Provider Enrollment Regulation
In order to view an actual copy of any of the documents referenced below, please click on the hyperlink at the bottom of the page for the Federal Register. Once there, please select the year in which the final rule was published and click "GO". Please continue to select the day on with the final rule was published. Scroll through the contents until you arrive at the "Centers for Medicare & Medicaid Services" section. Listed in this section will be the documents released for that specific date. Off to the side of the document title you will be able to select the formatting for your download (Text or PDF).
On April 27, 2012, we published a final rule titled "Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements" (CMS-6010-F) in the Federal Register. This rule finalized several provisions of the Affordable Care Act implemented in the May 5, 2010 interim final rule with comment period. It requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs. In addition, it requires physicians and other professionals who are permitted to order and certify covered items and services for Medicare beneficiaries to be enrolled in Medicare. Finally, it mandates document retention and provision requirements on providers and supplier that order and certify items and services for Medicare beneficiaries.
On May 16, 2012, we published a rule titled “Medicare and Medicaid Program; Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction” (CMS-9070-F) in the Federal Register. This rule eliminates the imposition of a reenrollment bar for providers and suppliers when a revocation is based on the failure of a provider or supplier to respond timely to revalidation or other requests for information.
On May 23, 2014, we published a rule titled “Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs” (CMS-4159-F) in the Federal Register. This rule requires physicians and eligible professionals who prescribe Part D drugs to be enrolled in or opted-out of Medicare; permits CMS to deny or revoke enrollment if the physician’s or eligible professional’s Drug Enforcement Administration (DEA) Certificate of Registration is suspended or revoked, or the applicable licensing or administrative body for any state in which the physician or eligible professional practices suspends or revokes the physician or eligible professional’s ability to prescribe drugs; permits CMS to revoke enrollment if the physician or eligible professional has a pattern or practice of prescribing Part D drugs that is abusive, represents a threat to the health and safety of Medicare beneficiaries or both, or the pattern or practice of prescribing fails to meet Medicare requirements. On December 5, 2014, we published a rule titled “Medicare Program; Requirements for the Medicare Incentive Reward Program and Provider Enrollment; Final Rule” (CMS-6045-F). This rule implements various provider enrollment requirements. These include: Expanding the instances in which a felony conviction can serve as a basis for denial or revocation of a provider or supplier's enrollment; if certain criteria are met, enabling us to deny enrollment if the enrolling provider, supplier, or owner thereof had an ownership relationship with a previously enrolled provider or supplier that had a Medicare debt; enabling us to revoke Medicare billing privileges if we determine that the provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements; and limiting the ability of ambulance suppliers to “backbill” for services performed prior to enrollment.
On February 2, 2011, we published a final rule with comment titled, "Medicare, Medicaid, and Children's Health insurance Programs (CHIP); Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers" in the Federal Register. This final rule with comment period will implement provisions of the ACA that establish procedures under which screening is conducted for providers of medical or other services and suppliers in the Medicare program, Medicaid program and CHIP.
On August 27, 2010, we published a final rule titled, "Medicare Program; establishing Additional Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Supplier Enrollment Safeguards" (CMS-6036-F) in the Federal Register. This final rule clarifies and expands on the existing enrollment requirements that DMEPOS suppliers must meet to establish and maintain billing privileges in the Medicare program.
On May 5, 2010, we published an interim final rule with comment titled, "Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements” in the Federal Register. This IFC will implement several of the requirements of the Patient Protection and Affordable Care Act (Affordable Care Act) (Pub. L. 111-148) designed to support the Administration's efforts to prevent and detect fraud, waste and abuse in the Medicare and Medicaid programs, and to ensure quality care for beneficiaries.
On January 2, 2009, we published a final rule titled, “Medicare Program; Surety Bond Requirement for Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); Final Rule.” Consistent with section 4312(a) of the BBA, this final rule implemented section 1834(a)(16) of the Act by requiring certain Medicare suppliers of DMEPOS to furnish CMS with a surety bond of no less than $50,000.
On November 19, 2008, we published a final rule with comment titled, “Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2009; E-Prescribing Exemption for Computer Generated Facsimile Transmissions; and Payment for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).” In part, this final rule with comment period established a number of provider enrollment provisions affecting physicians, non-physician practitioners, and other providers and suppliers, such as the re-enrollment bar of 1 to 3 years on revoked providers and suppliers, as well as the limitation on retroactive billing by providers and suppliers.
On June 27, 2008, we published a final rule titled, “Appeals of CMS or CMS Contractor Determinations When a Provider or Supplier Fails to Meet the Requirements for Medicare Billing Privileges.” This final rule implemented section 936 of the MMA and extended appeal rights to all providers and suppliers, including DMEPOS suppliers, whose enrollment applications for Medicare billing privileges are denied or revoked by CMS or a Medicare contractor (that is, carrier, fiscal intermediary, National Supplier Clearinghouse Medicare Administrative Contractor (MAC),or Part A/Part B MAC). This final rule also allowed providers and suppliers to seek judicial review after they have exhausted the administrative appeals process. In addition, this final rule also implemented provider enrollment provisions that apply to all provider and supplier types.
On November 27, 2007, we published a final rule titled, “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, and Other Part B Payment Policies for CY 2008; Revisions to the Payment Policies of Ambulance Services Under the Ambulance Fee Schedule for CY 2008; and the Amendment of the E-Prescribing Exemption for Computer Generated Facsimile Transmissions; Final Rule.” In this final rule, we clarified our interpretation of several of the existing independent diagnostic testing facility (IDTF) performance standards found at §410.33(b) and §410.33(g), proposed a new IDTF performance standard at §410.33(g)(15), and a new proposed IDTF provision at §410.33(i).
In the December 1, 2006, (71 FR 69624), we published a final rule titled, “Medicare Program; Revisions to Payment Policies, Five-Year Review of Work Relative Value Units, Changes to the Practice Expense Methodology Under the Physician Fee Schedule, and Other Changes to Payment Under Part B; Revisions to the Payment Policies of Ambulance Services Under the Fee Schedule for Ambulance Services; and Ambulance Inflation Factor Update for CY 2007.” In part, this final rule with comment established performance standards for independent diagnostic testing facilities.
On April 21, 2006, we published the Requirements for Providers and Suppliers to Establish and Maintain Medicare Enrollment final rule that implemented section 1866(j)(1)(A) of the Act. In this final rule, we required that all providers and suppliers (other than physicians or non-practitioners who have elected to “opt-out” of the Medicare program) complete an enrollment application and submit specific information to CMS in order to obtain Medicare billing privileges. This final rule also required that all providers and suppliers must periodically update and certify the accuracy of their enrollment information to receive and maintain billing privileges in the Medicare program. These regulatory provisions include requirements to protect beneficiaries and the Medicare Trust Fund by preventing unqualified, fraudulent, or excluded providers and suppliers from providing items or services to Medicare beneficiaries or from billing the Medicare program or its beneficiaries.
On October 11, 2000, we published the Additional Supplier Standards final rule with comment period where we listed the number of suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). In this rule, we established additional standards with which a DMEPOS supplier must comply in order to receive and maintain Medicare billing privileges. This final rule with comment period outlined the supplier requirements to ensure that suppliers of DMEPOS are qualified to furnish DMEPOS and to help safeguard the Medicare program and its beneficiaries from fraudulent or abusive billing practices.