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Revalidation

The Patient Protection and Affordable Care Act established a requirement for all enrolled providers/suppliers to revalidate their Medicare enrollment information roughly every five years. Revalidation is the process of reviewing all information that is on file with Medicare is correct. All information can be found in CMS Internet Only Manual (IOM), Publication 100-08, Chapter 15, Section 15.29

CMS has completed Cycle 1 Revalidation.

  • Phase 1 was to get everyone into PECOS. This helped clean up the claims system.
  • Phase 2 was making sure all organizations were revalidated.
  • Phase 3 revalidated everyone else.

Cycle 2 Revalidation began February 2016 which will start to establish the five-year cycle. All actively enrolled providers/suppliers will be required to revalidate. Providers opted out of Medicare or enrolled solely to order, certify, and prescribe do not have to revalidate.

View the below information on this page.

Due Dates

  • CMS has established due dates for Revalidation on last day of month (e.g. May 31, 2016, June 30, 2016)
  • To avoid deactivation of Medicare billing privileges, submit revalidation application to appropriate Medicare Administrator Contractor (MAC) within seven months of due date
  • If an application is submitted before seven months, it will be returned as unsolicited
    • If application changes any of Medicare information, changes will occur but will not revalidate the enrollment. Another application must be submitted within seven months of due date

Look-up Tool

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

  • View Medicare Revalidation List which includes all enrolled suppliers
  • All providers/suppliers not yet up for revalidation will display a "TBD" (To Be Determined) in due date field
    • If nothing is showing when and National Provider Identifier (NPI) is viewed, be sure there is not a space after the NPI. This will cause inaccurate information to display. If there is no space at end of NPI, and no due date populates, enrollment is not requested to revalidate at this time
  • If enrollment has revalidated successfully, or application is still in processing, due date will still populate on website
    • Once application has been completed, and notification letters have been sent, enrollment will not need to be revalidated again until requested
  • An option is available for organizations to view a list of all reassigning providers and their due dates
    • When looking up organization information in revalidation loop-up tool, select organization name. Here, names of providers who must revalidate, have revalidated, or have TBD will populate
  • Providers who are enrolled in Medicare solely to order, certify and/or prescribe or have opted out of Medicare, are not required to revalidate and will not appear on lookup tool
  • List will be updated every 60 days
  • Providers/Suppliers listed on website, with a due date, should submit their revalidation application. Do not wait for a letter. Providers/Suppliers are required to revalidate within their seven-month window
  • View the How to Use the Revalidation Due Date Lookup Tool Enrollment on Demand (EoD) to learn how to use the Revalidation Look up Tool on the CMS website

Notification

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

Failure to Revalidate

Pend Status

  • Organizations, sole proprietors and sole owners, will have their enrollment record placed into a pend status if a revalidation application isn't received by due date. Pend will be placed on group enrollment up to 25 days after due date
    • This means that it can be applied anywhere from 1-25 days after due date
  • Pend status holds Standard Remittance Advices (SPRs) and Electronic Funds Transfers (EFTs) from being issued until a revalidation application is received

Deactivation

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

Reactivation

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

Gap in Billing (Lapse in Coverage)

  • Gap in billing (lapse in coverage) is where the enrollment is deactivated when either revalidation date has passed, or revalidation application is rejected
  • Once Noridian receives a new application, enrollment will be reactivated with a gap in billing (lapse in coverage) on the enrollment
    • Payment will not be made from Medicare for dates of service within this gap in billing (lapse in coverage) on the enrollment
    • Original effective date of Provider Transaction Access Number (PTAN) would be used
  • For revalidation reactivations applications received on 03/12/2019 and later, a lapse in coverage may not apply. PTAN can be effective 30 days prior to application date of receipt
    • For example:
      • Provider deactivated 03/01/2019 for non-response to revalidation
      • Revalidation reactivation application received 03/12/2019
      • PTAN effective date can go back 30 days prior to 03/12/2019 which would be 02/10/2019
      • A lapse would not be applied
      • Original effective date of PTAN would be used
  • Best way to avoid any lapse in coverage is to make sure the application is submitted prior to due date listed on data.cms.gov. Deactivation of an organization will cause no payment to be made for any members associated to the organization. A lapse in coverage will occur from date of deactivation to when Noridian receives an application to reactivate enrollment. No payment will be made during those dates. A stop billing privileges letter will be sent and access to the Noridian Medicare Portal (NMP) will be revoked

Sole Owners

  • If you are a sole owner, meaning you have type 1 and a type 2 NPI, must revalidate BOTH enrollments at same time
    • This will apply even if one of enrollments has not been asked to revalidate
  • If completing application via PECOS, must submit two separate applications. One for individual enrollment and one for group enrollment
    • In PECOS it will show as an 855I for the individual and an 855B for the group enrollment. If only one is submitted, a development request will be sent asking for the additional application
  • If submitting application via Paper, only need to send in the 855I. Make sure that group information is in section 4

Application Submission

  • The fastest and most efficient way to submit revalidation information is via Internet-based PECOS Web. Applications can also be submitted via the paper CMS-855 forms.
    • For help on how to submit these applications, view the applicable Revalidation Enrollment on Demand.
Provider Type Required Application(s) Tips
Organization

PECOS

  • After logging in, select My Associates, View Enrollments next to the enrollment the needs to Revalidate, select Revalidate in the Existing Enrollments Box. Go through application to ensure all information is correct

Paper

  • Complete all sections of CMS-855B, even if nothing has changed
  • List all current, active practice locations
  • Use boxes/fields to indicate change, add, delete, and list an effective date

Both

  • Attach or upload all supporting documentation such as IRS document and/or voided check/bank letter
Sole Owner

PECOS

  • After logging in, select My Associates, View Enrollments next to the enrollment the needs to Revalidate, select Revalidate in the Existing Enrollments Box. Go through application to ensure all information is correct

Paper

  • Complete sections 1, 2, 3, 4A-4F, 6, 8, 13, and 15 of CMS-855I, even if nothing has changed
  • List all current, active practice locations
  • Use boxes/fields to indicate change, add, delete, and list an effective date
  • Include a contracted or W-2 managing employee

Both

  • Attach or upload all supporting documentation such as Diploma, Internal Revenue Service (IRS) document, Certification and/or voided check/bank letter
Sole Proprietor

PECOS

  • After logging in, select My Associates, View Enrollments next to the enrollment the needs to Revalidate, select Revalidate in the Existing Enrollments Box. Go through application to ensure all information is correct

Paper

  • Complete sections 1, 2, 3, 4A-4E, 6, 8, 13, and 15 of CMS-855I, even if nothing has changed
  • List all reassignments, if applicable, including other Organizations, PTANs, and NPIs in which provider renders services
  • List all current, active practice locations
  • Use boxes/fields to indicate change, add, delete, and list an effective date
  • List all directors, board members, and contracted or W-2 managing employee

Both

  • Attach all supporting documentation such as Diploma, IRS document (if billing with EIN), Certification and/or voided check/bank letter
Group Member

PECOS

  • After logging in, select My Associates, View Enrollments next to the enrollment the needs to Revalidate, select Revalidate in the Existing Enrollments Box. Go through application to ensure all information is correct

Paper

  • Complete sections 1, 2, 3, 4b, 13, and 15 of CMS 855I, even if nothing has changed
  • Complete sections 1, 2, 2e, 13 and 15 of CMS 855I for Physician Assistants (PAs), even if nothing has changed
  • List all reassignments including other Organizations, PTANs, and NPIs in which provider renders services

Both

  • Attach or upload all supporting documentation such as Diploma and Certification

 

Resources

 

Last Updated Mar 21, 2019