrollment/Forms/CMS-855S Form section of the NSC website.

CMS has contracted with Palmetto GBA to distribute applications, verify data, issue numbers to approved suppliers and maintain a national DMEPOS supplier file. The NSC does not process or maintain information on claims. Questions regarding claims should be directed to the DME MACs.

NSC Contact Information

Telephone 1-866-238-9652
Mailing Address National Supplier Clearinghouse
Palmetto GBA *
AG-495
PO Box 100142
Columbia SC 29202-3142
Courier Address National Supplier Clearinghouse
Palmetto GBA
AG-495
2300 Springdale Drive Bldg. 1
Camden SC 29020

NSC Enrollment

The applicant completes and submits the Medicare enrollment application, CMS-855S Form and all supporting documentation to the NSC.

  • Supporting documentation requirements are listed on the CMS-855S form.
  • Suppliers must furnish their NPI in the appropriate section(s) of the CMS-855S form and submit a copy of the notification received from NPPES verifying the NPI.
  • Suppliers must also complete and submit the Authorization Agreement for Electronic Funds Transfer (EFT), CMS-588 form.
  • For applications that are incomplete or require development, the NSC will notify the applicant that more information is required. Failure to respond within 30 days will result in denial of the application.

Site Visit

The NSC reviews the application and conducts a site visit to verify compliance with all DMEPOS supplier standards. Site visits:

  • Are a tool used by the NSC to assist in making a determination as to whether or not a supplier is in compliance with the thirty supplier standards
  • Are completed for initial applications, reenrollments, and reactivations
  • Can and will be conducted at any time if deemed necessary
    The site visit along with the application and supporting documentation are considered in making a determination to issue, deny or revoke a supplier's billing privileges.

Supplier Standards

Medicare regulations have defined standards that a supplier must meet to receive and maintain a supplier number. The supplier must certify in its application for billing privileges that it meets and will continue to meet the standards. The supplier standards in full can be found in 42 CFR Section 424.57 This link takes you to an external website..

The following is an abbreviated version of the supplier standards as provided on the CMS-855S form.

DMEPOS suppliers also have the option to disclose the following statement in order to satisfy the requirement outlined in Supplier Standard 16 in lieu of providing a copy of the standards to the beneficiary.

The products and/or services provided to you by [supplier legal business name or DBA] are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g., honoring warranties and hours of operation). The full text of these standards can be obtained at http://www.ecfr.gov/cgi-bin/ECFR. Upon request we will furnish you a written copy of the standards.

  1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.
  2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
  3. A supplier must have an authorized individual whose signature is binding sign the enrollment application for billing privileges.
  4. A supplier must fill orders from its own inventory or contract with other companies for the purchase of items necessary to fill orders. A supplier cannot contract with any entity that is currently excluded from the Medicare program, any State health care programs, or any other Federal procurement or non-procurement programs.
  5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.
  6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.
  7. A supplier must maintain a physical facility on an appropriate site and must maintain a visible sign with posted hours of operation. The location must be accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.
  8. A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the supplier's compliance with these standards.
  9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, answering service or cell phone during posted business hours is prohibited.
  10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier's place of business and all customers and employees of the supplier. If the supplier manufactures its own items this insurance must also cover product liability and completed operations.
  11. A supplier is prohibited from direct solicitation to Medicare beneficiaries. For complete details on this prohibition see 42 CFR Section 424.57(c) (11).
  12. A supplier is responsible for delivery of and must instruct beneficiaries on the use of Medicare covered items, and maintain proof of delivery and beneficiary instruction.
  13. A supplier must answer questions and respond to complaints of beneficiaries and maintain documentation of such contacts.
  14. A supplier must maintain and replace at no charge or repair cost either directly or through a service contract with another company, any Medicare-covered items it has rented to beneficiaries.
  15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
  16. A supplier must disclose these standards to each beneficiary it supplies a Medicare-covered item.
  17. A supplier must disclose any person having ownership, financial or control interest in the supplier.
  18. A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its' Medicare billing number.
  19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.
  20. Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint and any actions taken to resolve it.
  21. A supplier must agree to furnish CMS any information required by the Medicare statute and regulations.
  22. A supplier must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services for which the supplier is accredited in order for the supplier to receive payment for those specific products and services (except for certain exempt pharmaceuticals).
  23. A supplier must notify their accreditation organization when a new DMEPOS location is opened.
  24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.
  25. A supplier must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.
  26. A supplier must meet the surety bond requirements specified in 42 CFR Section 424.57(d).
  27. A supplier must obtain oxygen from a state-licensed oxygen supplier.
  28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 CFR Section 424.516(f).
  29. A supplier is prohibited from sharing a practice location with other Medicare providers and suppliers.
  30. A supplier must remain open to the public for a minimum of 30 hours per week except physicians (as defined in Section 1848(j) (3) of the Act), physical and occupational therapists or DMEPOS suppliers working with custom made orthotics and prosthetics.

Decision

After completing their review, the NSC notifies the applicant in writing about its enrollment decision. If a supplier meets all criteria to be a DME supplier, the NSC will issue a supplier number. Retain this number in a safe place. The issued number is commonly called a supplier number, Provider Transaction Access Number (PTAN), and a legacy number and should be used when calling or writing to Medicare. The NSC will retain the original application on file for seven years.

National Plan and Provider Enumeration System (NPPES) Update

Suppliers will also need to update the NPPES This link takes you to an external website. system with their NSC assigned supplier number before submitting claims to Medicare. Without establishing a crosswalk between the supplier number and the NPI, claims will be denied or rejected.

Accreditation

In order to participate in Medicare Part B, certain DMEPOS suppliers need to complete the accreditation process and be in compliance with new quality standards prior to enrolling as a supplier.

Quality Standards

The Quality Standards This link takes you to an external website. are a separate set of standards from the NSC Supplier Standards that are divided into the following areas:

  • Section I: Supplier Business Services Requirements
  • Section II: Supplier Product-Specific Service Requirements
  • Appendix A: Respiratory Equipment, Supplies, and Services
  • Appendix B: Manual Wheelchairs, Power Mobility Devices, and Complex Rehabilitative Wheelchairs and Assistive Technology
  • Appendix C: Custom Fabricated and Custom Fitted Orthoses, Prosthetic Devices, External Breast Prostheses, Therapeutic Shoes and Inserts, and their Accessories and Supplies; Custom-Made Somatic, Ocular and Facial Prostheses

There are several accrediting organizations This link takes you to an external website. recognized by CMS that have authority to accredit DMEPOS suppliers. These organizations have been approved for specific categories to accredit. For more information on accreditation, visit the NSC website.

Surety Bond

As of October 2, 2009, suppliers must have obtained a surety bond as a condition of new or continued Medicare enrollment. A DMEPOS surety bond is a bond issued by an entity (the surety) guaranteeing that a DMEPOS supplier will fulfill an obligation or series of obligations to a third party (the Medicare program). If the obligation is not met, the third party will recover its losses via the bond.

A list of sureties from which a bond can be secured from is found at the Department of the Treasury's "Listing of Certified Companies" website This link takes you to an external website.. For more information on the surety bond, visit the NSC website.
An Accreditation & Surety Bond Exemption Chart is available on the NSC Website. This chart illustrates DMEPOS supplier exemptions from either the accreditation or surety bond requirement to obtain/maintain Medicare billing privileges. Exempt suppliers are reminded that accreditation and surety bond exemptions only extend to the normal scope of services for the supplier specialty. Any products or services provided outside the normal range of services will require accreditation and/or a surety bond to obtain/maintain Medicare billing privileges.

Electronic Funds Transfer

As part of CMS's revalidation efforts, all suppliers and providers who are not currently receiving EFT payments will be identified and required to submit the CMS 588 EFT form with the Provider Enrollment Revalidation application. The NSC's role is to verify the proper contractor has been listed and the form is completed and signed appropriately. The NSC will then send the agreement to the appropriate DME MAC for processing.

Additional information regarding the EFT form and submission process is available on the Noridian EFT webpage.

Changes to Applications

Suppliers must notify the NSC within 30 days of any changes that occur after the initial application is filed. Changes must be submitted on the CMS-855S form.

Maintenance of the national supplier file is the responsibility of the NSC. Only the NSC can issue supplier numbers and collect ownership information. The NSC releases information from the national supplier file to all DME MACs.

To receive published Jurisdiction D DME literature and/or Medicare claim payments, the NSC must have the supplier's correct address. The NSC maintains the supplier's physical address, mailing address, and pay-to address and provides these to the DME MAC on an as-needed basis. The DME MAC cannot change a supplier's address. All changes of address must be processed through the NSC.

Do Not Forward (DNF)

The DME MACs use "return service requested" envelopes for all remittance advices (RAs) in addition to using them for hardcopy checks. When the post office returns checks or RAs, the DME MAC notifies the NSC and a Do Not Forward (DNF) flag is put on the supplier's account to cease generating payments to the supplier until the updated address is furnished and verified by the NSC. If a paper check from Medicare or a RA is returned, suppliers need to complete the CMS-855S Enrollment form with the appropriate changes and send that with a copy of the NPPES issued NPI notification letter to the NSC.

For suppliers who receive EFT payments, if the bank rejects an EFT transaction due to changes in the account, the DNF process begins and the supplier must complete the CMS-588 EFT form and send it to Noridian with a voided check, deposit slip, or account information on a bank letterhead.

Revalidation

CMS requires that all DMEPOS suppliers with Medicare billing privileges re-enroll with the Medicare program every three years through the NSC. Suppliers will be prompted to revalidate, formerly re-enroll, for billing privileges using the Internet-based PECOS system. Upon receipt of the revalidation letter, suppliers are required to go online and respond to the request within 30 days. If the NSC does not receive the completed revalidation packet, the supplier's billing privileges are subject to normal filing rules including revocation or inactivation.

Revocation

Suppliers found in noncompliance with the supplier standards are subject to revocation of their NSC-issued supplier number. The notification of revocation outlines the appeal process available to suppliers, including instructions for requesting an appeal.

Participating/Non-Participating

Suppliers have a choice when becoming a supplier whether to become a participating or non-participating Medicare provider. Suppliers can also change their participation status annually. Participation status is part of the enrollment process through the NSC.

Participation means the supplier always agrees to accept assignment for all services furnished to Medicare beneficiaries during a 12-month period, beginning January 1 of each year. By agreeing, the supplier always accepts the Medicare allowed amount as payment in full and doesn't collect more than the deductible and coinsurance from the beneficiary. By accepting assignment, the payment is sent to the supplier.

Suppliers who choose not to sign the participation contract are referred to as non-participating suppliers. For non-participating suppliers, the Medicare payment is sent to the beneficiary. The non-participating supplier can then bill the beneficiary for the difference between the submitted amount and the Medicare allowed amount, as well as the deductible and coinsurance on non-assigned claims. The non-participating supplier can choose on a claim by claim basis whether or not to accept assignment, except where CMS regulations require mandatory assignment, i.e., Medicare covered drugs or Indian Health Services.

Open enrollment forms (CMS-460, Participation Agreement Form) are mailed to all active suppliers every November. If an existing non-participating supplier wants to become participating, then the agreement form must be received during open enrollment and postmarked before December 31 of that year.

If a participating supplier wants to become non-participating, they can request to become non-participating by sending the request to the NSC on their company letterhead. The request must be postmarked before December 31 of that year to become non-participating effective January 1 of the next year.

Resources: Social Security Act Section 1842(h); 42 U.S.C. Section 1395u (h); 42 C.F.R. Sections 400.202, 424.55 (1999)

Medicare Participating Suppliers Directory

The NSC prepares the Medicare Participating Suppliers Directory (MEDPARD) This link takes you to an external website. that contains the names, addresses, telephone numbers, and specialties of Medicare participating suppliers. As a benefit, participating suppliers are added to the MEDPARD. The directory will serve as an aid to the beneficiary in selecting a supplier who accepts assignment as the beneficiary will have less out-of-pocket costs.

Supplier Audit and Compliance Unit (SACU)

The SACU is tasked to review new applicants and existing suppliers to determine if they are in compliance with current supplier standards. Most suppliers and supplier organizations are interested in fraud and abuse control to protect their industry's image with the public and Congress. This task is, by its nature, a cooperative effort. It involves beneficiaries, state Medicaid agencies, the DME MACs, and federal agencies such as CMS, the Office of the Inspector General (OIG), the Department of Health and Human Services (DHHS), and the United States Attorney's Office (USAO).

The SACU has the authority to deny new applicants and to recommend revocation to CMS and/or inactivate existing supplier numbers when it is determined that such suppliers are not in compliance with the published standards. In addition, the Health Insurance Portability and Accountability Act (HIPAA) of 1996 created criminal and civil penalties for suppliers who submit fraudulent applications to a government health care organization. Fully developed cases are submitted for prosecution to the U. S. Attorney's Office, Columbia, South Carolina. The U. S. Attorney has jurisdiction nationwide because all the applications are received, and the supplier numbers are issued, by the NSC in Columbia, South Carolina.

To report a possible supplier standard violation, contact the NSC This link takes you to an external website..

Last Updated Feb 10, 2017