[Federal Register: April 25, 2003 (Volume 68, Number 80)]
[Proposed Rules]
[Page 22063-22112]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr25ap03-14]
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Part III
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 420, et al
Medicare Program; Requirements for Establishing and Maintaining Medicare
Billing Privileges; Proposed Rule
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Proposed Rules
Federal Register
________________________________________________________________________
This section of the FEDERAL REGISTER contains notices to the public of
the proposed issuance of rules and regulations. The purpose of these
notices is to give interested persons an opportunity to participate in
the rule making prior to the adoption of the final rules.
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 420, 424, 489, and 498
[CMS-6002-P]
RIN 0938-AH73
Medicare Program; Requirements for Establishing and Maintaining
Medicare Billing Privileges
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
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SUMMARY: This proposed rule would require that all providers and
suppliers (other than physicians who have elected to ``opt-out'' of the
Medicare program) complete an enrollment form and submit specified
information to us, and periodically update and certify to the accuracy
of the enrollment information, to receive and maintain billing
privileges in the Medicare program. The information must clearly
identify the provider or supplier and its place of business, provide
documentation that it is qualified to perform the services for which it
is billing, ensure that it is not currently excluded from the Medicare
program, and meets any other applicable Medicare requirements. If we
determine the information submitted is incomplete, invalid, or
insufficient to meet Medicare requirements, we would have the
discretion to reject, deny, deactivate, or revoke billing privileges.
This proposed rule would implement provisions in the Medicare
statute that require the Secretary to ensure that all Medicare
providers and suppliers are qualified to provide the appropriate health
care services. These statutory provisions include requirements meant to
protect beneficiaries and the Medicare trust fund by preventing
unqualified, fraudulent, or excluded providers and suppliers from
providing services to Medicare beneficiaries or billing the Medicare
program or its beneficiaries.
DATES: We will consider comments if we receive them at the appropriate
address, as provided below, no later than 5 p.m. on June 24, 2003.
ADDRESSES: In commenting, please refer to file code CMS-6002-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission. Mail written comments (one original and
two copies) to the following address ONLY:
Centers for Medicare & Medicaid Services, Department of Health and
Human Services, Attention: CMS-6002-P, P.O. Box 8013, Baltimore, MD
21244-8013.
Please allow sufficient time for us to receive mailed comments on
time in the event of delivery delays.
If you prefer, you may deliver (by hand or courier) your written
comments (one original and two copies) to one of the following
addresses:
Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW.,
Washington, DC 20201, or Room C5-14-03, 7500 Security Boulevard,
Baltimore, MD 21244-8013.
(Because access to the interior of the HHH Building is not readily
available to persons without Federal Government identification,
commenters are encouraged to leave their comments in the CMS drop slots
located in the main lobby of the building. A stamp-in clock is
available if you wish to retain proof of filing by stamping in and
retaining an extra copy of the comments being filed).
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and could be considered late.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Michael C. Collett, (410) 786-6121.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: Comments received timely will be
available for public inspection as they are received, generally
beginning approximately 3 weeks after publication of a document, at the
headquarters of the Centers for Medicare & Medicaid Services, 7500
Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of
each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view
public comments, phone (410) 786-7197.
Copies: To order copies of the Federal Register containing this
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This Federal Register document is also available from the Federal
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Government Printing Office. The Web site address is: http://www.access.gpo.gov/nara/index.html
.
I. Background
A. General
The Medicare program, Title XVIII of the Social Security Act (the
Act), is currently the principal payer for health care for 39.2 million
enrolled beneficiaries. Under section 1802 of the Act, a beneficiary
may obtain health services from any institution, agency, or person
qualified to participate in the Medicare program. Qualifications to
participate are specified in statute and in regulations. See, for
example, sections 1814, 1815, 1819, 1833, 1834, 1842, 1861, 1866, and
1891 of the Act; and 42 CFR Chapter IV, Subchapter E, which concerns
standards and certification requirements.
Providers and suppliers furnishing services must comply with the
Medicare requirements stipulated in the Act and in our regulations.
These requirements are meant to ensure compliance with applicable
statutes, as well as to promote the furnishing of high quality care. We
and/or State Survey and Certification Agencies inspect facilities when
required, for compliance with regulatory and operational requirements
before we allow them to participate in the Medicare program.
Thereafter, either
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as part of a scheduled re-certification survey, or as a result of a
complaint or other information received that would directly affect the
provider's or supplier's business relationship with the Medicare
program or indicate non-compliance of this regulation, we will review
and re-verify the continued adherence to our requirements. The initial
certification and subsequent re-certification ensure that Medicare
requirements are met and continue to be met, and promote the
appropriate spending of the Medicare trust fund by helping to ensure
that unqualified providers and suppliers are not granted billing
privileges with the Medicare program.
Historically, a provider or supplier wishing to receive payment
from Medicare or its beneficiaries would contact a fiscal intermediary
(FI), State Survey Agency, or carrier. In compliance with sections 1816
or 1842 of the Act, as stipulated in 42 CFR Part 421, we contract with
FIs and carriers to administer payment for services and to carry out
other administrative responsibilities that the law imposes. Our
Regional Offices, State Survey Agencies, carriers and FIs use statutes,
regulations, and operating instructions as guidance when assigning
appropriate identification numbers and determining whether to grant
billing privileges in the Medicare program to providers and suppliers.
As Medicare program expenditures have grown, increasing attention
has been focused on strategies to curb improper Medicare payments by
implementing business processes and standards that safeguard the
Medicare program and its beneficiaries, while ensuring that well
qualified individuals and health care organization serve beneficiaries
as promptly as possible.
B. Specific Authority to Collect Enrollment Information
1. Various sections of the Act and the Code of Federal Regulations
require providers and suppliers to furnish information concerning the
amounts due and the identification of individuals or entities who
furnish medical services to beneficiaries before payment can be made.
Sections 1102 and 1871 of the Act allow general authority for the
Secretary to prescribe regulations for the efficient administration of
the Medicare program. Under the above authority, this proposed
regulation will require the collection of information from providers
and suppliers for the purpose of enrolling in the Medicare program and
granting privileges to bill the program for health care services
rendered to Medicare beneficiaries.
Sections 1814(a), 1815(a), and 1833(e) of the Act require the
submission of information necessary to determine the amounts due to a
provider or other person.
Section 1842(r) of the Act requires us to establish a system for
furnishing a unique identifier for each physician who furnishes
services for which payment may be made. To do so, we need to collect
information unique to that physician.
Section 1862(e)(1) of the Act states that no payment may be made
when an item or service was at the medical direction of an individual
or entity that has been excluded in accordance with sections 1128,
1128A, 1156, or 1842(j)(2) of the Act.
Section 1834(j) of the Act states that no payment may be made for
items furnished by a supplier of durable medical equipment,
prosthetics, orthotics, and supplies (DMEPOS) unless that supplier
obtains, and renews at such intervals as we may require, a billing
number.
The Balanced Budget Act of 1997 (BBA) (Public Law 105-33), section
4313, amended sections 1124(a)(1) and 1124A of the Act to require
disclosure of both the Employer Identification Number (EIN) and Social
Security Number (SSN) of each provider or supplier, each person with
ownership or control interest in the provider or supplier, any
subcontractor in which the provider or supplier directly or indirectly
has a five percent or more ownership interest, and any managing
employees. The Secretary of Health and Human Services (the Secretary)
signed and sent to the Congress a ``Report to Congress on Steps Taken
to Assure Confidentiality of Social Security Account Numbers as
Required by the Balanced Budget Act'' on January 26, 1999, with
mandatory collection of SSNs and EINs effective on or about April 26,
1999.
2. Section 31001(i)(1) of the Debt Collection Improvement Act of
1996 (DCIA) (Public Law 104-134) amended 31 U.S.C. section 7701 by
adding paragraph (c) to require that any person or entity doing
business with the Federal Government must provide their Tax
Identification Number (TIN).
3. We are authorized to collect information on the Form CMS 855
(Office of Management and Budget (OMB) approval number 0938-0685) to
ensure that correct payments are made to providers and suppliers under
the Medicare program as established by Title XVIII of the Act.
II. Current Enrollment Initiatives
For a number of years, concern about easy entry into the Medicare
program by unqualified or even fraudulent providers or suppliers has
led us to step up our efforts on a number of fronts to establish more
stringent controls on provider and supplier entry into the Medicare
system. For example, in 1993 we established the National Supplier
Clearinghouse (NSC), our contractor for enrolling suppliers of DMEPOS
in Medicare. We instituted new procedures to use validation software to
certify the existence of the listed business address for suppliers of
DMEPOS. The NSC also checked the DMEPOS supplier telephone numbers
against a national directory. This initial effort resulted in the
revocation of about 1,500 supplier billing numbers and an estimated
savings of $7 million per month to the Medicare trust fund.
In fiscal year 1998, we required site visits for all new DMEPOS
suppliers. The DMEPOS visits resulted in:
[sbull] 156 denials of new applicants, out of 159 visits; and
[sbull] 656 revocations of existing suppliers, out of 2,091 visits.
In fiscal years 1998 and 1999, our carriers and FIs submitted
proposals to conduct site visits for those provider or supplier types
that they believed would yield the greatest benefit in their regions.
After reviewing the submitted proposals, we funded 320 site visits to
various enrolling and currently enrolled Independent Diagnostic Testing
Facilities (IDTFs), skilled nursing facilities (SNFs), home health
agencies (HHAs), rural health clinics, comprehensive outpatient
rehabilitation facilities, physician groups, clinical psychologists,
and ambulance companies. The project provided useful information for
making appropriate determinations for the eligibility to bill Medicare.
In the course of these reviews--
[sbull] 219 provider numbers were authorized or maintained;
[sbull] 30 provider numbers were deactivated;
[sbull] 37 provider applications were denied; and
[sbull] 34 providers were referred to contractor fraud units.
These site visits proved valuable to some providers by helping them
to enroll in the Medicare program properly. The site visits were also
helpful to us in ensuring that we only conduct business with legitimate
providers. We believe that site visits are an important component of
successful provider enrollment. As past experience has demonstrated, in
many cases site
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visits are the only method we have to ensure that providers and
suppliers actually exist and meet the requirements to participate in
the Medicare program, particularly in the absence of State licensure or
regulation. Left unchecked, Medicare program resources and the health
of Medicare beneficiaries may be vulnerable.
III. Provisions of the Proposed Rule
This proposed rule would build on our collective experience and set
forth our standard enrollment requirements in new subpart P in Part 424
of this chapter. We are proposing that all providers and suppliers,
other than the ``opt-out'' physicians and ``opt-out'' practitioners
described below, must submit an enrollment application with specific
information to enroll in the Medicare program, obtain a Medicare
billing number, and receive Medicare billing privileges. The provisions
of this proposed rule would supplement, but not replace or nullify,
existing regulations concerning the establishment of provider or
supplier agreements, the issuance of provider or supplier billing
numbers, and payment for Medicare covered services or supplies to
eligible providers or suppliers.
Specifically, we are proposing to require that providers and
suppliers prove their qualifications and identity and submit specified
information to us before they are granted billing privileges in the
Medicare program. If the provider or supplier fails to meet the
requirements or submit the required information, we would not enroll it
in the Medicare program or, if it is currently in the program, we would
revoke its billing privileges. We believe the documentation and
associated verification methods we use to determine whether to grant a
provider or supplier billing privileges are necessary to ensure
compliance with Medicare requirements and to prevent abuse of the
Medicare program and the inappropriate use of Medicare funds. We also
believe that such requirements will not hinder qualified individuals
and organizations from enrolling or maintaining enrollment in the
Medicare program.
A. Scope and Definitions
We are proposing to establish our standard enrollment requirements
in Part 424, new subpart P. In proposed Sec. 424.500 (Scope) we are
stating that these requirements apply to all providers and suppliers
except those physicians and other eligible practitioners who have
elected to ``opt-out'' of Medicare as described in Part 405, subpart D
of our regulations.
In proposed Sec. 400.502 (Definitions) we are establishing the
definitions for several key terms used throughout subpart P. The terms
``provider'' and ``supplier'' are not defined in this subpart because
their definitions have already been established throughout 42 CFR. The
term ``provider'' is defined in both Sec. 488.1 and Sec. 400.202.
Together these sections define a provider as including a hospital, a
critical access hospital, a skilled nursing facility, a nursing
facility, a comprehensive outpatient rehabilitation facility, a home
health agency, or a hospice, that has in effect an agreement to
participate in Medicare; or a provider of outpatient physical therapy
or speech pathology services; or a community mental health center. The
term ``supplier,'' as defined in Sec. 400.202, is a physician or other
practitioner, or an entity other than a provider (as defined in
Sec. Sec. 400.202 and 488.1) that furnishes health care services under
Medicare. Section 488.1 also defines ``supplier'' to mean independent
laboratory; portable X-ray services; physical therapist in independent
practice; ESRD facility; rural health clinic; Federally qualified
health center; or chiropractor. The term ``supplier'' also includes
``indirect suppliers,'' as indicated in 45 CFR 61.3.
We define ``managing employee'' to be ``a general manager, business
manager, administrator, director, or other individual that exercises
operational or managerial control over, or who directly or indirectly
conducts the day-to-day operations of, the institution, organization,
or agency, either under contract or through some other arrangement,
regardless of whether the individual is a W-2 employee.''
Section 1124A of the Act and 42 CFR 420.204 authorize the Secretary
to collect information about ``managing employees.'' Section 1124A
incorporates by reference the following definition of ``managing
employee,'' contained in 1126(b) of the Act: ``An individual, including
a general manager, business manager, administrator, and director, who
exercises operational or managerial control over the entity, or who
directly or indirectly conducts the day-to-day operations of the
entity.'' We have found that a number of providers and suppliers are
managed by individuals that have control over the day-to-day operations
of the entity and are not ``employees.'' Some of these individuals have
been known to bill Medicare fraudulently, and are on the Office of
Inspector General (OIG) ``List of Excluded Individuals and Entities
and/or the General Services Administration'' (GSA) ``List of Parties
Excluded from Federal Procurement and Nonprocurement Programs''. These
lists are commonly referred to as the ``OIG Sanction List'' for those
parties excluded by the QIG from participation in any Federal health
care programs (as defined in section 1128B(f) of the Act), and the
``GSA Debarment List'' for those parties debarred, suspended or
otherwise excluded by other Federal agencies from participation in
Federal procurement and non-procurement programs and activities, in
accordance with the Federal Acquisition and Streamlining Act of 1994,
and with the HHS Common Rule at 455 CFR Part 76.
Extending the term ``managing employee'' to include individuals
performing managerial duties who are not technically employees would be
consistent with the legislative intent to require information on those
individuals that have effective control over a provider's or supplier's
day-to-day operations.
B. Basic Enrollment Requirement
Proposed Sec. 424.505 requires a provider or supplier to have a
valid Medicare billing number for the date a service was rendered in
order to receive payment for covered Medicare services from either
Medicare (in the case of assigned claims) or the Medicare beneficiary
(in the case of unassigned claims).
Under longstanding policy and operating procedures, any claim
submitted without an active billing number is incomplete and cannot be
processed for payment. Providers and suppliers who are not enrolled in
the Medicare program must adhere to the mandatory claims submission
rules found at Sec. 424.32(a)(1) (Basic requirements for all claims)
and section 1848(g)(1)(B) of the Act. In addition, a claim submitted
without a valid Medicare billing number would not be considered a valid
claim and would be rejected. If the mandatory claims submission
requirements are not met the provider or supplier could have sanctions
imposed as outlined in section 1848(g)(4) of the Act for failure to
file a claim as required.
C. Requirements for Obtaining a Billing Number and Medicare Billing
Privileges
To obtain a Medicare billing number and be eligible to receive
payment for Medicare covered services, providers and suppliers must
enroll in the Medicare program and meet other applicable Federal
requirements. The Medicare program, through its contractors, requires
specific identifying
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information from a provider or supplier before payment is authorized.
Our issuance of an identification number to a provider or supplier does
not automatically convey the privilege to bill Medicare. There must be
a corresponding approval of the provider or supplier as meeting all
Federal requirements to bill Medicare for the number to be an approved
and active Medicare billing number.
In new Sec. 424.510 (Form CMS 855), we propose that a provider or
supplier must submit to us the appropriate completed form CMS 855--
Provider/Supplier Enrollment Application based on the type of provider
or supplier enrolling. As part of our continuing efforts to improve the
enrollment process, the series of CMS 855 enrollment forms with
proposed revisions are being submitted with this proposed rule, to be
published in the Federal Register concurrently for review and public
comment. Some of the proposed revisions are the removal of certain data
collections from all forms in the series such as information on
clearinghouses used in claims submission, practice locations from the
CMS 855R, and a shortened attachment for ambulance companies in the CMS
855B. We have also simplified the sections for reporting owners and
managers and added instructional clarifications. The forms are
identified as follows:
[sbull] Form CMS 855A--For providers billing fiscal intermediaries.
[sbull] Form CMS 855B--For supplier organizations billing carriers.
[sbull] Form CMS 855I--For individual health care practitioners
billing carriers.
[sbull] Form CMS 855R--For individual health care practitioners to
reassign benefits to an organization.
[sbull] Form CMS 855S--For DMEPOS Suppliers billing the NSC.
The CMS 855 applications will be used to gather information on
providers and suppliers for the purpose of authorizing billing numbers
and establishing eligibility to furnish services to Medicare
beneficiaries. The information submitted will also uniquely identify
the providers and suppliers for the purpose of enumeration and payment.
OMB has approved the CMS 855 for these purposes (OMB approval number
0938-0685).
At proposed Sec. 424.510(a)(1) we are requiring that a provider or
supplier submit the following on its CMS 855: Complete and accurate
responses to all information requested within each section as
applicable to the provider or supplier type.
[sbull] Any documentation currently required by CMS under this or
other statutory or regulatory authority to uniquely identify the
provider or supplier (for example, a social security number (SSN) or a
tax identification number (TIN)).
[sbull] Any documentation currently required by CMS under this or
other statutory or regulatory authority to establish the provider or
supplier's eligibility to furnish services to beneficiaries in the
Medicare program (for example, a medical license or business license).
Under the authorities mentioned earlier in this preamble all
providers, suppliers, and other health care related individuals and
entities who will receive Medicare reimbursements, either directly or
indirectly as a result of enrolling in the Medicare program, must
furnish their SSN and/or TIN as a condition of maintaining an active
enrollment status and billing privileges. We also maintain the right to
require persons with ownership or control interests (as that term is
defined in section 1124(a)(3) of the Act) in such providers and
suppliers, and of all managing employees (as that term is defined in
section 1126(b) of the Act and at 42 CFR 420.201) of such providers and
suppliers to also furnish their SSN and/or TIN as a condition of
enrollment.
We are proposing that providers and suppliers must certify that all
the information furnished on the CMS 855 is accurate, complete,
truthful, and verifiable. Any concealment or misrepresentation of
material information in these applications constitutes a violation of
this regulation and may result in the rejection, denial, or revocation
of the provider or supplier's enrollment and billing privileges. In
addition, such concealment or misrepresentation will be referred to the
Office of Inspector General for investigation and appropriate criminal,
civil or administrative action.
In Sec. 424.510(a)(2), we propose that the CMS 855 must be signed
by an individual who has the authority to bind the provider or supplier
both legally and financially to the requirements set forth in subpart
P. This person must be the individual practitioner or have an ownership
or control interest in the provider or supplier, as that term is
defined in section 1124(a)(3) of the Act, such as, be the provider's or
supplier's general partner, chairman of the board, chief financial
officer, chief executive officer, president, or hold a position of
similar status and authority within the provider or supplier
organization. The signature would attest that the information submitted
is accurate, complete, and truthful, and the provider or supplier is
aware of, and will abide by, Medicare rules and regulations.
To ensure that the individual signing the form can bind the
enrollee from a financial and legal standpoint, we would require the
following persons to sign the enrollment form:
[sbull] In the case of an individual practitioner, the applying
practitioner.
[sbull] In the case of a sole proprietorship, the applying sole
proprietor.
[sbull] In the case of a corporation, partnership, group, limited
liability company (LLC), or other organization, an authorized official,
as defined in Sec. 424.502. When an authorized official signs the
application, the signed application is considered binding upon the
corporation partnership, organization, group, or LLC (hereafter
referred to in this section as an organization), as applicable. This
requirement establishes accountability for the accuracy of the
information on the CMS 855 and ensures that the provider or supplier is
committed to taking the necessary steps to comply with these
requirements. In addition to the signature requirements, we are
establishing a delegation of authority. As required above, the original
and all subsequent revalidation CMS 855s submitted by an organization
to enroll or maintain enrollment in the Medicare program must have
certification statements signed by the current authorized official on
file with Medicare. Any subsequent updates or changes made outside the
enrollment or revalidation process may be signed by a delegated
official of the enrolled organization.
The delegated official must be a W-2 managing employee of the
provider or supplier who is enrolling in, or currently enrolled in, the
Medicare program, or be an individual with ownership or control
interest in the provider or supplier.
The delegation of signature authority will not apply for individual
practitioners and sole proprietors. All CMS 855s submitted by
individual practitioners or sole proprietors must be signed by the
enrolling/enrolled individual.
As proposed in Sec. 424.510(a)(2)(ii), the delegation of authority
must be assigned by the authorized official currently on file with us
or the authorized official who has signed the CMS 855 currently being
submitted to us. All delegations of authority must be submitted via the
CMS 855 and must include the title of each person delegated authority
to update or change the organization's enrollment information. The
assignment
[[Page 22068]]
must be signed by both the authorized official currently on file with
Medicare and the person(s) being delegated as an official of the
organization. The signature of the delegated official will bind the
organization both legally and financially, as if the signature was that
of the authorized official. Once the delegation of authority is
established, the signatures of the authorized official or the assigned
delegated official(s) will be the only acceptable signature(s) on
correspondence to report updates or changes to the enrollment
information.
As proposed in Sec. 424.510(b), we would verify initial compliance
with Medicare statutes and regulations before providers and suppliers
are granted billing privileges, as well as on a continuing basis. The
verifications would be based on information submitted by providers and
suppliers on the CMS 855.
We are proposing in Sec. 424.510(c) that providers and suppliers,
including those that are deemed to meet Medicare health and safety
requirements by virtue of their accreditation by a national accrediting
body, must attest via signature on the CMS 855 that they have met all
the requirements set forth in this regulation before they are granted
billing privileges. Those providers for which certification is required
must meet the provisions of 42 CFR Part 488 concerning mandatory State
survey and certification requirements. Providers also must have
completed a provider agreement in accordance with 42 CFR Part 489,
which specifies the requirements for provider agreements. In addition,
in paragraphs (d) and (e) in proposed Sec. 424.510, we are requiring
that providers and suppliers must be operational as defined in Sec.
424.502 and must meet additional requirements that apply to both
enrolling and currently enrolled providers and suppliers before
receiving a Medicare billing number and becoming eligible for Medicare
payments.
In recognition of the effectiveness of site visits, we are
proposing, at Sec. 424.510(f), a plan for integrating site visits as
part of our enrollment validation process and general program oversight
activities. We are reserving the right to perform on-site inspections
of the provider or supplier when we deem necessary to ensure compliance
with Medicare enrollment requirements. For certain providers and
suppliers this practice has always been the case (for example,
Hospitals, Skilled Nursing Facilities (SNFs), and Home Health Agencies
(HHAs)), but we are extending this to all providers and suppliers when
deemed necessary based on questionable enrollment information. Site
visits for enrollment purposes will not affect those site visits
performed for establishing conditions of participation. Our proposed
site visits and on-site inspections to ensure compliance with Medicare
enrollment requirements are unrelated to the compliance-related site
visits already being conducted by the OIG. After a provider or supplier
enters into a corporate integrity agreement with the OIG, usually as
the result of a Federal False Claims Act settlement, the OIG may
conduct a site visit as part of its work in monitoring the provider or
supplier's compliance with the terms of the corporate integrity
agreement. Upon the provider or supplier's successful completion of the
enrollment process, including State survey and certification,
accreditation, and approval of the CMS 855, we will grant Medicare
billing privileges and issue a billing number if one has not already
been issued. The effective date for reimbursement of Medicare covered
services will continue to be determined based on current Medicare
regulations and policy based on the type of provider or supplier
submitting claims. Currently, the effective dates for reimbursement can
be found at Sec. 489.13 for providers and suppliers requiring State
survey or certification or accreditation, Sec. Sec. 424.5 and 424.44
for non-surveyed or certified/accredited suppliers, and Sec. 424.57
and section 1834(j)(1)(A) of the Act for DMEPOS suppliers. For those
providers and suppliers seeking accreditation from a CMS approved
accreditation organization, the effective date for reimbursement will
be the later of the date accreditation was received or the final
approval of the CMS 855. Based on the regulations cited above, CMS will
not issue Medicare billing numbers or grant Medicare billing privileges
retroactive to the date that the provider or supplier received final
approval of their enrollment application (CMS 855). We are proposing to
use this process because we believe there is a relationship between
fulfilling the requirements stipulated in the Medicare program statutes
and related laws, the integrity of the provider and supplier, the
quality of care furnished to Medicare beneficiaries, and the confidence
of the public in the Medicare program.
In the future there will be universal provider and supplier
numbers, as required by the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), for uniquely identifying a provider
or supplier and for purposes of billing all health plans, including
Medicare and Medicaid. When this universal number is in place, it will
still be necessary for providers and suppliers to apply for enrollment
as a Medicare provider or supplier and be granted Medicare billing
privileges.
D. Requirements for Reporting Changes and Updates To, and the
Periodic Revalidation of, Medicare Enrollment Information
We propose that, under new Sec. 424.515, a provider or supplier
must update its enrollment information, and re-certify as to its
accuracy when any changes are made. We will also periodically require
revalidation of the enrollment information by all providers and
suppliers when enrollment information has aged over three years. The
revalidation process will ensure that we have complete and current
information on all Medicare providers and suppliers and ensure
continued compliance with Medicare requirements. In addition, this
process further ensures that Medicare beneficiaries are receiving
services furnished only by legitimate providers and suppliers, and
strengthens our ability to protect the Medicare trust fund.
The accuracy of the data describing the individuals or
organizations with whom we do business is essential to efficient and
effective operation of the Medicare program. For this reason, we are
proposing at Sec. 424.520(b), that individuals and organizations are
responsible for updating their CMS 855 information to reflect any
changes in a timely manner. We define timely as meaning within 90 days,
with the exception of a change in ownership or control of the provider
or supplier which must be reported within 30 days. Failure to do so may
result in deactivation or even revocation of their billing privileges.
We will determine, upon receipt of any changes, if continued
enrollment in the Medicare program is proper. We expect that in the
vast majority of cases, updates or changes will not affect the status
of the provider or supplier. Where it does, we will follow the
revocation procedures outlined later in this rule.
When no such changes or updates have been reported or submitted for
a period of time, we believe that it is prudent to take steps to
confirm the continued validity of the information that was previously
submitted. We believe that this revalidation of enrollment information
should be accomplished in a way that minimizes the reporting burden to
the provider or supplier, but also mitigates the risk to the program of
maintaining incomplete or inaccurate information that materially
affects the relationship of the program to the provider or supplier.
For
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this reason, we are proposing that we would initiate a revalidation
process for any individual or organization that has not submitted a
change or update within the last three years. Routine revalidation may
or may not be accompanied by site visits.
We reserve the right to perform non-routine revalidation and
request the provider or supplier to re-certify as to the accuracy of
the enrollment information when warranted to assess and confirm the
validity of the enrollment information. Non-routine revalidation may be
triggered as a result of information indicating local problems,
national initiatives, fraud investigations, complaints from
beneficiaries, or other reasons that cause us to question the integrity
of the provider or supplier in its relationship with the Medicare
program. Like routine revalidation, non-routine revalidation may or may
not be accompanied by site visits.
We are proposing that the revalidation of enrollment information
occur no more than once every 3 years. We reserve the right to adjust
this schedule if we determine that revalidation should occur on a more
frequent basis due to complaints or evidence we receive indicating non-
compliance with the Medicare statute or regulations by specific
provider or supplier types. The schedule may also be on a less frequent
basis if we determine that the integrity of and compliance with the
Medicare statute and regulations by specific provider or supplier types
indicates that less frequent validation is justified. If such a change
were to occur, we will notify all affected providers and suppliers in
writing at least 90-days in advance of implementing the change. We will
continue to revalidate enrollment information for Ambulance Service
Suppliers in accordance with regulations set forth at Sec.
410.41(c)(2) (Requirements for ambulance suppliers), and DME suppliers
will continue to renew enrollment in accordance with regulations set
forth at Sec. 424.57(e) (Special payment rules for items furnished by
DMEPOS suppliers and issuance of DMEPOS supplier billing numbers). We
specifically invite further comments on the initially proposed
revalidation time frame.
We propose at new Sec. 424.515(a) that during the revalidation or
update process all providers and suppliers must attest by way of a
signed certification statement that the requirements set forth in this
regulation continue to be met. This requirement will not only ensure
continued accuracy of the CMS 855 information, but will also ensure
that the provider or supplier is committed to taking the necessary
steps to maintain compliance with these requirements. However, it
should be noted that periodic validation of a provider or supplier's
Medicare enrollment information is separate from the survey
requirements for the provider or supplier as contained in 42 CFR
chapter IV, subchapter E (standards and certification).
We would require the information submitted for revalidation or
update to include any new or changed documentation as required by CMS
under this or other statutory or regulatory authority that identifies
the provider or supplier, and any documentation as required by CMS
under this or other statutory or regulatory authority required to
verify the provider or supplier's continued eligibility to furnish
services to beneficiaries in the Medicare program. We would also
require a signature on the completed CMS 855 that meets the
requirements proposed in Sec. 424.510(a)(3).
We are also requiring at proposed Sec. 424.515(b) that a provider
or supplier must submit a CMS 855 with complete information for
revalidation within 60 calendar days of our revalidation notification.
For those providers and suppliers who initially enrolled in the
Medicare program via the CMS 855, we would furnish a copy of the
information currently on file for their review, request that they make
any changes, and certify via their signature that the information is
accurate, complete, and truthful. We estimate that completion of the
form will require on average 8 hours. Therefore, we believe 60 days is
a reasonable time frame for providers and suppliers to comply.
As part of the revalidation process, we would verify the accuracy
of the reported information on the applicable CMS 855. Because survey
and certification are independent program requirements distinct from
the revalidation of enrollment information requirements set forth in
this subpart, we are stating in proposed Sec. 424.515(c) that new
surveys or certifications are not required for the revalidation
process. However, providers must continue to meet the provisions of 42
CFR Part 488 concerning mandatory State survey and certification
requirements. When applicable, providers must also have completed a
provider agreement in accordance with 42 CFR Part 489, which specifies
the requirements for provider agreements. We would also reserve the
right, at proposed Sec. 424.575(d), to perform on-site inspections, to
further ensure compliance with Medicare requirements.
We understand that the resubmission and update of enrollment
information will place an obligation on providers and suppliers. We are
considering a variety of ways to minimize the burden of this important
information collection and verification provision (including the use of
Internet technology).
To reduce the burden when reporting updates or changes in the
future, we will require that all providers and suppliers currently in
the Medicare program complete, in its entirety, the CMS 855 at least
once if they have not done so in the past. This will ensure that we
have the most current and accurate information, and will allow us to
make full use of electronic data submissions via the Internet. By
having a complete enrollment record, we will be able to produce and
transmit or mail the CMS 855, pre-complete with previously reported
information, to the provider or supplier for their review and signature
certification as to the continued accuracy of the information and
require them to update any information that is no longer current.
E. Additional Provider and Supplier Requirements for Enrolling and
Maintaining Active Enrollment Status in the Medicare Program
In new Sec. 424.520, we are specifying the additional requirements
that providers and suppliers must meet to enroll or maintain enrollment
in the Medicare program. The provider or supplier must certify that it
meets, and continues to meet, the following requirements:
[sbull] Compliance with Title XVIII of the Act (Medicare Statutory
Provisions) and applicable regulations.
[sbull] Compliance with all applicable Federal and State licensure
and regulatory requirements that apply to the specific provider or
supplier type that relate to providing health care services.
[sbull] Not employing or contracting with individuals or entities
excluded from participation in Federal Health care programs for the
provision of items and services reimbursable under these programs in
violation of section 1128A(a)(6) of the Act.
The OIG program exclusion regulations were amended effective August
25, 1995, in accordance with the Federal Acquisition Streamlining Act
of 1994 (FASA), and with the HHS Common Rule at 45 CFR part 76, to
explain the scope and effect of an OIG exclusion. In accordance with
the FASA, government-wide reciprocal effect will be given by all
Federal
[[Page 22070]]
agencies to an administrative sanction imposed by any Federal agency.
Specifically, the law provides that: ``No agency shall allow a party to
participate in any procurement and non-procurement activity if any
[other] agency has debarred, suspended, or otherwise excluded, that
party from participation in a procurement or non-procurement
activity.'' (FASA, section 2455). Therefore, consistent with FASA, its
implementing regulation, and OIG regulations (42 CFR 1001.1901(b)), we
would deny or revoke enrollment (revocation effective on the date of
the exclusion) if the provider or supplier is subject to an OIG
exclusion, or is debarred, suspended or otherwise excluded by any other
Federal health care program or agency.
F. Rejection of a Provider or Supplier's CMS 855 for Medicare
Enrollment
In new Sec. 424.525, we propose that if a provider or supplier
enrolling in the Medicare program for the first time fails to furnish
complete information on the CMS 855, or fails to furnish missing
information or any necessary supporting documentation as required by
CMS under this or other statutory or regulatory authority within 60
calendar days of our request to furnish the information, we would
reject the provider or supplier's CMS 855 application. Rejection will
not occur if the provider or supplier is actively communicating with
CMS to resolve any issues regardless of any timeframes.
Upon notification of a rejected CMS 855, the provider or supplier
must again begin the enrollment process by completing and submitting a
new CMS 855 and all applicable documentation. We are specifying in
Sec. 424.525(b) that the new form must also update any information
that is different from that originally submitted. This will ensure that
we have the most recent information about the provider or supplier. The
enrollment process would culminate in the granting of billing
privileges, or denial or rejection of the application.
G. Denial of Enrollment
We would deny enrollment in the Medicare program to providers or
suppliers whom we determine to be ineligible. Providers and suppliers
who are denied enrollment would not receive Medicare billing
privileges. In Sec. 424.530(a) we are proposing that a provider or
supplier applying for enrollment in the Medicare program may be denied
enrollment for the following reasons:
[sbull] Under Sec. 424.530 (a)(1), enrollment may be denied if the
provider or supplier were found not to be in compliance (for example,
failure to furnish required documentation, lack of qualified practice
location) with the Medicare enrollment requirements applicable to the
type of provider or supplier enrolling, unless the reason for non-
compliance were corrected or the provider or supplier has submitted a
plan of corrective action as outlined in Part 488 and under section
1812(h)(2)(c) of the Act.
[sbull] In Sec. 424.530(a)(2) we propose that enrollment may also
be denied if: (A) the provider or supplier, or any owner, managing
employee, authorized or delegated official; or (B) any supervising
physician, medical director, or other health care personnel furnishing
Medicare reimbursable services who is required to be reported on the
providers' or suppliers' CMS 855--(for example, an ambulance crew
member.)
[sbull] Is excluded from the Medicare, Medicaid and any other
Federal health care programs, as defined in Sec. 1001.2, in accordance
with Sec. 1001.1901(a);
[sbull] Is debarred, suspended, or otherwise excluded from
participating in any other Federal procurement or non-procurement
activity in accordance with FASA section 2455; (See HHS Common Rule
provisions that discuss the effect of a program exclusion under Title
XI of the Act, as well as other Federal agency debarments, suspensions,
and exclusions found at 45 CFR 76.100(c) and (d)).
We are required to ensure that no payments are made to any
providers or suppliers who are excluded from participation in the
Medicare program under authorities found in sections 1128, 1156, 1862,
1867, and 1892 of the Act, or who are debarred, suspended or otherwise
excluded as authorized by FASA. This includes any individual, entity,
or any provider or supplier that arranges or contracts with (by
employment or otherwise) an individual or entity that the provider or
supplier knows or should know is excluded from participation in a
Federal health care program for the provision of items or services for
which payment may be made under such a program (section 1128A(a)(6) of
the Act), and any provider or supplier that has been debarred,
suspended, or otherwise excluded from participation in any other
Executive Branch procurement or non-procurement programs or activity
(FASA, section 2455).
Therefore, when an individual or entity is excluded by the OIG
under section 1128 of the Act, the exclusion is applicable to
participation in all Federal health care programs (including Medicare
and Medicaid as defined in section 1128B(f) of the Act). In addition,
section 1862(e) of the Act prohibits the Secretary from paying for
items and services furnished by excluded individuals. We believe that
our general authorities, in combination with the prohibition against
paying for items or services furnished by excluded individuals,
provides authority for us to deny enrollment unless a provider or
supplier terminates its relationship with the relevant individual. The
denial would remain effective until that provider, supplier, managing
employee, or an authorized or delegated official; or a medical
director, supervising physician, or other health care personnel
furnishing Medicare reimbursable services, is no longer excluded or
sanctioned. Section 424.530(b)(3) also provides that the denial may be
within 30 days of the denial notification.
We also propose, in Sec. 424.530(a)(3), that we may deny
enrollment in the Medicare program if the provider or supplier, or any
owner of the provider or supplier, has been convicted of a Federal or
State felony offense that we determine to be detrimental to the best
interests of the Medicare program or its beneficiaries. This authority
is afforded to us in many of the HIPAA fraud and abuse provisions and
section 4302 of the BBA. In making assessments, we are proposing to
include any felony convictions from the last 10 years or more. In
addition, we will consider the severity of the underlying offense.
Felonies that we determine to be detrimental to the best interests
of the Medicare program or its beneficiaries include:
[sbull] Within the last 10 years or more preceding enrollment or
revalidation of enrollment, crimes against persons, such as rape,
murder, kidnapping, assault and battery, robbery, and other similar
crimes for which the individual was convicted, including guilty pleas
and adjudicated pre-trial diversions. We believe it is reasonable for
the Medicare program to question the ability of the individual or
entity with such a history to respect the life and property of program
beneficiaries.
[sbull] Within the last 10 years or more preceding enrollment or
revalidation of enrollment, financial crimes, such as extortion,
embezzlement, income tax evasion, making false statements, insurance
fraud and other similar crimes for which the individual was convicted,
including guilty pleas and adjudicated pre-trial diversions. We believe
it is reasonable for the Medicare program to question the honesty and
integrity of the individual or entity with such a history in providing
services and
[[Page 22071]]
claiming payment under the Medicare program.
[sbull] Within the last 10 years or more preceding enrollment or
revalidation of enrollment, 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.
[sbull] Any felonies referred to in section 1128 of the Act.
Under section 1128(a) of the Act, the Secretary must exclude
individuals or entities convicted of certain crimes, such as program-
related crimes, crimes related to patient abuse or neglect, and
conviction of a felony related to health care fraud or controlled
substances. In addition, the Secretary has authority to exclude
individuals and entities for other adverse actions including when an
individual or entity is owned or controlled by a sanctioned or
convicted individual, in accordance with section 1128(b)(8) of the Act.
In cases where the provider or supplier is not a convicted
individual but, rather, has an ownership or management relationship
with a convicted or excluded individual, that provider or supplier may
also be subject to civil monetary penalties (section 1128A(a)(6) of the
Act). In addition, we may deny or revoke billing privileges if such a
relationship exists. However, the denial may be reversed if, within 30
days of the denial notification, the provider or supplier terminates
its ownership or management relationship with the convicted or excluded
individual or organization. We specifically invite further comments on
our approach to treating convicted felons, and any impact that may have
on access to care for Medicare beneficiaries.
We propose in Sec. 424.530(a)(4) that we may deny enrollment if
the provider or supplier has deliberately submitted false or misleading
information on their CMS 855 to gain enrollment in the Medicare
program. Offenders may be subject to fines or imprisonment, or both, in
accordance with current law and regulation.
In Sec. 424.530(a)(5) we propose possible denial of enrollment
where there are repeated instances in which, upon onsite review or
other reliable evidence, we do not find present those licensed medical
professionals required under the Medicare statute or regulations to
supervise treatment or provide Medicare covered services for Medicare
patients; or we determine that the provider or supplier is not
operational to furnish Medicare covered services or supplies.
As outlined in proposed Sec. 424.530(b), if the denied provider or
supplier appeals the decision, and the denial is upheld, that provider
or supplier may submit a new CMS 855 after we notify it that the
original determination has been upheld. If the provider or supplier did
not appeal the determination, it may submit a new CMS 855 when the time
frame for appeal rights has lapsed. We are proposing this latter
requirement to prevent administrative difficulties that might result in
processing two enrollment forms if a new one is submitted during the
time period when the provider or supplier may appeal an initial denial.
Medicare enrollment denials will impact the provider or supplier on
a national scale. In proposed Sec. 424.530(c), we state that when a
provider or supplier is denied enrollment in Medicare, we will review
all other related Medicare enrollment files that the denied provider or
supplier has an association with (for example, as an owner or managing
employee) to determine if the denial warrants an adverse action of the
associated Medicare provider or supplier.
H. Revocation of Enrollment and Billing Privileges from the Medicare
Program
Revocation occurs when an enrolled provider or supplier's billing
privileges are terminated. In proposed Sec. 424.535, we outline the
causes for revocation and what a provider or supplier would need to do
to re-enroll in the Medicare program after revocation. In considering
whether to revoke enrollment and billing privileges in the Medicare
program, we would consider the severity of the offenses, mitigating
circumstances, program and beneficiary risk if enrollment continued,
possibility of corrective action plans, beneficiary access to care, and
any other pertinent factors.
In general, we propose revocation criteria that are similar to our
reasons for denial of initial Medicare program enrollment. In Sec.
424.535(a)(1) we propose that a provider or supplier's enrollment and
billing privileges may be revoked if, at any time, it is determined to
be out of compliance with the Medicare enrollment requirements outlined
in subpart P including failure to report changes to enrollment
information timely or failure to adhere to corrective action plans, and
has not corrected the problem within 30 days of notice of non-
compliance or submitted a plan of corrective action as cited earlier.
We are providing that we may request additional documentation from the
provider or supplier to determine compliance if adverse information is
received or otherwise found concerning the provider or supplier. If
requested documentation as required by CMS under this or other
statutory or regulatory authority is not submitted within 30 calendar
days of our request, we would immediately begin revocation proceedings.
If the documentation is received timely, we would review and verify the
information to determine if we should proceed with the revocation.
Providers requiring State survey and certification would continue to
receive payment during the data verification review under current
regulations found at Part 488 and under section 1819(h)(2)(c) of the
Act. Providers and suppliers not subject to State survey and
certification may have its payments suspended during the data review.
We are also proposing that we may revoke a provider or supplier's
billing privileges if the provider or supplier establishes:
[sbull] Repeated instances in which, upon onsite review or other
reliable evidence, we do not find present those licensed medical
professionals required under the Medicare statute or regulation to
supervise treatment of, or to provide Medicare covered service for,
Medicare patients. Additional proposed reasons that may result in the
revocation of billing privileges in Sec. 424.535(a) include the
following:
[sbull] In accordance with section 1862(e)(1) and (2) of the Act,
the provider or supplier, any owner, managing employee, authorized or
delegated official, supervising physician or other health care
personnel who must be reported on the CMS 855 (for example, ambulance
crew member), of the provider or supplier, becomes excluded from the
Medicare, Medicaid or any other Federal health care programs, as
defined in Sec. 1001.2, in accordance with section 1128 or 1156 of the
Act, or is debarred, suspended or otherwise by any Federal health care
program or agency.
[sbull] The provider or supplier, or any owner of the provider or
supplier, is convicted of a Federal or State felony offense that we
determine to be detrimental to the best interests of the program as
outlined in ``Denial of Enrollment'' above.
[sbull] The provider or supplier certified as ``true'' deliberately
submitted false or misleading information on the CMS 855 in order to
enroll or maintain enrollment in the Medicare program. (Offenders may
be subject to criminal or civil prosecution, in accordance with current
laws and regulations).
[sbull] Upon onsite review, we determine that the provider or
supplier is no longer operational to furnish Medicare covered services
or supplies.
[[Page 22072]]
[sbull] The provider or supplier fails to furnish complete and
accurate information on the CMS 855 and any applicable documentation
within 60 calendar days of our notice to re-certify its enrollment
information.
[sbull] The provider or supplier knowingly sells to or allows
another individual or entity to use its billing number.
In addition to the revocation of the provider's or supplier's
billing privileges, we propose at Sec. 424.535(b) that any provider
agreement in effect at the time of revocation will also be terminated
effective with the date of revocation. We do not feel it would be
prudent for CMS to maintain an active provider agreement for a provider
or supplier whose business relationship with Medicare was adverse
enough as to cause the revocation of their billing privileges. Section
1866(b)(2)(A) of the Act states that the Secretary may terminate a
provider agreement after the Secretary ``has determined that the
provider fails to comply substantially with the provisions of Title
XVIII.'' We will amend Sec. Sec. 489.53 and 498.3 to reflect this
proposal.
In new Sec. 424.535(c) we propose that upon notification of the
revocation of its billing number, if the provider or supplier seeks to
re-establish enrollment and billing privileges in the Medicare program
(either after the appeals process is exhausted or in place of the
appeals process), then the provider or supplier must complete and
submit a new CMS 855 as a new provider or supplier and applicable
documentation. Providers must be re-surveyed or re-certified by the
State survey agency as a new provider and must establish a new provider
agreement with our Regional Office.
If the billing privileges are revoked due to the adverse activity
of an individual or organization other than the provider or supplier,
the revocation may be reversed if the provider or supplier terminates
their business relationship with the individual or organization that
was responsible for the revocation within 30 days.
As with a denial of Medicare enrollment, revocations would impact
the provider or supplier on a national scale. As proposed in Sec.
424.535(d), if a provider or supplier's billing privileges are revoked,
we would review all other related Medicare enrollment files that the
revoked provider or supplier has an association with (for example, as
an owner or managing employee) to determine if the revocation warrants
an adverse action of the associated Medicare provider or supplier.
I. Deactivation of Medicare Billing Privileges
When a provider or supplier's billing number is deactivated,
billing privileges have been temporarily suspended, but can be restored
upon the submission of updated or re-certified information. In new
Sec. 424.540, we propose to deactivate a provider or supplier's
Medicare billing number if no Medicare claims are submitted for 2
consecutive calendar quarters (6 months) unless current policy or
regulations specify otherwise for specific provider or supplier types.
Our current policy requires deactivation of billing numbers after 4
consecutive calendar quarters (12 months) of no claim submissions. We
are including this reduction to the current requirement because we are
aware of a number of program integrity issues related to inactive
Medicare billing numbers. We wish to prevent, for example, questionable
businesses from deliberately obtaining multiple numbers so that they
could keep one ``in reserve'' in the event their practices result in
suspension of claims payment under their active number. We also wish to
prevent fraudulent entities from obtaining information about
discontinued providers or suppliers, for example, using the Medicare
billing number of a deceased physician. While we are proposing to use 6
months of no billing as a criteria for deactivation, we are seeking
comments on the feasibility and reasonableness of this time frame. We
are interested in receiving comments on whether this time frame should
apply to all categories of providers and suppliers, or whether there
should be a special process for categories of providers and suppliers
that would have reason to bill Medicare infrequently.
We are also proposing to deactivate a billing number if we discover
changes to the information provided on the provider or supplier's CMS
855 that were not reported within 90 days of the change. This includes,
but is not limited to, changes to billing services, a change in the
practice location, or a change of any managing employee. A change in
ownership or control must be reported within 30 calendar days.
Deactivation of Medicare billing privileges is considered a
temporary action to protect the provider or supplier from misuse of
their billing number and to also protect the Medicare trust fund from
unnecessary overpayments. The temporary deactivation of a billing
number will not have any effect on a provider or supplier's
participation agreement or conditions of participation.
In proposed Sec. 424.540(b), we state that a provider or supplier
whose billing number has been deactivated for any reason other than
non-submission of a claim for 6 months and who wants to reactivate its
Medicare billing number must complete and submit a new CMS 855. Those
providers and suppliers whose billing number has been deactivated after
non-submission of a claim must re-certify that the enrollment
information current on file with Medicare is correct before the claim
will be paid. In addition, the provider or supplier must meet all
current Medicare requirements in place at the time of the re-
activation. The provider or supplier must also be prepared to submit a
valid claim or risk subsequent deactivate of their billing number. Once
notified, we will give all reactivations of Medicare billing numbers
priority handling to ensure expedient payment of claims. Reactivation
of a Medicare billing number would not require re-survey or
certification by State agency, or the establishment of a new provider
agreement.
J. Provider and Supplier Appeal
In new Sec. 424.545, we propose that a provider or supplier that
has been denied enrollment in the Medicare program, or whose enrollment
has been revoked, may appeal our decision in accordance with our
regulations at Part 405, Subpart H, for suppliers or Part 498, Subpart
A, for providers. CMS is currently drafting a single regulatory appeals
process for all providers and suppliers denied or revoked from
participation in the Medicare program. In keeping with current policy,
we also propose that no payments will be made during the appeals
process. If the provider or supplier is successful in overturning a
denial or revocation, unpaid claims for services furnished during the
overturned period may be resubmitted.
In addition, we propose in new Sec. 424.545(b) that a provider or
supplier whose billing privilege has been deactivated may file a
rebuttal using procedures found at Sec. 405.74.
K. Prohibitions on the Sale or Transfer of Billing Privileges
We propose in new Sec. 424.550 that a provider or supplier would
be prohibited from selling its Medicare billing number to any
individual or entity, or allowing another individual or entity to use
its Medicare billing number. Similarly, we would prohibit a provider or
supplier from transferring its Medicare billing privileges to any
individual or entity, except during a change in ownership, as stated
below. A
[[Page 22073]]
provider or supplier does not have independent authority to sell or
transfer any billing number issued or the billing privileges granted
with the billing number assigned.
We propose this policy because only we and our agents have the
authority to issue Medicare billing numbers and grant Medicare billing
privileges. These numbers are issued only after the information about
the provider or supplier collected on the CMS 855 is verified. Because
it is used to uniquely identify a provider or supplier, the Medicare
billing number we issue is solely for use by the specific provider or
supplier to whom it was issued.
In the case of a provider or supplier undergoing a change of
ownership as described in part 489 subpart A, we would require at Sec.
424.550(b) that a CMS 855 be completed and submitted by both the
current owner and the new owner before the completion of the ownership
change. Failure of the current owner to submit the CMS 855 prior to the
change of ownership may result in sanctions and/or penalties, after the
date of ownership change, in accordance with Sec. Sec. 424.520,
424.540, and 489.53. Failure of the new owner to submit the CMS 855
prior to the change of ownership may result in the deactivation of the
Medicare billing number until the CMS 855 has been submitted.
We may deactivate a Medicare billing number at any time before
final transference of the provider agreement to the new owner. This may
occur as a result of the submission of a CMS 855 with material
omissions, or preliminary information received or determined by us that
makes us question whether the new owner will ultimately be granted a
final transference of the provider agreement. This allows us the right
to ensure that billing privileges are given only to a new owner for
which we have adequate information to, at a minimum, determine that the
new owner should have billing privileges prior to the complete
validation of their CMS 855 and the transfer of the provider agreement.
We understand that not all enrollment information is available
before the change of ownership. We will work with the new owner(s) to
ensure a seamless transition, but it is the provider's or supplier's
responsibility to report this and any other changes to us to prevent us
from imposing any adverse action against it.
For those providers and supplier not covered by Part 489, any
change in the ownership or control of the provider or supplier must be
reported on the CMS 855 within 90 days of the change as noted in Sec.
424.540(a)(2). Generally, a change of ownership that also changes the
tax identification number will require a new CMS 855 from the new
owner.
L. Payment Liability
In new Sec. 424.555, we propose that any expenses for services
furnished to a Medicare beneficiary by those categories of suppliers
covered by section 1834 of the Act (that is, suppliers of DMEPOS) are
the responsibility of that supplier if the supplier has been denied
Medicare billing privileges. We further propose that no payment may be
made for covered services furnished to a Medicare beneficiary by a
provider or supplier whose billing privileges have been deactivated or
revoked. The Medicare beneficiary will have no financial responsibility
for this type of expense, and the provider or supplier must refund on a
timely basis any amounts collected from the beneficiary for those
covered services.
We are proposing these provisions because a provider or supplier
who fails to provide valid enrollment information, or who is not a
valid provider or supplier type under the Medicare program, cannot be
verified as a legitimate provider or supplier for purposes of this
rule. Claims or bills submitted for covered Medicare services must have
an active Medicare billing number. Claims or bills submitted by a
provider or supplier who is not properly enrolled, and does not have an
active Medicare billing number, would be considered incomplete and
would be returned. The provider or supplier would then be in violation
of the mandatory claims submission requirements and could be fined for
each occurrence. An incomplete claim returned for this reason would not
be afforded appeal rights for the provider or supplier. However, as
described earlier, a provider or supplier may appeal a denial or
revocation of enrollment in accordance with regulations elsewhere in
this subpart.
Sections 1802(b), 1834(j), 1866, and 1870 of the Act, provide
Medicare beneficiaries with certain protections against liabilities
imposed by providers and suppliers. In section 1834(j)(4), for example,
the statute protects the beneficiary against demands for payment for
covered Medicare services by certain categories of suppliers that have
not been granted Medicare billing privileges. Section 1866 of the Act
prohibits providers that have entered into agreements described in that
section from charging the beneficiary for covered items or services
that are not paid by Medicare because the provider has failed to comply
with certain requirements. Furthermore, section 1802(b) of the Act,
which sets forth a variety of criteria under which physicians and
practitioners may enter into private contracts with Medicare
beneficiaries, provides for additional beneficiary protection. Section
1870 provides that, except under certain circumstances, any payment to
a provider of services with respect to items or services furnished
shall be considered a payment to the individual, but that the
individual will not be liable for overpayment to the provider where the
individual is without fault.
In addition, section 1128A(a)(6) of the Act provides for criminal
penalties for providers and suppliers having knowledge of events
affecting the right to benefit or payment, and concealing or failing to
disclose such an event with an intent to fraudulently secure benefit or
payment when it is not authorized.
IV. Data Requested on the CMS 855 and Its Iterations
Because we are intending to use the CMS 855 series of forms as the
principal information collection instrument, we are providing the
following information about the data requested on the CMS 855 forms. In
addition to the legal authority already cited in this preamble, the
following additional provisions of the statute grant us the authority
to collect the information required to complete the CMS 855:
[sbull] Section 1814(a) of the Act states that payment for services
furnished to an individual may only be made to providers eligible under
section 1866 and only if a written request is filed in such a form and
manner as the Secretary may prescribe.
[sbull] Sections 1815(a) and 1833(e) of the Act authorize the
Secretary to withhold Medicare payments until the provider or supplier
furnishes such information as may be necessary to determine amounts
due.
[sbull] Section 1866(a)(1) of the Act establishes provider
agreement requirements; including a requirement not to charge the
beneficiary (except as provided in section 1866(a)(2)) for items or
services for which the beneficiary would have been entitled to have
payment had the provider complied with procedural requirements.
A. Information Collection on the CMS 855
Since its inception in April 1996, the CMS 855 has been revised
three times, in May 1997, January 1998, and in November 2001. A new
proposed revision of the CMS 855 series is being submitted with this
proposed rule for
[[Page 22074]]
additional public comment. Each revision has been based on comments
received from our contractors, the health care industry, and new
requirements imposed through legislation. All revisions are submitted
to OMB and published in the Federal Register for public comment before
approval and implementation.
The primary function of the CMS 855 is to gather information from a
provider or supplier that tells us who it is, whether it meets certain
qualifications to be a health care provider or supplier, where it
practices or renders its services, the identity of the owners of the
enrolling entity, and information necessary to establish the correct
claims payment. The goal of evaluating and revising the CMS 855 is to
simplify and clarify the information collection without jeopardizing
our need to collect specific information. Listed below are the various
sections of the CMS 855 and the information that each section collects.
Not all sections apply to all provider and supplier types. For specific
information collection requirements by provider or supplier type,
review the applicable CMS 855 as mentioned earlier in this preamble.
1. Provider or Supplier Application
To ensure efficient processing of the CMS 855, this section
requires the provider or supplier to give the reason for submission of
the CMS 855 and to state whether it is currently known (enrolled) in
Medicare and for any current Medicare identifiers (billing numbers or
Medicare contractor name(s)).
2. General Identification Information
This section collects personal and business information to uniquely
identify the provider or supplier with such information as type or
specialty, name, business name, address, date of birth, SSN, EIN,
correspondence address, and other similar information. This information
is needed to uniquely identify the provider or supplier. Moreover, as
detailed above, section 1124(a)(1) of the Act requires disclosure of
both EINs and SSNs. See also section 31001(I) of the DCIA.
3. Adverse Legal Action(s) and Overpayment(s)
The information obtained in this section enables us to determine if
an individual or entity should have its Medicare billing number denied
or revoked. Table A in this section cites specific adverse legal
actions which have a direct bearing on the individual's or entity's
professional competence, professional performance, or financial
integrity that the provider or supplier must report to Medicare. These
actions may serve as a basis for the Secretary, as set forth in section
1128 of the Act, to exclude an individual or entity from participation
in Medicare and all other Federal health care programs.
4. Current Practice Location(s)
This section collects information to verify that the practice
location where services are proposed to be or are being furnished by
the enrolling provider or supplier meets Medicare requirements.
5. Ownership Interest and/or Managing Control Information
(Organizations)
6. Ownership Interest and/or Managing Control Information (Individuals)
7. Chain Home Office Information
The information collected in the above three sections (5 through 7)
is needed to ensure that all individuals and entities deriving
financial benefit from the Medicare program are identified as required
in sections 1124 and 1124A(a) of the Act, and in Sec. 420.204. Those
sections state that as a condition for approval or renewal of a
contract or agreement, and for an entity to receive payment under Title
XVIII, complete information as to the identity of each person and/or
organization with an ownership or controlling interest of 5 percent or
more and each managing employee as defined in section 1126(b) of the
Act and Sec. 420.201, must be disclosed.
8. Billing Agency
This section is needed to capture identifying information, such as
legal business name and address, and to obtain information about the
contract between the provider or supplier and the billing agency that
submits bills or claims for Medicare payments on behalf of a Medicare
provider or supplier. In addition, we need this information to verify
that the biller has been authorized by the provider or supplier to
submit bills or claims on the provider or supplier's behalf. We need to
be able to monitor agreements made between billing and collection
agents and providers and suppliers to ensure compliance with Medicare
requirements found at 1842(b)(6) of the Act and Sec. Sec. 424.73 and
424.80.
9. For Future Use
10. Staffing Company
This section is needed to capture identifying information, such as
legal business name and address, and to obtain information about the
contract between the provider or supplier and the staffing company that
submits bills or claims for Medicare payments on behalf of a Medicare
provider or supplier. In addition, we need this information to verify
that the biller has been authorized by the provider or supplier to
submit bills or claims on the provider or supplier's behalf. We need to
be able to monitor agreements made between staffing companies and
providers and suppliers to ensure compliance with Medicare requirements
found at section 1842(b)(6) of the Act and Sec. Sec. 424.73 and
424.80.
11. Surety Bond Information
This section will be used on an ``as needed'' basis and would
furnish us with information regarding certain providers and suppliers
that are required to obtain a surety bond under section 4312 of the BBA
(codified at sections 1834(a)(16), 1861(o)(7), 1861(p)(4)(A)(v) and
1861(cc)(2)(I)) of the Act. The BBA further grants the Secretary the
authority, at his or her discretion, to impose the requirements on
other Medicare providers or suppliers (other than physicians or other
practitioners as defined in section 1842(b)(18)(C) of the Act). See
also section 1834(a)(16) of the Act.
12. Capitalization Requirements for Home Health Agencies (HHAs)
This section collects information required by Sec. 489.28, which
requires all HHAs enrolling in Medicare for the first time to submit
proof of sufficient operating funds.
13. Contact Person(s)
This information will allow a Medicare contractor to establish a
direct point of contact to resolve issues pertaining to the completion
and validation of the information furnished in the CMS 855.
14. Penalties for Falsifying Information on this Enrollment Application
This section is informational only. It cites various statutory
references in the United States Code and the Social Security Act
concerning actual knowledge, deliberate ignorance or reckless disregard
of the truth or falsity of the information contained therein on an
application to receive payment.
15. Certification Statement
The certification statement is being revised. Statement 3 on the
CMS 855A, CMS 855B, and CMS 855S forms and statement 4 on the CMS 855I
form have been changed to provide a better understanding of Medicare
policy. An additional statement is also being added to the CMS 855A and
CMS 855B forms for providers and suppliers that receive
[[Page 22075]]
accreditation from an outside organization authorizing the release of
the survey to us or our agents. By adding this language to the
certification statement, the current CMS 1514 form will be eliminated
for Medicare purposes.
16. Delegated Official (Optional)
The signature(s) obtained in sections 15 and 16 would attest that
the provider or supplier has submitted accurate, complete, and truthful
information as required by sections 1814(a) and 1833(e) of the Act, and
that the person the provider or supplier has authorized to sign for the
provider or supplier attests on behalf of the provider or supplier to
having read and understood the information furnished and collected in
the CMS 855, and that the information is accurate, complete, and
truthful. By signing the certification statement, the provider or
supplier, or the authorized or delegated official signing on behalf of
the provider or supplier, is attesting, among other things, that the
provider or supplier is aware of and will abide by all applicable
Medicare laws and regulations.
17. Attachments
This section is a checklist of possible documents that should be
submitted with the enrollment application. These documents are used as
evidence or proof of the validity of the information furnished through
the CMS 855.
B. Information Pertaining to Specific Provider and Supplier Types
1. Attachment 1 to Form CMS 855B--Ambulance Service Suppliers
We must collect specific information on ambulance service suppliers
to verify their eligibility to receive payment for Medicare covered
services. Section 410.41 (Requirements for ambulance suppliers) sets
forth the requirements for ambulance service suppliers. An ambulance
must 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.
We require that, at a minimum, an ambulance contain a stretcher,
linens, emergency medical supplies, oxygen equipment, and other
lifesaving emergency medical equipment as required by State or local
laws, and be equipped with emergency warning lights, sirens, and two-
way telecommunications.
Note: This attachment replaced the HCFA R-88 (OMB Approval
Number 0938-0460).
2. Attachment 2 to Form CMS 855B--Independent Diagnostic Testing
Facilities (IDTFs)
IDTFs must submit specific information to us to justify their
eligibility to receive payment for Medicare covered services. The
information collected in this attachment allows us to assess compliance
with 42 CFR Sec. 410.33 (Independent diagnostic testing facility). In
addition, 42 CFR Sec. 440.30 (Other laboratory and x-ray services)
defines laboratory and X-ray services. These services may be provided
in an office or similar facility other than a hospital outpatient
facility or clinic, and must be furnished by a laboratory that meets
the requirements of Part 493 of chapter IV, 42 CFR.
C. Supplemental Applications
1. Supplemental Application CMS 855S (DMEPOS Supplier Application)
The information collected in this iteration of the CMS 855 allows
us to assess compliance with Sec. 424.57 (Special payment rules for
items furnished by DMEPOS suppliers and issuance of DMEPOS supplier
billing numbers), which outlines specific standards that must be met
for the enrollment and renewal of enrollment for DMEPOS suppliers. This
collection was previously approved by OMB via the HCFA 192 (OMB
Approval Number 0938-0594). The CMS 855S has replaced the HCFA 192.
Note: A DMEPOS supplier is not required to submit a CMS 855B
form in addition to a CMS 855S.
2. Supplemental Application CMS 855R (Individual Reassignment of
Benefits Application)
The CMS 855R will be used to link individual Medicare suppliers
with Medicare entities to whom the individual reassigns his or her
benefits and is used in conjunction with the CMS 855I or the CMS 855B
during initial enrollment into the Medicare program, or whenever an
individual supplier wishes to, or is required to, reassign its
benefits. The CMS 855R contains only the information needed to identify
and link individual suppliers reassigning their benefits to the
individuals and entities to whom their benefits are being reassigned.
V. Sanctions and Penalties
The CMS 855 states that the following penalties may be imposed:
[sbull] 18 U.S.C. 1001 authorizes criminal penalties against an
individual who in any matter within the jurisdiction of any department
or agency of the United States knowingly and willfully falsifies,
conceals or covers up by any trick, scheme or device a material fact,
or makes or uses any false, fictitious, or fraudulent statements or
representations, or makes any false writing or document knowing the
same to contain any false, fictitious or fraudulent statement or entry.
Individual offenders are subject to fines of up to $250,000 and
imprisonment for up to 5 years. Offenders that are organizations are
subject to fines of up to $500,000. 18 U.S.C. 3571(d) also authorizes
fines of up to twice the gross gain derived by the offender.
[sbull] Section 1128B(a)(1) of the Act authorizes criminal
penalties against an individual who ``knowingly and willfully makes or
causes to be made any false statement or representation of a material
fact in any application for any benefit or payment under a Federal
health care program.'' The offender is subject to fines of up to
$25,000 or imprisonment for up to 5 years, or both.
[sbull] The Civil False Claims Act, 31 U.S.C. 3729, imposes a civil
penalty of $5,000 to $10,000 per violation, plus three times the amount
of damages sustained by the Government and imposes civil liability, in
part, on any person who--
[sbull] Knowingly presents, or causes to be presented, to an
officer or an employee of the United States Government a false or
fraudulent claim for payment or approval;
[sbull] Knowingly makes, uses, or causes to be made or used, a
false record or statement to get a false or fraudulent claim paid or
approved by the Government; or
[sbull] Conspires to defraud the Government by getting a false or
fraudulent claim allowed or paid.
[sbull] Section 1128A(a)(1) of the Act imposes administrative
sanctions on a person for the submission to a Federal health care
program of false or otherwise improper claims.
These administrative sanctions include a civil monetary penalty of
up to $10,000 for each item or service falsely or fraudulently claimed
an assessment of up to triple the amount claimed, and exclusion from
participation in all Federal health care programs.
The government may assert common law claims such as ``common law
fraud,'' ``money paid by mistake,'' and ``unjust enrichment.'' Remedies
include compensatory and punitive damages, restitution, and recovery of
the amount of the unjust profit.
In addition, the following two sanctions will be added to the CMS
855 form:
[[Page 22076]]
[sbull] 18 U.S.C. 1035 authorizes criminal penalties against
individuals in any matter involving a health care benefit program who
knowingly and willfully falsifies, conceals, or covers up by any trick,
scheme, or device a material fact; or makes any materially false,
fictitious, or fraudulent statements or representations, or makes or
uses any materially false fictitious, or fraudulent statement or entry,
in connection with the delivery of or payment for health care benefits,
items, or services. The individual shall be fined or imprisoned up to 5
years or both.
[sbull] 18 U.S.C. 1347 authorizes criminal penalties against
individuals who knowing and willfully execute, or attempt, to execute a
scheme or artifice to defraud any health care benefit program, or to
obtain, by means of false or fraudulent pretenses, representations, or
promises, any of the money or property owned by or under the control
of, any health care benefit program in connection with the delivery of
or payment for health care benefits, items, or services. Individuals
shall be fined or imprisoned up to 10 years or both. If the violation
results in serious bodily injury, an individual shall be fined or
imprisoned up to 20 years, or both. If the violation results in death,
the individual shall be fined or imprisoned for any term of years or
for life, or both.
VI. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995 (PRA), agencies are
required to provide a 60-day notice in the Federal Register and solicit
public comment before a collection of information requirement is
submitted to OMB for review and approval. To evaluate fairly whether an
information collection should be approved by OMB, section 3506(c)(2)(A)
of the PRA requires that we solicit comments on the following issues:
[sbull] Whether the information collection is necessary and useful
to carry out the proper functions of the agency;
[sbull] The accuracy of the agency's estimate of the information
collection burden;
[sbull] The quality, utility, and clarity of the information to be
collected; and
[sbull] Recommendations to minimize the information collection
burden.
Therefore, we are soliciting public comment on each of these issues
for the information collection requirement discussed below.
The following sections of this document contain information
collection requirements:
Section 424.510 Requirements for Obtaining a Billing Number and
Medicare Billing Privileges
To enroll in the Medicare program and obtain and activate a
Medicare provider or supplier billing number, Sec. 424.510(a) requires
a provider or supplier to complete and submit a CMS 855 to us,
demonstrating that the provider or supplier meets all of the
requirements set forth in this section. The burden associated with
these requirements are currently captured in the CMS 855 (OMB Approval
Number 0938-0685) and shown below in Table 1.
Table 1.--Current Estimated Hours for Completion of CMS 855 Forms for Initial Enrollment
----------------------------------------------------------------------------------------------------------------
Estimated Estimated time for Total number Total cost in
CMS form number number of completion per of hours for dollars
respondents respondent completion (million)
----------------------------------------------------------------------------------------------------------------
855A.................................. 5,000 8 Hours................. 40,000 $3
855B.................................. 10,000 8 Hours................. 80,000 $6
855I.................................. 50,000 5 Hours................. 250,000 $3
855R.................................. 100,000 15 Minutes.............. 25,000 $.3
855S.................................. 9,000 8 Hours................. 72,000 $5.4
-------------------------------
Total Estimated Hourly and .............. ........................ 467,000 $17.7
Financial Burden.
----------------------------------------------------------------------------------------------------------------
The estimated number of respondents is based on current Medicare
contractor workload reports. The cost in dollars is based on hourly
salaries for applicable staff to complete the applications.
Section 424.510(f) states that we reserve the right to perform on-
site inspections of a provider or supplier to verify and ensure
validity of the information submitted to us or our agents and to
determine compliance with Medicare requirements. We intend to conduct
on-site visits of all new suppliers of DMEPOS before they can enroll in
the Medicare program. The burden associated with these requirements are
currently captured and approved in form HCFA-R-263 (OMB Approval Number
0938-0749).
We also intend to conduct approximately 490 on-site visits to
Community Mental Health Centers. The burden associated with these
requirements are currently captured and approved in form HCFA-R-273 OMB
Approval Number 0938-0770). We also intend to conduct approximately
2800 visits to IDTFs on an annual basis. We will seek OMB approval for
these visits. The burden associated with this requirement is the time
and effort necessary for a facility to provide documentation to verify
information provided on their CMS 855 and to demonstrate that they meet
other necessary Medicare requirements and regulations.
Table 2.--Estimated Annual Reporting Burden
----------------------------------------------------------------------------------------------------------------
Average burden
CFR sections Annual number Frequency per response Annual burden Annual cost
of responses (hours) (hours)
----------------------------------------------------------------------------------------------------------------
424.510(f)...................... 2800 1 4 11,200 $0
----------------------------------------------------------------------------------------------------------------
Since these site visits are unannounced and performed to ensure
proper physical location, equipment, and personnel to meet Medicare
requirements, we do not expect the
[[Page 22077]]
provider or supplier to incur any financial burden.
We may also conduct on-site visits of providers or suppliers based
on any information that leads us or our agents to believe that an
administrative action, investigation or audit is warranted. Information
collected under these situations is exempt from the PRA, as stipulated
under 5 CFR 1320.4.
Section 424.515 Requirements for Reporting Changes and Updates to, and
the Periodic Revalidation of, Medicare Enrollment Information
A provider or supplier must re-certify for revalidation its
enrollment information no more than once every 3 years. Section
424.515(b) states that within 60 calendar days of our notice to re-
certify their enrollment information for revalidation, a provider or
supplier must submit any new or revised CMS 855 information and
documentation necessary to demonstrate that they meet the requirements
set forth in this section.
Table 3.--Estimated Annual Reporting Burden
----------------------------------------------------------------------------------------------------------------
Average
Annual number burden per Annual burden Annual cost
CFR sections of responses Frequency response (hours) (million)
(minutes)
----------------------------------------------------------------------------------------------------------------
424.515(b)...................... 387,000 (**) 95 612,750 $15
----------------------------------------------------------------------------------------------------------------
** Frequency is no more than once every 3 years. (1.16 million providers and suppliers/3 years x 95 minutes/60
minutes.)
The burden hours shown above are for the most restrictive
reporting. As indicated elsewhere in this preamble, we are exploring
various options and are soliciting comments on ways of minimizing the
burden on providers and suppliers during the process of revalidating
their enrollment information.
The estimated cost is based on $40 per application per provider to
review and return.
Section 424.520 Additional Provider and Supplier Requirements for
Enrolling and Maintaining Active Enrollment Status in the Medicare
Program
Following enrollment and periodic recertification of enrollment
information, a provider or supplier must report to us any changes to
the information furnished on the CMS 855 or supporting documentation
within 90 calendar days of the change.
Table 4.--Estimated Annual Reporting Burden
----------------------------------------------------------------------------------------------------------------
Average burden
CFR section Annual number Frequency per response Annual burden Annual cost
of responses (hours) (hours) (millions)
----------------------------------------------------------------------------------------------------------------
424.20.......................... 40,000 1 1 40,000 $1.6
----------------------------------------------------------------------------------------------------------------
Section 424.525 Rejection of a Provider or Supplier's CMS 855 for
Medicare Enrollment
We will reject a provider or supplier's CMS 855 if the provider or
supplier does not furnish missing or necessary information and
documentation to us within 60 calendar days of a request. We believe
that the burden associated with this requirement is captured in Sec.
424.515, as we will merely be seeking the information initially
requested in the CMS 855.
Section 424.525(b) states that upon notification of a rejected CMS
855, the provider or supplier must once again begin the enrollment
process by completing and submitting a new CMS 855 and all applicable
documentation if it wishes to obtain a Medicare billing number.
Table 5.--Estimated Annual Reporting Burden
----------------------------------------------------------------------------------------------------------------
Average burden
CFR sections Annual number Frequency per response Annual burden Annual cost
of responses (minutes) (hours)
----------------------------------------------------------------------------------------------------------------
424.525(b)...................... 11,250 1 95 17,812 $563,000
----------------------------------------------------------------------------------------------------------------
The annual dollar cost is based on $50 per respondent to update and
resubmit a previously submitted enrollment application.
Section 424.535 Revocation of Enrollment and Billing Privileges From
the Medicare Program
Section 424.535(b) states that upon notification of the revocation
of its billing number and billing privileges, if the provider or
supplier seeks to re-establish enrollment in the Medicare program it
must re-enroll in the Medicare program through the completion and
submission of a new CMS 855 and applicable documentation.
[[Page 22078]]
Table 6.--Estimated Annual Reporting Burden
----------------------------------------------------------------------------------------------------------------
Average burden
CFR sections Annual number Frequency per response Annual burden Annual cost
of responses (hours) (hours) (millions)
----------------------------------------------------------------------------------------------------------------
424.535(b)...................... 2000 1 8 16,000 $1.2
----------------------------------------------------------------------------------------------------------------
The annual dollar cost is based on $600 per respondent to re-enroll
in the Medicare program.
Providers must also be re-surveyed or re-certified by the State
Survey Agency and must establish a new provider agreement with our
Regional Office. The burden associated with the survey and
certification requirement is exempt from the PRA, as provided in
section 4204(c) of Pub. L. 100-203 COBRA 87, as amended by Pub. L. 100-
360 (Medicare Catastrophic Coverage Act of 1988). The burden associated
with the requirement to establish a new provider agreement (Form HCFA-
460) is currently approved under OMB Approval Number 0938-0373.
Section 424.540 Deactivation of Medicare Billing Privileges
Section 424.540(a)(1) states that if no Medicare claims are
submitted for two consecutive calendar quarters (6 months) we would
deactivate a provider or supplier's Medicare billing number. The
provider or supplier must complete and submit a CMS 855 for validation
to reactivate its Medicare billing number and billing privileges.
Table 7.--Estimated Annual Reporting Burden
----------------------------------------------------------------------------------------------------------------
Average burden
CFR sections Annual No. of Frequency per response Annual burden Annual cost
responses (minutes) hours
----------------------------------------------------------------------------------------------------------------
424.540 (a)(1).................. 1200 1 95 1,900 $48,000
----------------------------------------------------------------------------------------------------------------
The annual cost is based on $40 per respondent to review and re-
certify via signature their previously submitted enrollment
application/information.
Table 8 below shows the total estimated hourly and financial burden
for all requirements outlined and proposed in this rule.
Table 8.--Estimated Hourly and Financial Burden for All Requirements
----------------------------------------------------------------------------------------------------------------
Annual No. of Annual burden Annual cost
CFR section responses hours (million)
----------------------------------------------------------------------------------------------------------------
424.500......................................................... 618,250 1.2 million $36.6
----------------------------------------------------------------------------------------------------------------
We have submitted a copy of this proposed rule to OMB for its
review of the information collection requirements in Sec. Sec.
424.510, 424.515, 424.520, 424.525, 424.535, and 424.540 and related
forms in the addendum. These requirements are not effective until they
have been approved by OMB.
If you have any comments on any of these information collection and
record keeping requirements, please mail the original and 3 copies
directly to the following:
Centers for Medicare and Medicaid Services, Office of Information
Services, Information Technology Investment Management Group, Division
of CMS Enterprise Standards, Room C2-26-17, 7500 Security Boulevard,
Baltimore, MD 21244-1850, Attn.: John Burke CMS-6002-P.
And,
Office of Information and Regulatory Affairs, Office of Management and
Budget, Room 10235, New Executive Office Building, Washington. DC
20503, Attn: Brenda Aguilar, CMS Desk Officer.
VII. Regulatory Impact Analysis
We have examined the impacts of this proposed rule under Executive
Order (E.O.) 12866, the Unfunded Mandate Reform Act of 1995, and the
Regulatory Flexibility Act. E.O. 12866 directs agencies to assess all
costs and benefits of available regulatory alternatives and, when
regulation is necessary, to select regulatory approaches that maximize
net benefits. In addition, a Regulatory Impact Analysis must be
prepared for major rules with economically significant effects ($100
million or more in any one year). This proposed rule would establish in
regulations specific provider and supplier initial enrollment
procedures and the periodic revalidation of eligibility. It is not
expected to have an impact that would meet the threshold criteria to be
considered economically significant.
The Unfunded Mandate Reform Act of 1995, in section 202, requires
that agencies prepare an assessment of anticipated costs and benefits
before proposing any rule that may result in an annual expenditure by
State, local, or tribal governments, in the aggregate, or by the
private sector, of $110 million adjusted for inflation. The rule has no
consequential adverse impact on State, local, or tribal governments.
This rule may reduce some State burdens since they will no longer
certify providers that are not qualified to participate in the Medicare
program. The impact on the private sector is well below the threshold.
Consistent with the Regulatory Flexibility Act, we prepare a
Regulatory Flexibility Analysis (RFA) unless we certify that a rule
would not have a
[[Page 22079]]
significant economic impact on a substantial number of small entities.
The RFA is to include a justification of why action is being taken, the
kinds and number of small entities that the proposed rule will affect,
and an explanation of any considered meaningful options that achieve
the objectives and would lessen any significant adverse economic impact
on the small entities. For purposes of the RFA, entities with annual
revenues of $5 million to $25 million depending on the type of health
care provider and non-profit organizations are considered to be small
entities. Because of the scope of this rule, all small entities that
participate in the Medicare program are considered providers and
suppliers and will be affected, but we do not expect that effect to be
of a significant nature. As we show in section B of this impact
analysis, the annual burden on providers and suppliers for completing
the CMS 855 forms would not rise to the level of a significant burden.
The following analysis, together with the rest of this preamble,
explains the rationale, purpose, and alternatives considered in the
proposed rule. This is an administrative initiative that may result in
Medicare program savings but at this time those savings are
inestimable. We believe the probable costs providers or suppliers would
incur as a result of this rule to be negligible.
A. Rationale, Purpose, and Alternatives Considered
As noted elsewhere in this preamble, we are responsible for
protecting the Medicare trust fund by ensuring that unqualified,
fraudulent, or excluded providers and suppliers do not bill the
Medicare program. Past experience with a number of program integrity
efforts have identified that granting billing privileges to entities
that do not exercise sound business practices can result in
uncollectable overpayments. The ease of obtaining a billing number in
the past has paved the way for unscrupulous businesses to defraud the
government deliberately by billing for services never furnished or
furnished at inflated prices.
The provisions of this proposed rule supplement, but do not replace
or nullify, existing regulations concerning the establishment of
provider or supplier agreements, the issuance of provider or supplier
billing numbers, and payment for Medicare covered services or supplies
to eligible providers and suppliers. Basically, this rule consolidates
current regulations found throughout the Code of Federal Regulations
and more clearly defines what Medicare expects from providers and
suppliers rendering services to the Medicare beneficiaries. Moreover,
we have revised the ``Provider Supplier Enrollment Application (CMS
855)'' which will greatly decrease the current burden to the provider
or supplier when applying for billing privileges. We expect this rule
to ensure that the Medicare program has adequate information on those
who seek to bill the program for services. Furthermore, it assures us
that information will be periodically updated and reviewed. We believe
that establishing the foundation for a sound business relationship with
providers and suppliers will minimize billing problems and otherwise
protect the Medicare trust fund. Similarly, we believe it is necessary
for us to impose the requirements of this regulation on existing
providers and suppliers and to establish safeguards that enable us to
deny enrollment of unqualified providers and suppliers, and to revoke
the billing privileges of egregious offenders whose actions place the
Medicare trust fund at risk.
The primary goal of this rule, through standard enrollment
requirements and periodic revalidation of the enrollment information,
is to allow us to collect and maintain (keep current) a unique and
equal data set on all current and future providers and suppliers that
are or will bill the Medicare program for services rendered to our
beneficiaries. By achieving this goal, we will be better positioned to
combat and reduce the number of fraudulent and abusive providers and
suppliers in the Medicare program, thereby protecting the trust fund
and the Medicare beneficiaries. This rule will also allow us to
develop, implement, and enforce national provider and supplier
enrollment procedures to be administered uniformly by all Medicare
contractors. Over time, we strongly believe that any current burden
imposed on the providers and suppliers will be greatly diminished
through the use of computer storage and web based internet technology.
Studies performed by our contractors, the GAO and OIG have shown
numerous instances of fictitious applicants being granted Medicare
billing numbers. This proposed rule would integrate the request for
enrollment with sufficient data to substantiate an appropriate level of
performance on the part of a new or continuing business. In prior
studies, the OIG has found applicants who had submitted applications
with nonexistent addresses. In some instances suppliers had no
inventory of goods to be sold, lacked business licenses, had no
financial investment, or lacked any experience in the business venture.
The GAO report concluded: ``Weaknesses in CMS' current provider
enrollment process have made Medicare vulnerable to dishonest
providers. To protect the integrity of Medicare, CMS and its
contractors must have effective practices for reviewing applicants to
verify that they are eligible for enrollment in the program, as well as
the authority to deny or revoke enrollment to those that are not.''
This report also concluded that, ``: Periodic revalidation of provider
enrollment data should be a valuable means of ensuring that CMS has
current, useful data on active providers and that providers no longer
eligible to participate in Medicare are dropped from the program.''
Therefore, based on the above recommendation and our own successes with
our 3-year re-enrollment policy currently in effect for DME suppliers,
we are seeking to expand this requirement to all providers and
suppliers billing the Medicare program.
We have already stepped up our efforts to seek more uniformity in
the enrollment process. However, our experience clearly shows that the
best means for preventing payment errors and, in worst cases, abuse by
providers and suppliers, is to discourage and prevent their entry into
the Medicare program through this rule and the authority to deny
enrollment or revoke their billing number.
We realize that some entities will perceive our proposed
requirements as a barrier to their access to serving Medicare
beneficiaries. We do not believe that bona fide businesses will
experience any difficulty in obtaining or maintaining a Medicare
billing number. We also do not believe that the impact of these
proposed requirements would fall any more heavily on underserved areas
than on major metropolitan areas. We estimate that furnishing the
requested information would require no more than 8 hours of a provider
or supplier's time. Most businesses should have the information readily
available.
B. Rural Hospital Impact Statement
Section 1102(b) of the Act requires us to prepare a regulatory
impact analysis if a rule may have a significant impact on the
operations of a substantial number of small rural hospitals. Such an
analysis must conform to the provisions of section 603 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a Metropolitan
Statistical Area and has fewer than 100 beds. As noted above, there is
a minimum amount of time needed to gather data and provide the
information requested on the CMS 855
[[Page 22080]]
when initially enrolling or when resubmitting enrollment information to
obtain and maintain a Medicare billing number. We are not preparing a
rural impact statement since we have determined, and certify, that we
do not expect this rule to impose any additional burden or otherwise
significantly impact the operations of a substantial number of small
rural hospitals. By default, due to their smaller size, the burden to
small rural hospitals would actually be less than the average provider.
There are currently about 1.2 million providers (hospitals, home
health agencies, rural health clinics, skilled nursing facilities,
etc.) and suppliers (physicians, nurses, ambulance companies, clinical
laboratories, durable medical equipment suppliers, etc.) enrolled in
the Medicare program. In addition, about 74,000 new providers and
suppliers apply to enroll in Medicare each year. Listed below is the
current estimated annual burden on the affected public in both hours
and dollars.
1. Estimated Costs for Completion of CMS 855 Forms for Initial
Enrollment
Assumptions:
a. The monetary cost to the respondents is calculated as follows
based on the following assumptions:
[sbull] The CMS 855I and CMS 855R will be completed by clerical
staff (secretary), and
[sbull] The CMS 855A, CMS 855B, and CMS 855S will be completed by
professional staff (attorney or accountant).
b. Estimated Cost per Form
The monetary cost to the respondent to complete and submit the
necessary CMS 855 form is:
[sbull] $600 for the CMS 855A, CMS 855B, and CMS 855S
[sbull] $60 for the CMS 855I, and
[sbull] $3 for the CMS 855R
c. Estimated Hourly Wage for Staff Completing Forms. The cost per
respondent per form has been determined using the following wages:
[sbull] $12.00 per hour (clerical wage)
[sbull] $75.00 per hour (professional wage)
Current Estimated Hours for Completion of CMS 855 Forms for Initial New Enrollments
----------------------------------------------------------------------------------------------------------------
Estimated Estimated time for Total number Total costs in
CMS form number number of completion per of hours for dollars
respondents respondent completion (million)
----------------------------------------------------------------------------------------------------------------
855A.................................. 5,000 8 Hours................. 40,000 $3
855B.................................. 10,000 8 Hours................. 80,000 $6
855I.................................. 50,000 5 Hours................. 250,000 $3
855R.................................. 100,000 15 Minutes.............. 25,000 $.3
855S.................................. 9,000 8 Hours................. 72,000 $5.4
---------------------------------------
Total Estimated Hourly and 467,000 $17.7
Financial Burden.
----------------------------------------------------------------------------------------------------------------
The estimated number of respondents is based on current Medicare
contractor workload reports.
2. Completing Forms to Report Changes to Enrollment Information
The hourly burden and monetary cost estimate for this activity for
all forms is:
[sbull] 100,000 respondents X 1 hour each = 100,000 hours
Average cost per respondent = $420
Total cost for all respondents = $42 million
3. Completing Forms to Re-Certify Enrollment Information (3 yr cycle)
The hourly burden and monetary cost estimate for this activity for
all forms is:
[sbull] 330,000 respondents X 2 hours each = 660,000 hours Average
cost per respondent = $40
Total cost for all respondents = $13.2 million
Based on the above, the estimated current total annual hour burden
for all classes of providers (hospitals, home health agencies, rural
health clinics, skilled nursing facilities, etc.) and suppliers
(physicians, nurses, ambulance companies, clinical laboratories,
durable medical equipment suppliers, etc.) is 1,227,000 hours.
Based on the above, the estimated current annual monetary burden
for all classes of providers (hospitals, home health agencies, rural
health clinics, skilled nursing facilities, etc.) and suppliers
(physicians, nurses, ambulance companies, clinical laboratories durable
medical equipment suppliers, etc.) is $32.9 million. The 1997 revenue
receipts for all classes of providers and suppliers is $913.7 billion.
The cost of obtaining and maintaining billing privileges in the
Medicare program on average is less than 1 percent of the total
revenue.
Although it is possible that a few entities may be significantly
affected by these proposed rules, we do not expect that a substantial
number of affected entities will experience a significant increase in
the reporting burden; therefore, the Secretary certifies that this rule
is not expected to impose any additional burden or otherwise
significantly impact a substantial number of small entities. We also
invite comments on our impact analysis and regulatory flexibility
analysis.
C. Alternatives Considered
Since this proposed rule is a codification of our current policies
on provider and supplier enrollment, with the exception of imposing a
cyclical revalidation process, we did not seek alternatives to this
process. However, the current process was reviewed and, when possible,
proposed or made that would reduce the current burden, such as the time
frame for reporting changes.
Although we do not expect this rule to have a significant economic
impact, we are revising the requirements for reporting changes to the
provider or supplier's enrollment information to reduce the current
burden. Currently, provides and suppliers must report any changes to
their enrollment information within 30-days. We are proposing to change
this requirement to 90-days (or quarterly). We considered retaining the
current requirement but determined the 30-day timeframe as too
stringent in light of the rapid changes seen in today's health care
industry. This change is expected to reduce the administrative burden
for the providers, suppliers, our contractors, and us.
In accordance with the provisions of Executive Order 12866, this
rule was reviewed by OMB.
VIII. Response to Comments
Because of the large number of items of correspondence we normally
receive on Federal Register documents published for comment, we are not
able to acknowledge or respond to them individually. We will consider
all comments we receive by the date and time specified in the DATES
section of this preamble, and, if we proceed with a subsequent
document, we will
[[Page 22081]]
respond to the major comments in the preamble to that document.
List of Subjects
42 CFR Part 420
Fraud, Health facilities, Health professions, Medicare.
42 CFR Part 424
Emergency medical services, Health facilities, Health professions,
Medicare.
42 CFR Part 489
Health facilities, Medicare, Reporting and recordkeeping
requirements.
42 CFR Part 498
Administrative practice and procedure, Health facilities, Health
professions, Medicare, Reporting and recordkeeping requirements.
For the reasons set forth in this preamble, 42 CFR chapter IV is
proposed to be amended as set forth below:
PART 420--PROGRAM INTEGRITY: MEDICARE
1. The authority citation for part 420 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. In Sec. 420.201, the definition for managing employee is
revised to read as follows:
* * * * *
Managing employee means a general manager, business manager,
administer, director, or other individual that exercises operational or
managerial control over, or who directly or indirectly conducts, the
day-to-day operation of the institution, organization, or agency,
either under contract or through some other arrangement, whether or not
the individual is a W-2 employee.
* * * * *
PART 424--CONDITIONS FOR MEDICARE PAYMENT
1. The authority citation for part 424 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. In Sec. 424.1, the introductory text to paragraph (a)(1) is
republished, and the following statutory reference is added to
paragraph (a)(1) in numerical order to read as follows:
Sec. 424.1 Basis and scope.
(a) Statutory basis. (1) This part is based on the indicated
provisions of the following sections of the Act:
* * * * *
1833(e)--Requirement to furnish information to determine payment.
* * * * *
3. Subparts N and O are added and reserved.
4. Subpart P is added to read as follows:
Subpart P--Requirements for Establishing and Maintaining Medicare
Billing Privileges
Sec.
424.500 Scope.
424.502 Definitions.
424.505 Basic enrollment requirement.
424.510 Requirements for obtaining a billing number and Medicare
billing privileges.
424.515 Requirements for reporting changes and updates to, and the
periodic revalidation of, Medicare enrollment information.
424.520 Additional provider and supplier requirements for enrolling
and maintaining active enrollment status in the Medicare program.
424.525 Rejection of a provider or supplier's CMS 855 for Medicare
enrollment.
424.530 Denial of enrollment.
424.535 Revocation of enrollment and billing privileges in the
Medicare program.
424.540 Deactivation of Medicare billing privileges.
424.545 Provider and supplier appeal rights.
424.550 Prohibitions on the sale or transfer of billing privileges.
424.555 Payment liability.
Subpart P--Requirements for Establishing and Maintaining Medicare
Billing Privileges
Sec. 424.500 Scope.
The provisions of this subpart contain the requirements for
enrollment, periodic resubmission and certification of enrollment
information for revalidation, and timely reporting of updates and
changes to enrollment information. These requirements apply to all
providers and suppliers except for physicians and practitioners who
have entered into a private contract with a beneficiary as described in
part 405, subpart D of this chapter. Providers and suppliers must meet
and maintain these enrollment requirements to bill either the Medicare
program or its beneficiaries.
Note to Sec. 424.500: Throughout subpart P, references to
``supplier'' or ``suppliers'' do not include those physicians or
practitioners who have elected to ``opt-out'' of Medicare as
described in part 405, subpart D of this chapter.
Sec. 424.502 Definitions.
As used in this subpart, unless the context indicates otherwise--
Approve/Approval means the enrolling provider or supplier has been
determined to be eligible under Medicare rules and regulations to
receive a Medicare billing number and Medicare billing privileges.
Authorized official 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 laws, regulations, and
program instruction of the Medicare program.
Deactivate means that the provider or supplier's billing privileges
have been temporarily stopped, but can be restored upon the submission
of updated information.
Delegated official means an individual who has been delegated by
the ``Authorized official'', the authority to report changes and
updates to the enrollment record. The delegated official must be an
individual with ownership or control interest in, or be a W-2 managing
employee of the provider or supplier.
Deny/Denial means the enrolling provider or supplier has been
determined to be ineligible to receive Medicare billing privileges for
Medicare covered services provided to Medicare beneficiaries. Providers
and suppliers who have been denied Medicare enrollment cannot bill for
Medicare covered services.
Enroll/Enrollment means the process that Medicare uses to--
(1) Identify a provider or supplier;
(2) Validate its eligibility to provide services to Medicare
beneficiaries;
(3) Identify and confirm the provider or supplier's practice
location(s) and owner(s); and
(4) Grant the provider or supplier Medicare billing privileges.
Managing employee means a general manager, business manager,
administrator, director, or other individual that 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.
[[Page 22082]]
Operational means 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 supplies being rendered), to furnish
these services.
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 section 1124A(a) of the Act.
Reject/Rejected means that the provider or supplier's enrollment
application has not been processed due to incomplete information or
that additional information or corrected information was not received
from the provider or supplier within 60 days after it was requested.
Revoke/Revocation means that the provider or supplier's billing
privileges have been terminated.
Sec. 424.505 Basic enrollment requirement.
To receive payment for covered Medicare services from either
Medicare (in the case of assigned claims) or a Medicare beneficiary (in
the case of unassigned claims), a provider or supplier must have a
valid Medicare billing number and been granted billing privileges for
the date the service or supplies were furnished.
Sec. 424.510 Requirements for obtaining a billing number and Medicare
billing privileges.
Providers and suppliers must submit enrollment information via the
applicable form CMS 855 for verification by the Medicare program to
obtain a Medicare billing number and be granted billing privileges.
Upon the provider or supplier's successful completion of the enrollment
process, including State survey and certification, accreditation, and
approval of the CMS 855, The Centers for Medicare & Medicaid Services
(CMS) issues a billing number and grants billing privileges that enable
the provider or supplier to bill the Medicare program or the Medicare
beneficiaries for Medicare covered services. Currently, the effective
dates for reimbursement can be found at Sec. 489.13 of this chapter
for providers and suppliers requiring State survey or certification or
accreditation, Sec. 424.5 and Sec. 424.44 for non-surveyed or
certified/accredited suppliers, and Sec. 424.57 and section
1834(j)(1)(A) of the Act for DMEPOS suppliers. For those providers and
suppliers seeking accreditation from a CMS approved accreditation
organization, the effective date for reimbursement will be the later of
the date accreditation was received or the final approval of the CMS
855. CMS will not issue Medicare billing numbers or grant Medicare
billing privileges retroactive to the date that the provider or
supplier received final approval of their enrollment application (CMS
855). To obtain a billing number and be granted billing privileges, the
following enrollment requirements must be met:
(a) Form CMS 855. A provider or supplier must submit to CMS the
applicable completed CMS 855--Medicare Health Care Provider/Supplier
Enrollment Application. The completed form will provide information for
the purpose of establishing eligibility to receive payment for covered
services furnished to Medicare beneficiaries. The information obtained
uniquely identifies the provider and supplier for the purpose of
enumeration, and provides information to CMS necessary for CMS to
verify that the provider or supplier is not, and should not be,
excluded from participation in the Medicare program, and that it
renders services covered by the Medicare program.
(1) Content. The submitted CMS 855 must include the following:
(i) Complete, accurate, and truthful responses to all information
requested within each section as applicable to the provider or supplier
type.
(ii) Any documentation required by CMS under this or other
statutory or regulatory authority to uniquely identify the provider or
supplier. This documentation may include, but is not limited to, proof
of the legal business name, practice location, social security number
(SSN), tax identification number (TIN), and owners of the business.
(iii) Any documentation required by CMS under this or other
statutory or regulatory authority to establish the provider or
supplier's eligibility to furnish services to beneficiaries in the
Medicare program, including copies of pertinent licenses.
(2) Signature(s). The certification statement found on the CMS 855
must be signed by an individual who has the authority to bind the
provider or supplier, both legally and financially, to the requirements
set forth in this chapter. This person must also have an ownership or
control interest in the provider or supplier, as that term is defined
in section 1124(a)(3) of the Act, such as, be the general partner,
chairman of the board, chief financial officer, chief executive
officer, president, or hold a position of similar status and authority
within the provider or supplier organization. The signature attests
that the information submitted is accurate and that the provider or
supplier is aware of, and will abide by, all applicable Medicare laws,
regulations, and program instructions.
(i) Requirements. The signature requirements set forth below
outline who must sign the CMS 855 for an enrolling provider or
supplier:
(A) In the case of an individual practitioner, the applying
practitioner.
(B) In the case of a sole proprietorship, the applying sole
proprietor.
(C) In the case of a corporation, partnership, group, limited
liability company, or other organization (hereafter referred to
collectively in this section as an organization), an authorized
official, as defined in Sec. 424.502. When an authorized official
signs the certification statement on behalf of an organization, the
signed statement is considered legally binding upon the organization.
(ii) Delegation of Authority. The original CMS 855 submitted for an
organization's initial enrollment and all subsequent CMS 855s submitted
for periodic revalidation of the organization's enrollment data (as
required to maintain enrollment in the Medicare program) must be signed
by an authorized official. Any updates or changes reported outside of
the initial enrollment or periodic revalidation process may be signed
by a delegated official(s) of the organization. The delegated
official's 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 CMS 855 to report updates or changes to the enrollment
information will be that of the authorized official currently on file
with Medicare. Once the delegation of authority is established, the
only acceptable signatures on correspondence to report updates or
changes to the enrollment information will be those of the authorized
official and the person(s) to whom this authority has been delegated in
accordance with the procedures detailed herein. Individual
practitioners and sole proprietors can not delegate signature authority
when submitting a CMS 855 for any reason. All CMS 855s submitted by
individual practitioners and sole proprietors must be signed by the
enrolling/enrolled individual. Each delegation of authority to a
delegated official must--
[[Page 22083]]
(A) Be assigned by the authorized official currently on file with
CMS;
(B) Be submitted to CMS via the CMS 855;
(C) Include the title of each person delegated authority to update
or change the organization's enrollment information;
(D) Include the SSN of the delegated individual where that
individual has an ownership or control interest in the organization or
is a W-2 managing employee as defined in section 1126(b) of the Act;
and
(E) Be signed by the authorized official and the delegated
official(s) of the organization.
(1) Verification of information. The information submitted by the
provider or supplier on the applicable CMS 855 must be such that CMS
can validate it for accuracy as of the time of submission.
(2) Completion of any applicable State surveys, certifications, and
provider agreements. The providers or suppliers who are mandated under
the provision in Part 488 of this chapter to be surveyed or certified
by the State Survey and Certification Agency, and to also enter into
and sign a provider agreement as outlined in part 489 of this chapter,
must also meet those requirements as part of the process to obtain
Medicare billing privileges.
(3) Ability to furnish Medicare covered services or supplies. The
provider or supplier must be operational to furnish Medicare covered
services and/or supplies before being granted Medicare billing
privileges.
(4) Additional requirements. Providers and suppliers must meet the
provisions of Sec. 424.520 regarding additional compliance and
reporting requirements.
(5) On-site inspections. CMS reserves the right, when we deem
necessary, to perform on-site inspections of a provider or supplier to
verify that the enrollment information submitted to CMS or its agents
is accurate and to determine compliance with Medicare enrollment
requirements. Site visits for enrollment purposes will not affect those
site visits performed for establishing conditions of participation.
(b) [Reserved]
Sec. 424.515 Requirements for reporting changes and updates to, and
the periodic revalidation of, Medicare enrollment information.
To maintain Medicare billing privileges a provider or supplier must
resubmit and re-certify as to the accuracy via an authorized signature,
its enrollment information for validation no more than once every 3
years. Initially, all providers and suppliers currently in or initially
enrolling in the Medicare program will be required to complete the
applicable CMS 855 at least once. The provider or supplier will enter
the three-year revalidation cycle once a completed CMS 855 has been
submitted and validated. (Ambulance service providers will continue to
resubmit enrollment information in accordance with Sec. 410.41(c)(2)
and DME suppliers will continue to renew enrollment in accordance with
Sec. 424.57(e) of this chapter). The requirements for the
resubmission, recertification and reverification of enrollment
information include the following:
(a) Submission of form CMS 855 and supporting documentation. The
provider or supplier must meet the submission, content, signature,
verification, operational, inspection, and other requirements outlined
in Sec. 424.510.
(b) Processing time. A provider or supplier must submit to us the
applicable CMS 855 with complete and accurate information and
applicable supporting documentation within 60 calendar days of our
notification to resubmit and certify to the accuracy of its enrollment
information.
(c) Completion of any applicable State surveys, certifications and
provider agreements. A new survey and certification and a new provider
agreement are not required for the purpose of resubmission and
certification for revalidation of enrollment information. Providers and
suppliers must continue to meet the requirements of parts 488 and 489
of this subchapter, if applicable.
(d) On-site inspections. CMS reserves the right to perform on-site
inspections of a provider or supplier to verify that the information
submitted to CMS or its agents is accurate and to determine compliance
with Medicare enrollment requirements. Site visits for enrollment
purposes will not affect those site visits performed for establishing
conditions of participation.
(e) Adjustments to 3-year re-validation cycle and non-routine re-
validations. (1) Revalidation of enrollment information will occur no
more than once every 3 years. CMS reserves the right to adjust this
schedule if it is determined that revalidation should occur on a more
frequent basis due to complaints or evidence received indicating non-
compliance with the Medicare statute or regulations by specific
provider or supplier types. The schedule may also be on a less frequent
basis if it is determined that the integrity of and compliance with the
Medicare statute and regulations by specific provider or supplier types
indicate that less frequent validation is justified. CMS will continue
to revalidate enrollment information for Ambulance Service Suppliers in
accordance with regulations set forth at Sec. 410.41(c)(2) of this
chapter (Requirements for ambulance suppliers), and DME suppliers will
continue to renew enrollment in accordance with regulations set forth
at Sec. 424.57(e) (Special payment rules for items furnished by DMEPOS
suppliers and issuance of DMEPOS supplier billing numbers).
(2) CMS also reserves the right to perform non-routine revalidation
and request the provider or supplier to re-certify as to the accuracy
of the enrollment information when warranted to assess and confirm the
validity of the enrollment information. Non-routine revalidation may be
triggered as a result of random checks, information indicating local
problems, national initiatives, complaints, or other reasons that cause
CMS to question the integrity of the provider or supplier in its
relationship with the Medicare program. Like routine revalidation, non-
routine revalidation may or may not be accompanied by site visits.
Sec. 424.520 Additional provider and supplier requirements for
enrolling and maintaining active enrollment status in the Medicare
program.
(a) Certifying compliance. CMS enrolls and maintains an active
enrollment status for a provider or supplier when that provider or
supplier certifies that it meets, and continues to meet, and CMS
verifies that it meets, and continues to meet, all of the following
requirements:
(1) Compliance with Title XVIII of the Social Security Act and
applicable Medicare regulations.
(2) Compliance with Federal and State licensure, certification and
regulatory requirements, as required, based on the type of services or
supplies the provider or supplier type will furnish and bill Medicare.
(3) Not employing or contracting with individuals or entities--
(i) Excluded from participation in any Federal health care
programs, for the provision of items and services covered under the
programs, in violation of section 1128A(a)(6) of the Act; or
(ii) Debarred by the General Services Administration (GSA) from any
other Executive Branch procurement or non-procurement programs or
activities, in accordance with the Federal Acquisition and Streamlining
Act of 1994, and with
[[Page 22084]]
the HHS Common Rule at 45 CFR part 76.
(b) Reporting requirements. Following enrollment, a provider or
supplier must report to CMS any changes to the information furnished on
the CMS 855 or supporting documentation within 90 calendar days of the
change, with the exception of changes in ownership or control of the
provider or supplier which must be reported within 30 calendar days.
Failure to do so may result in the deactivation or revocation of the
provider or supplier's Medicare billing number.
Sec. 424.525 Rejection of a provider or supplier's CMS 855 for
Medicare Enrollment
(a) Reasons for rejection. CMS rejects a provider or supplier's CMS
855 for the following reasons:
(1) The provider or supplier fails to furnish complete information
within 60 calendar days of CMS's request for the information as
required.
(2) The provider or supplier fails to furnish supporting
documentation within 60 calendar days of CMS's request for the
documentation as required.
(b) Extension of 60-day period. CMS will not reject any provider or
supplier enrollment application if the provider or supplier is actively
communicating with CMS to resolve any issues regardless of the length
of time it takes to resolve those issues.
(c) Resubmission after rejection. To enroll in Medicare and obtain
a Medicare billing number and billing privileges after notification of
a rejected CMS 855, the provider or supplier must complete and submit a
new CMS 855 and all applicable documentation for CMS review and
approval.
Sec. 424.530 Denial of enrollment.
(a) Reasons for denial. CMS may deny a provider or supplier's
enrollment in the Medicare program for the following reasons:
(1) Compliance. The provider or supplier at any time is found not
to be in compliance with the Medicare enrollment requirements described
in the CMS 855 enrollment form applicable to the type of provider or
supplier enrolling, and has not submitted a plan of corrective action
as outlined in part 488 of this chapter and under section 1819(h)(2)(c)
of the Act.
(2) Provider or supplier conduct. The provider or supplier, or any
owner, managing employee, or an authorized or delegated official; or
any medical director, supervising physician, or other health care
personnel furnishing Medicare reimbursable services who is required to
be reported on the CMS 855, in accordance with section 1862(e)(1) of
the Act,--
(i) Is excluded from the Medicare, Medicaid and any other Federal
health care programs, as defined in Sec. 1001.2 of this title, in
accordance with section 1128 or 1156 of the Act; or
(ii) Is debarred, suspended, or otherwise excluded from
participating in any other Federal procurement or non-procurement
activity in accordance with FASA section 2455; or
(3) Felonies. The provider, supplier, or any owner of the provider
or supplier, has been convicted of a Federal or State felony offense
that CMS has determined to be detrimental to the best interests of the
program and its beneficiaries. The conviction must have occurred within
the last 10 years or more and CMS will consider the severity of the
underlying offense.
(i) Offenses include--
(A) Felony crimes against persons (such as rape, murder, or
assault) and other similar crimes for which the individual was
convicted, including guilty pleas and adjudicated pre-trial diversions.
(B) 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 pre-
trial diversions.
(C) 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).
(D) Any felonies outlined in section 1128 of the Act.
(ii) Denials 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.
(4) False or misleading information. The provider or supplier has
submitted false or misleading information on the CMS 855 to gain
enrollment in the Medicare program. (Offenders may be referred to the
Office of Inspector General for investigation and possible criminal,
civil, or administrative sanctions).
(5) Onsite review. Upon onsite review or other reliable evidence--
(i) There are repeated instances in which we do not find present or
available those medical professionals required under the Medicare
statute and regulations to supervise treatment of, or provide Medicare
covered services for, Medicare patients; or
(ii) We determine that the provider or supplier is not operational
to furnish Medicare covered services.
(b) Resubmission after denial. A provider or supplier that is
denied enrollment in the Medicare program must not submit a new CMS 855
until the following has occurred:
(1) If the denial was not appealed, the provider or supplier may
reapply after its appeal rights have lapsed.
(2) If the denial was appealed, the provider or supplier may
reapply after CMS notification that the original determination has been
upheld.
(c) Reversal of denial. If the denial was due to adverse activity
(sanction, exclusion, debt, felony) of an owner, managing employee, or
an authorized or delegated official; or of a medical director,
supervising physician, or other health care personnel of the provider
or supplier furnishing Medicare reimbursable services, the denial may
be reversed if the provider or supplier terminates and submits proof
that it has terminated its business relationship with that individual
or organization within 30 days of the denial notification.
(d) Additional review. When a provider or supplier is denied
enrollment in Medicare, CMS automatically reviews all other related
Medicare enrollment files that the denied provider or supplier has an
association with (for example, as an owner or managing employee) to
determine if the denial warrants an adverse action of the associated
Medicare provider or supplier.
Sec. 424.535 Revocation of enrollment and billing privileges in the
Medicare program.
(a) Reasons for revocation. We may revoke a currently enrolled
provider or supplier's Medicare billing privileges and any
corresponding provider agreement for the following reasons:
(1) Non-compliance. The provider or supplier, at any time is
determined not to be in compliance with the enrollment requirements
described in the CMS 855 enrollment form applicable to its provider or
supplier type and has not submitted a plan of corrective action as
outlined in part 488 of this chapter and under section 1819(h)(2)(C) of
the Act. All providers and suppliers will be granted an opportunity to
correct the deficient compliance requirement prior to a final
determination to revoke billing privileges.
(i) CMS may request additional documentation from the provider or
supplier to determine compliance if adverse information is received or
otherwise found concerning the provider or supplier.
[[Page 22085]]
(ii) Requested additional documentation must be submitted within 60
calendar days of request.
(2) Provider or supplier conduct. The provider or supplier, or any
owner, managing employee, authorized or delegated official, medical
director, supervising physician, or other health care personnel of the
provider or supplier is--
(i) Excluded from the Medicare, Medicaid, and any other Federal
health care program, as defined in Sec. 1001.2 of this title, in
accordance with section 1128 or 1156 of the Act; or
(ii) Is 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.
(3) Felonies. The provider, supplier, or any owner of the provider
or supplier, has been convicted of a Federal or State felony offense
that CMS has determined to be detrimental to the best interests of the
program and its beneficiaries. The conviction must have occurred within
the last 10 years or more and CMS will consider the severity of the
underlying offense.
(i) Offenses include--
(A) Felony crimes against persons (such as rape, murder, or
assault) and other similar crimes for which the individual was
convicted, including guilty pleas and adjudicated pre-trial diversions.
(B) 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 pre-
trial diversions.
(C) 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.
(D) Any felonies outlined in section 1128 of the Act.
(ii) Denials 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.
(4) False or misleading information. The provider or supplier
certified as ``true'' false or misleading information on the CMS 855 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 law and regulations.)
(5) Onsite review. CMS determines, upon onsite review, that the
provider or supplier is no longer operational to furnish Medicare
covered services or supplies, or we do not find present or available
those professionals required under Medicare statute or regulation to
supervise treatment of, or to provide Medicare covered services for,
Medicare patients.
(6) Inadequate re-verification information. The provider or
supplier fails to furnish complete and accurate information and any
applicable documentation within 60 calendar days of the provider or
supplier's notification from CMS to resubmit and certify to the
accuracy of its enrollment information.
(7) Misuse of billing number. 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 who enter
into a valid reassignment of benefits as outlined in Sec. 424.80.
(b) Effect of revocation on provider agreements. When a provider's
or supplier's billing privilege has been revoked, any provider
agreement in effect at the time of revocation will be terminated
effective with the date of revocation.
(c) Re-enrollment after revocation. If a provider or supplier seeks
to re-establish enrollment in the Medicare program after notification
that its billing number and billing privileges have been revoked
(either after the appeals process is exhausted or in place of the
appeals process) the following conditions apply:
(1) The provider or supplier must re-enroll in the Medicare program
through the completion and submission of a new applicable CMS 855 and
applicable documentation, as a new provider or supplier, for validation
by CMS.
(2) Providers must be re-surveyed and/or re-certified by the State
Survey Agency as a new provider and must establish a new provider
agreement with CMS's Regional Office.
(d) Reversal of revocation. If the revocation was due to adverse
activity (sanction, exclusion, debt, 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 if the provider or supplier terminates and submits proof
that it has terminated its business relationship with that individual
within 30 days of the revocation notification.
(e) Additional review. When a provider or supplier is revoked from
the Medicare program, CMS automatically reviews all other related
Medicare enrollment files that the revoked provider or supplier has an
association with (for example, as an owner or managing employee) to
determine if the revocation warrants an adverse action of the
associated Medicare provider or supplier.
Sec. 424.540 Deactivation of Medicare billing privileges.
(a) Reasons for deactivation. CMS deactivates a provider or
supplier's Medicare billing privileges for the following reasons:
(1) The provider or supplier does not submit any Medicare claims
for two consecutive calendar quarters (6 months), unless current policy
or regulations specify otherwise for your provider or supplier type.
(2) The provider or supplier does not report a change to the
information supplied on its CMS 855 within 90 calendar days of when the
change occurred. Changes that must be reported include, but are not
limited to, a change in practice location, a change of any managing
employee, and a change in billing services. A change in ownership or
control must be reported within 30 calendar days as stated in
Sec. Sec. 424.520(b) and 424.550(b).
(b) Reactivation of billing privileges. The provider or supplier
must either complete and submit a new CMS 855 to reactivate its
Medicare billing number and billing privileges or, at a minimum, re-
certify that the enrollment information currently on file with Medicare
is correct. The provider or supplier must meet all current Medicare
requirements in place at the time of reactivation, and be prepared to
submit a valid Medicare claim. Reactivation of a Medicare billing
number does not require a new survey and certification of the provider
or supplier by the State Survey Agency or the establishment of a new
provider agreement.
(c) Effect of deactivation. Deactivation of Medicare billing
privileges is considered a temporary action to protect the provider or
supplier from misuse of Medicare billing numbers and to protect the
Medicare trust fund from unnecessary overpayments. The temporary
deactivation of a Medicare billing number will not have any effect on a
provider or supplier's participation agreement or any conditions of
participation.
[[Page 22086]]
Sec. 424.545 Provider and supplier appeal rights.
(a) A provider or supplier that has been denied enrollment in the
Medicare program or whose Medicare enrollment has been revoked may
appeal CMS's decision in accordance with part 405, subpart H, for
suppliers, or part 498, subpart A for providers, of this chapter, which
set forth the appeals process for providers and suppliers. When
revocation of billing privileges also results in the termination of a
corresponding provider agreement, the provider may appeal CMS's
decision in accordance with part 489 with the final decision of the
appeal applying to both the billing privileges and the provider
agreement. No payment will be made during the appeals process. If the
provider or supplier is successful in overturning a denial or
revocation unpaid claims for services furnished during the overturned
period may be resubmitted.
(b) A provider or supplier whose billing privileges have been
deactivated may file a rebuttal in accordance with Sec. 405.374 of
this chapter.
Sec. 424.550 Prohibitions on the sale or transfer of billing
privileges.
(a) General rule. A provider or supplier is prohibited from selling
its Medicare billing number or privileges to any individual or entity,
or allowing another individual or entity to use its Medicare billing
number.
(b) Change of ownership. In the case of a provider undergoing a
change of ownership in accordance with part 489, subpart A of this
chapter, the current owner and the prospective new owner must complete
and submit a CMS 855 before completion of the change of ownership. If
the current owner fails to complete and submit a CMS 855 to report the
change, they may be sanctioned or penalized, even after the date of
ownership change, in accordance with Sec. Sec. 424.520, 424.540, and
489.53 of this chapter. If the prospective new owner fails to submit a
new CMS 855 containing information concerning the new owner within 30
days of the change of ownership, CMS may deactivate the Medicare
billing number. If an incomplete CMS 855 is submitted, CMS may also
deactivate the Medicare billing number based upon material omissions on
the submitted CMS 855, or based on preliminary information received or
determined by CMS that makes CMS question whether the new owner will be
ultimately granted a final transference of the provider agreement.
(c) Providers and suppliers not covered by part 489 of this
chapter. For those providers and suppliers not covered by part 489, any
change in the ownership or control of the provider or supplier must be
reported on their CMS 855 within 30 days of the change as noted in
Sec. 424.540(a)(2). Generally, a change of ownership which also
changes the tax identification number will require the completion and
submission of a new CMS 855 from the new owner.
Sec. 424.555 Payment liability.
(a) No payment may be made for services furnished to a Medicare
beneficiary by suppliers of durable medical equipment, prosthetics,
orthotics, and other supplies unless the supplier obtains (and renews,
as set forth in section 1834(j) of the Act) Medicare billing
privileges.
(b) No payment may be made for covered services furnished to a
Medicare beneficiary by a provider or supplier if the billing
privileges of the provider or supplier have been deactivated, denied,
or revoked. The Medicare beneficiary has no financial responsibility
for such expenses, and the provider or supplier must refund on a timely
basis to the Medicare beneficiary any amounts collected from the
Medicare beneficiary for these covered services.
(c) If any provider or supplier furnishes a service for which
payment may not be made by reason of paragraph (b) of this section, any
expense incurred for such service shall be the responsibility of the
provider or supplier. The provider or supplier may also be criminally
liable for pursuing payments that may not be made by reason of
paragraph (b) of this section, in accordance with section 1128A(a)(6)
of the Act.
PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL
7. The authority citation for part 489 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
8. In Sec. 489.53, paragraph (a)(15) is added to read as follows:
Sec. 489.53 Termination by CMS.
(a) * * *
(15) It had its enrollment in the Medicare program revoked pursuant
to Sec. 424.535 of this chapter.
* * * * *
PART 498--APPEALS PROCEDURES FOR DETERMINATIONS THAT AFFECT
PARTICIPATION IN THE MEDICARE PROGRAM AND FOR DETERMINATIONS THAT
AFFECT THE PARTICIPATION OF ICFS/MR AND CERTAIN NFS IN THE MEDICARE
PROGRAM
9. The authority citation for part 498 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
10. In Sec. 498.3, paragraph (b)(16) is added to read as follows:
Sec. 498.3 Scope and applicability.
* * * * *
(b) * * *
(16) Whether a provider or supplier has had its Medicare enrollment
revoked pursuant to Sec. 424.535 of this chapter.
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.774,
Medicare--Supplementary Medical Insurance Program.)
Dated: October 19, 2001.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.
Approved: January 10, 2003.
Tommy G. Thompson,
Secretary.
BILLING CODE 4120-01-P
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[Federal Register: April 25, 2003 (Volume 68, Number 80)]
[Proposed Rules]
[Page 22113-22162]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr25ap03-15]
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[Federal Register: April 25, 2003 (Volume 68, Number 80)]
[Proposed Rules]
[Page 22163-22212]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr25ap03-16]
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[Federal Register: April 25, 2003 (Volume 68, Number 80)]
[Proposed Rules]
[Page 22213-22262]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr25ap03-17]
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[[Continued on page 22263]]
[Federal Register: April 25, 2003 (Volume 68, Number 80)]
[Proposed Rules]
[Page 22263-22265]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr25ap03-18]
[[pp. 22263-22265]] Medicare Program; Requirements for Establishing and Maintaining
Medicare Billing Privileges
[[Continued from page 22262]]
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[FR Doc. 03-9943 Filed 4-24-03; 8:45 am]
BILLING CODE 4120-01-P