CMS issues new forms for medicare provider enrollment - Medicare/Medicaid - Centers for Medicare and Medicaid Services

In its continual efforts to manage Medicare provider enrollment, CMS has revised its provider application forms. Along with the revised forms is a new requirement for a three-year cycle revalidation process that could present a considerable challenge to large providers. Also of note are longer processing periods for initial enrollment, suspension of payments if current address information is not maintained, and deactivation of a provider's number if 12 months pass without claim activity Improvements that providers may appreciate include electronic access to forms and a decrease in the amount of in formation required to enroll.

The Centers for Medicare and Medicaid Services (CMS) considers provider enrollment critical to ensure that only qualified, eligible individuals and entities receive payment for services furnished to Medicare beneficiaries. In recent years, the HHS Office of Inspector General (OIG) has focused predominantly on the crackdown on fraud and abuse by government third-party payers. This attention and, more specifically, the introduction of the 855 form in 1998, have resulted in a substantial increase in the amount of information providers must supply to enroll in the Medicare program.

Revalidation. Perhaps the most significant long-term change is a requirement that all providers need to be revalidated every three years. One-third of the providers would be selected for revalidation each year. The methodology for cycling of the providers' revalidation has not been determined at this time. However, it is expected that the first two years would be random, and then the third year would cover the remaining pool of providers not yet revalidated. The cycle then would repeat.

The revalidation process would require a new enrollment form for most providers, but providers with general application 855 forms on file may submit a photocopy of those forms instead, provided changes have not occurred since initial filing. The photocopy must be submitted with a new original signature and date to attest that there have been no changes. Only providers that have enrolled since the updated forms were introduced in 1998 would have this form on file.

Whether CMS actually will allow resubmission of the forms remains uncertain, as the original 855 forms officially became invalid when the new ones were introduced in January 2002. Also, because the goal is to have all providers enroll in Medicare in a uniform manner, conventional wisdom would suggest that all providers would be required to file their revalidations on the new forms.

The impact of the revalidation requirement would be dramatic for large providers, such as academic medical centers, large group practices, and hospital systems that employ large groups of physicians. Under the requirement, for example, if an academic medical center has 600 providers, 200 of those providers would need to be revalidated annually--a situation posing a heavy administrative burden to maintain compliance. To date, implementation of the revalidation requirement has been delayed indefinitely.

Format. Although the new forms affected by the change are longer (eg, the entire 8551 form is 67 pages), they may be easier to complete, because instructions are posted on every other page. Exhibit 1 lists the newly required forms.

Another advantage to the new forms is that they can be accessed via the Internet (www.hcfa/gov/medicare/enrollment/forms) Providers can either complete the forms on-line or print them in a PDF format and then fill them out on paper. One benefit to the on-line version is that prompts alert the provider when required fields are incomplete or, in some instances, if the information provided is not appropriate. No matter which method is used, a final paper copy must be sent to CMS to provide original signatures and dates.

Additional required information. Information required for completion of the application has been expanded on the new forms. The location of patient records needs to be identified in detail. In addition, individual providers now are required to disclose gender. Absence of either of these items from the forms can result in denial of the application.

Notification of changes. Modifications in a provider's enrollment, such as changes of address or ownership, have to be reported to CMS via the local carrier or intermediary within 30 days. There no longer is an 855C change-of-information form. Changes now must be reported on the appropriate enrollment form. If CMS discovers that a change was not reported within 30 days, the agency may deactivate the provider's number.

Employer identification number. CMS has changed the group/clinic application by requiring that the employment identification number correspond with the provider's name on IRS Form CP575, which continues to be a required attachment.

Tax identification number. Solo practitioners now will practice under a tax identification number instead of their social security numbers. To receive this number, individuals need to enroll the office as a clinic/group and then reassign benefits to themselves. Prior to 2002, the solo practitioner could opt to enroll as a clinic or sole provider.

National provider identification. In 1996, CMS announced its intention to adopt a national provider identification number (NPI) for providers that would serve as the only provider number to cross all states. Although rollout of NPI implementation has been postponed for the past five years, it now is slated for 2003. CMS plans to work with commercial payers so that they also adopt the NPI. In this regard, the simplification would be a strong move toward standardization.

Returned applications. CMS occasionally returns an enrollment application to a provider for reasons such as missing information, illegible attachments, or missing signatures and/or dates. In such an instance, the provider must supply the requested information within 60 days. If the provider responds within this period, the application typically returns to its original place in the processing cycle. If the provider misses this deadline, the application is rejected and the provider must begin the process anew, with a new signature and date. Prior to 2002's revisions, the process for returned applications was not consistent. For instance, Illinois might allow the application to go back into its original processing slot and Missouri might not. Now, the process will be applied uniformly to all providers.

Processing periods. CMS determines the application-processing schedule of local carriers. In 2002, the time frame for an initial enrollment is 60 days, compared with 45 days in 2000-01. If a provider's application is rejected, the new application will once again be subjected to the 60-day processing standard.

Signature and date comparison. Original signature and date always have been required on provider enrollment applications. What providers may not have realized, however, is that copies of enrollment forms can be submitted as long as the signature is original and the date is current.

For instance, if a Form 855B is returned to a provider for additional information, the information can be provided on the copy, but the provider has to sign and date the application again. (Blue ink is recommended to show that the signature and date are new.) Effective in 2002, signatures on all changes and revalidations will be compared against the original Form 855 on file. Applications with signatures that do not match will be returned for clarification.

Electronic fund transfer (EFT) and electronic data interchange (EDI). Submission guidelines for forms requesting an EFT or EDI have changed. New entities that intend to submit claims and receive payments electronically now are required to send those forms with the enrollment applications.

Backdating. Although managed care organizations traditionally have banned backdating of provider numbers and effective dates, CMS has allowed this practice. To date, CMS has allowed applicants to request an effective date for their enrollment. The requested date may be earlier than the date the application is filed. With this benefit, a physician who does not have Medicare patients might treat a new patient who is qualified for Medicare benefits. The physician then may submit a Medicare enrollment application with a backdated requested effective date to cover the patient's treatment.