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Provider Enrollment Review Process

Institutional providers that are initially enrolling in Medicare, adding a practice location, or revalidating their enrollment information per 42 CFR §424.515, are required to submit an application fee. If using Internet-based PECOS to submit your CMS-855A enrollment application, the fee is paid as part of that process. If you submit a paper CMS-855A application, the application fee is paid on the Centers for Medicare & Medicaid Services (CMS) website.

For paper applications, if the fee is paid before the application is submitted, please include a copy of the payment confirmation with your application. Your application will not be accepted until confirmation of the application fee is received. If the application fee is not submitted with the application, your facility will be sent a letter requesting payment. Payment must be received within 30 days of the date of the letter. Failure to submit the application fee within this time period will result in initial enrollment or new location applications to be denied pursuant to 42 CFR 424.530(a)(9), or a current Medicare provider's billing privileges will be revoked pursuant to 42 CFR 424.530(a)(6).

Fingerprint-Based Background Checks

Fingerprint-based background checks are generally completed on individuals with a 5 percent or greater ownership interest in a provider or supplier that falls under the high risk category. A 5 percent or greater owner includes any individual that has any partnership in a high risk provide or supplier.

NOTE: The high level of risk category applies to home health agencies who submit an initial enrollment application. As a result, this request may delay the processing of home health initial applications.

Process Timeline

CMS-855A applications are typically completed within 45-60 calendar days from receipt. Extenuating circumstances may extend these time frames. The following summarized the review process.

  • Within 3-10 days after receipt of an enrollment application, CGS will issue an acknowledgement letter with a reference number.
  • Enter the reference number on the CGS Application Status Check tool on the CGS website to check the status of your application.
  • Within 15-20 days after receipt of an enrollment application, a development letter will be issued if additional information is needed.
    • An email is the preferred method of communication. Additional information will be requested via email to the contact person listed in Section 13 of the CMS-855A.
    • Additional information must be submitted within 30 days from the request. Tips to avoid rejection due to not providing information timely include:
      • CGS is only required to contact the provider one time; therefore, it is important that you respond as soon as possible. This will allow more time for CGS to work with providers to complete the application.
      • Address all information being requested.
      • Call if you have questions about what is being requested. The contact information is included in the letter or email.
      • If development letter is sent, submit a copy of the development letter with the requested information to ensure it is matched with the correct record.
  • Tips to decrease the typical completion time:
    • Clean applications are processed quicker
    • Faster response to development request

Note: If requested information is not received, or is incomplete, the application will be rejected and a new 855A application must be submitted.

Initial Enrollment

Once the application review is complete, CGS will send a letter of recommendation (approval or denial) to the provider, State Agency, and the CMS Regional Office (RO).

  • If approved, the State Agency and the CMS Regional Office (RO) will complete the survey process and issue the Medicare provider number. Contact information is provided in the recommendation letter. This allows you to follow-up with the state or RO on the status of the provider number assignment. The process for completing the survey and issue the final determination via a CMS-2007 certification notice (also known as a Tie-In Notice) can take up to 6-9 months.

Note: CGS does not take any further action on the initial application until the tie-in notice is received.

In addition, some provider types may require a site visit once the tie-in notice is received. As a result, if any information on the initial enrollment changes, providers are required to submit updates.

It is the applicant's responsibility to submit the CMS-855A enrollment application information timely and in accordance with CMS requirements. Applications are processed in the order of receipt, and CGS cannot accommodate requests to expedite the review process.

Posted: 03.14.16

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