Medicare Provider Enrollment: Understanding Reactivation Policies & Billing Privileges (CR 8901)

For healthcare providers, maintaining active Medicare billing privileges is crucial for uninterrupted revenue and patient care. Understanding the nuances of Medicare provider enrollment and provider reactivation policies is essential for compliance and avoiding disruptions. This post examines key changes introduced by Change Request (CR) 8901, initially implemented on March 18, 2015, which incorporated significant updates into Chapter 15 of the Medicare Program Integrity Manual (PIM). While CR 8901 established foundational rules, providers must always refer to the most current CMS guidelines and program integrity manual updates for definitive, up-to-date information regarding Medicare billing privilege rules.

Effective Date of Medicare Billing Privileges Upon Reactivation

One of the primary changes associated with the reactivation of Medicare billing privileges for Part B non-certified providers/suppliers pertains to the effective date. When a Medicare Administrative Contractor (MAC) approves a reactivation request, the effective date of reactivation is now the date the MAC received the complete reactivation request. This includes either the CMS-855 application for reactivation or a Reactivation Certification Package (RCP).

Defining a Part B Non-Certified Provider/Supplier

A “Part B non-certified provider/supplier” refers to a diverse group of provider types that are not Ambulatory Surgical Centers (ASCs) or Portable X-ray suppliers. This category is broad and includes, but is not limited to, individual physicians, physician assistants, nurse practitioners, physical therapists, occupational therapists, speech-language pathologists, chiropractors, independent diagnostic testing facilities (IDTFs), and ambulance suppliers. This distinction is important because the specific reactivation rules, including the effective date of billing privileges and the issuance of a new Provider Transaction Access Number (PTAN), primarily apply to this group.

Obtaining a New Provider Transaction Access Number (PTAN) Upon Reactivation

In conjunction with the reactivation of billing privileges for a Part B non-certified provider/supplier, the MAC will issue a new Provider Transaction Access Number (PTAN). It’s crucial for providers to understand that they do not actively “obtain” a new PTAN; rather, it is assigned by CMS through their MAC as part of the reactivation process. Upon approval, providers should anticipate receiving communication from their MAC detailing their new PTAN. Key steps and implications include:

Monitoring Communications: Providers must closely monitor their correspondence from the MAC following reactivation application submission.
Updating Systems: The new PTAN must be updated in all billing software, electronic health record (EHR) systems, and any third-party credentialing platforms to ensure accurate claims submission.
Impact on Claims: Using an outdated PTAN can lead to claim rejections and significant delays in reimbursement.
PECOS Verification: Providers can typically verify their new PTAN through the Provider Enrollment, Chain, and Ownership System (PECOS) once the reactivation is processed.

Reasons for Medicare Enrollment Denial or Revocation

CMS maintains strict guidelines regarding provider enrollment and has the authority to deny applications or revoke existing enrollments under various circumstances. Understanding these potential pitfalls is critical for maintaining Medicare billing privileges and ensuring compliance. Here are detailed explanations for common reasons related to prescription privileges and drug-related issues:

Denial of Enrollment (§ 424.530(a)(11))

A physician’s or eligible professional’s Form CMS-855 enrollment application may be denied if:

Suspension or Revocation of DEA Certificate: The physician’s or eligible professional’s Drug Enforcement Administration (DEA) Certificate of Registration to dispense controlled substances is currently suspended or revoked. This highlights the critical importance of maintaining an active and valid DEA certificate for any provider authorized to prescribe controlled substances. A lapse or disciplinary action here directly impacts Medicare enrollment eligibility.
Suspension or Revocation of State Prescribing Ability: The applicable licensing or administrative body for any state in which the physician or eligible professional practices has suspended or revoked their ability to prescribe drugs. This includes situations where such suspension or revocation is in effect on the date the enrollment application is submitted to the Medicare contractor. Providers must ensure their state licenses and prescribing authorities are in good standing across all practice locations.

Revocation of Enrollment Due to Prescribing Issues (§ 424.535(a)(13))

CMS may revoke a physician’s or eligible professional’s Medicare enrollment if:

DEA Certificate Suspension or Revocation: The physician’s or eligible professional’s DEA Certificate of Registration is suspended or revoked. This mirrors the denial criterion and emphasizes that an existing enrollment can be terminated if DEA privileges are compromised.
State Prescribing Ability Suspension or Revocation: The applicable licensing or administrative body for any state in which the physician or eligible professional practices has suspended or revoked their ability to prescribe drugs. This confirms that ongoing state-level prescribing disciplinary actions can lead to loss of Medicare enrollment, even if the enrollment was initially approved.

Revocation for Abusive Part D Prescribing Patterns (§ 424.535(a)(14))

CMS may revoke a physician’s or eligible professional’s Medicare enrollment if it determines that the physician or eligible professional has a pattern or practice of prescribing Part D drugs that falls into one of the following categories:

Abusive or Threatening to Beneficiary Health: The pattern or practice is determined to be abusive or represents a threat to the health and safety of Medicare beneficiaries, or both. This often involves concerns such as over-prescribing opioids, polypharmacy issues, or prescribing medications without a legitimate medical purpose. CMS utilizes data analytics to identify unusual prescribing patterns.
Failure to Meet Medicare Requirements: The pattern or practice of prescribing fails to meet established Medicare requirements. This can include non-compliance with drug utilization review guidelines, lack of proper documentation for prescribed medications, or prescribing outside the scope of practice. Providers should consult the Medicare Program Integrity Manual and relevant CMS guidance on Part D prescription drug coverage to understand these requirements.

Best Practices for Medicare Provider Enrollment Compliance

Staying compliant with Medicare’s ever-evolving provider enrollment and reactivation policies is crucial for uninterrupted billing and avoiding penalties. Providers should:

Regularly Review CMS Updates: Consistently check the CMS website and subscribe to MAC newsletters for the latest guidance and transmittals.
Maintain Accurate Records: Keep all licensure, DEA certificates, and practice information up-to-date and readily accessible.
Understand PTAN Implications: Be aware of when a new PTAN may be issued and the necessary steps to update all billing systems.
Scrutinize Prescribing Practices: Ensure all Part D prescribing aligns with current medical necessity guidelines and CMS requirements to prevent issues related to abusive patterns or non-compliance.

By proactively managing Medicare provider enrollment and understanding the implications of policies like CR 8901, healthcare professionals can safeguard their Medicare billing privileges and maintain essential services for beneficiaries.