ABA Health eSource
 September 2006 Volume 3 Number 1

Provider Enrollment Update: CMS Issues New Instructions to Contractors
by Mandy C. Foster, Sullivan Stolier Resor, APLC, New Orleans, LA and Stephen Sullivan, Sullivan Stolier Resor, APLC, Lafayette, LA

Mandy Foster and Stephen SullivanIt is no secret to those who work on the provider enrollment side of the Medicare process that getting an enrollment application through a fiscal intermediary in a timely fashion can be trickier than making a field goal from the 50-yard line: all the training and preparation in the world may not be enough without a little luck on your side. In July 2006, however, CMS announced revisions to the instructions to its contractors regarding the enrollment process. These changes may get providers a little closer to the goal of timely enrollment.

Effective July 3, 2006, CMS revised Chapter 10 of the Medicare Program Integrity Manual ("Manual"). This chapter includes instructions to fiscal intermediaries ("FIs") on how to process CMS 855 applications for provider participation in Medicare. Under the revisions, FIs must process applications for initial enrollments, acquisitions and mergers, and changes of ownership within the following timeframes:

  • 80 percent of applications must be processed within 60 calendar days of receipt;
  • 90 percent of applications must be processed within 120 calendar days of receipt; and
  • 99 percent of applications must be processed within 180 calendar days of receipt.

The Manual states that these processing time clocks for initial applications cannot be stopped or suspended for any reason. The Manual instructs FIs to document and explain any special circumstances that require an application to be processed beyond the 60-day timeframe.

These timeframes only begin when the FI has completed what is called the "pre-screening" process. Within 15 days after the application is received in the FI's mailroom, the FI must complete a review of the application to determine if any data element or supporting documentation is missing. Prior to the Manual revisions, the FI was entitled to return the application to the provider if any items were deemed missing during the pre-screening process. This effectively removed the application from the queue and could result in significant delays. Section 3.1 of Chapter 10 of the Manual now states that when an application arrives with a missing data element, or without supporting documentation, the FI "shall send a letter to the provider -- preferably by e-mail or fax" with a list of elements needed. The ability to receive notice via e-mail and fax should reduce delays in processing.

The FI is permitted to impose its own timeframe on when the missing items must be submitted. A newly signed statement certifying that the information reported on the application is accurate is required for missing data elements, but not for supporting documentation.

Section 3.1 of Chapter 10 of the revised Manual also discusses the grounds for rejecting an application. The FI may reject the application if the provider fails to furnish all of the information and documentation requested in the prescreening letter within 60 calendar days of the FI's request for missing items.

Section 3.2 of Chapter 10 of the revised Manual discusses the grounds for returning an application, rather than waiting for the missing data elements.

These grounds include:

  • Failing to include an original, dated signature;
  • using an old 855 form or an 855 form intended for use by another type of provider;
  • submitting the application more than three months before an anticipated change of ownership; and
  • submitting the application by a method other than mail.

According to the Manual, the difference between a "rejected" application and a "returned" application is that an application may be rejected if the provider fails to respond to a request for more information; on the other hand, a returned application is essentially a non-application.

Being familiar with the Medicare Program Integrity Manual can help providers negotiate any snags in the enrollment process. Relevant portions of the Manual can be found at http://www.cms.hhs.gov/manuals/downloads/pim83c10.pdf.