Posts Tagged provider enrollment

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Authorized Official vs. Delegated Official: What’s the Difference?

Understanding the Difference Between Delegated and Authorized Officials According to Medicare

Medicare distinguishes between authorized officials and delegated officials on their enrollment forms and many people wonder what the difference is.

Authorized Official Definition

An authorized official means an appointed official (i.e. chief executive officer, chief financial officer, general partner, chairman of the board, or 5% or greater direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization’s enrollment information in the Medicare program, and to commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.

Authorized Official Authority

  • The authorized official is the only individual that has the authority to sign the initial CMS 855S application. By this signature the authorized official agrees to notify the Medicare program contractor if any of the information on the application is incorrect or untrue. Also, the authorized official agrees to notify the NSC of any changes within 30 days of the change (Supplier Standard 2).
  • An authorized official is the only individual that can add and remove delegated officials.
  • Suppliers may have as many authorized officials as desired as long as the individual meets the definition of an authorized official.

Delegated Official Definition

Delegated officials are persons who are delegated the legal authority by the authorized official to make changes to the supplier file.
A delegated official must be a W-2 employee of the supplier or an individual with 5 percent or greater direct ownership interest in, or an individual with partnership interest in the enrolling supplier. If the delegated official is the managing employee, this individual must be a W-2 employee and the NSC may request proof this individual is a W-2 employee.

Delegated Official Authority

  • A delegated official can make changes or updates to the supplier file, such as address changes or the addition of a part owner.
  • The delegated official may also sign and submit the CMS 855S to enroll additional locations, revalidate or reactivate an existing supplier.
  • A delegated official may not delegate its authority to another individual. Only the authorized official may appoint someone as a delegated official
  •  A delegated official may not sign the initial CMS 855S application for the initial location.
  • A supplier may have as many delegated officials as desired as long as the individual meets the definition of a delegated official.

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Posted in: Finance, Medicare & Reimbursement

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CMS Announces Medicare Providers Must Begin to Revalidate Enrollment By March 2013

Announcement from CMS:

All providers and suppliers who enrolled in the Medicare program prior to Friday, March 25, 2011, will be required to revalidate their enrollment under new risk screening criteria required by the Affordable Care Act (section 6401a).  Providers/suppliers who enrolled on or after Friday, March 25, 2011 have already been subject to this screening, and need not revalidate at this time.

New Screening Criteria

In the continued effort to reduce fraud, waste, and abuse, CMS implemented new screening criteria to the Medicare provider/supplier enrollment process beginning in March 2011.  Newly-enrolling and revalidating providers and suppliers are placed in one of three screening categories – limited, moderate, or high – each representing the level of risk to the Medicare program for the particular category of provider/supplier, and determining the degree of screening to be performed by the Medicare Administrative Contractor (MAC) processing the enrollment application. More information on the screening categories is here.

Notices Will Be Sent to Providers/Suppliers

Between now and March 2013, MACs will be sending notices to individual providers/suppliers; please begin the revalidation process as soon as you hear from your MAC.  Upon receipt of the revalidation request, providers and suppliers have 60 days from the date of the letter to submit complete enrollment forms.  Failure to submit the enrollment forms as requested may result in the deactivation of your Medicare billing privileges.  The easiest and quickest way to revalidate your enrollment information is by using Internet-based PECOS (Provider Enrollment, Chain, and Ownership System), at https://pecos.CMS.hhs.gov.

Fees Levied

Section 6401a of the Affordable Care Act requires institutional providers and suppliers to pay an application fee when enrolling or revalidating (“institutional provider” includes any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A; CMS-855B, not including physician and non-physician practitioner organizations; CMS-855S; or associated Internet-based PECOS enrollment applications); these fees may be paid via www.Pay.gov.

In order to reduce the burden on the provider, CMS is working to develop innovative technologies and streamlined enrollment processes – including Internet-based PECOS.  Updates will continue to be shared with the provider community as these efforts progress.

For more information about provider revalidation, review the Medicare Learning Network’s Special Edition Article #SE1126, titled “Further Details on the Revalidation of Provider Enrollment Information.”

Posted in: Medicare & Reimbursement, PECOS

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My Notes from the CMS Open Door Forum on May 19, 2010: PECOS, DMEPOS and Blue Ink on Paper Forms

CMS held a two-hour Open Door Forum today and there was so much good information shared that I thought I’d pass my notes from the call along to you.

New EFT Form

The revised EFT (Electronic Funds Transfer) authorization form 588 is available here (pdf.) The old form will still work for a few months longer before it becomes invalid.

Changes to the Medicare Program Integrity Manual

The Program Integrity Manual (publication 100-08) will have revisions related to the changes in provider enrollment.  The online-only manual here will have content moved from Chapter 10 to Chapter 15 and the provider enrollment information will be easier to understand. 🙂

The Question on Everyone’s Lips

How do I know if I’m listed in PECOS (Provider Enrollment and Chain/Ownership System) and how do I know if others are listed in PECOS?  A new downloadable file is now available here (12,000 pages!) and everyone listed in this Ordering/Referring file has approved enrollment status.  Anyone not appearing on this list is not in approved status, or has opted completely out of the Medicare program.

Advanced Diagnostic Imaging

Beginning in January 2012, all diagnostic magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine imaging such as positron emission tomography (PET) must be performed in a facility accredited by the American College of Radiology (ACR), The Joint Commission (TJC) or the Intersocietal Accreditation Commission (IAC) for the technical component of the test to be reimbursed by Medicare.  This rule does not apply to x-rays, ultrasound, fluoroscopy, mammography or DEXA scans and does not apply to any professional component.

Hospital Revalidations

Hospitals not enrolled in PECOS or not receiving EFT (Electronic Funds Transfer) will be contacted by CMS in an attempt to get all hospitals revalidated.

PECOS (pronounced “pay-cose”)

CMS recommends that anyone with questions or just getting started in PECOS read the “Getting Started Guide”, of which there are two versions, both available here in pdf form.  One is for providers and one is for suppliers of DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.) You need to know your corporate structure before getting started because the business must enroll before the providers can assign benefits to the business.  The 855I is for individual/solos providers and the 855B is for non-individuals (multiple owners) billing Medicare Part B and assigning benefits to a legal entity/corporation.  Dentists and pediatricians who order or refer services for Medicare patients are required to have an enrollment record in the PECOS. Residents and interns are exempt from the enrollment requirement, but an attending physician needs to be identified on the claim when a service is ordered or referred. The main page for enrollment is https://www.cms.gov/MedicareProviderSupEnroll/

Two Ways to Get Into PECOS

One is to complete the paper form in BLUE INK (and if time is of the essence CMS suggests that you use the paper form) and let the MAC enter it into PECOS for you.  The other is to use the internet-PECOS system directly, and sign, date and mail the certification statement to complete the process.  Submit the participation form or EFT form if required.  The certification form for the paper process is NOT the same as the certification from for the internet-PECOS process.

What is the 30-day rule?

The 30-day rule states that you can bill for services provided to Medicare patients up to 30 days prior to your filing date.  The filing date is the date your enrollment is accepted, not the date you mailed it.  Online it will say “Status Approved”, and you will receive an email, and then a letter confirming it. You will appear on the Ordering/Referring file on the CMS website.

What happens to payments for patients that were referred by a provider not enrolled on PECOS?

Even though you are enrolled, if the referring physician is not enrolled, you will not be paid for that patient’s services.  However, if that referrer becomes enrolled, you can resubmit the claim and it will be paid.

What happens on July 6, 2010? When does this happen?

July 6, 2010 The compliance date for Part A providers (hospitals, skilled nursing homes and home health agencies) and Part B providers (physicians, ambulance) must be enrolled in PECOS as ordering/referring physicians for payments to be made has been delayed indefinitely!

What happens on July 13, 2010?

DMEPOS (pronounced “demmy-pos”) providers must be enrolled in PECOS to receive Medicare payments.

What should be done if a provider leaves a group?

The provider or his Authorized Official (CEO, CFO, Manager) should file a 855R or make the change in PECOS as soon as possible.

Why do provider offices still request UPINs from our office?

Unclear.  UPINs were no longer required as of May 23, 2008.  The NPI is the only number accepted on Medicare claims.

Should the information submitted on a 855 be the same information in PECOS?

Yes, if it isn’t, contact the Help Desk.  Their toll-free number is 1-866-484-8049 and their e-mail address is eussupport@cgi.com.

For more information on the nuts and bolts of PECOS, see my post here.

Posted in: Headlines, Medicare & Reimbursement, PECOS

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May 19, 2010 Centers for Medicare & Medicaid Services Special Open Door Forum: Medicare Provider & Supplier Enrollment

The Centers for Medicare & Medicaid Services (CMS) will hold a Special Open Door Forum (ODF) to discuss Medicare provider enrollment issues. During this call, CMS staff will discuss:

  • The May 5, 2010 provider enrollment regulation titled, “Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements (CMS-6010-IFC)”
  • Medicare ordering and referring issues, including physician notification
  • Documentation requirements
  • Internet-based Provider Enrollment, Chain and Ownership System (PECOS)
  • Physician, non-physician practitioner, provider and supplier organizations
  • Upcoming availability of Internet-based PECOS for DMEPOS suppliers
  • Pharmacy accreditation issues
  • Advanced diagnostic imaging accreditation
  • Provider and supplier reporting responsibilities
  • Revalidation efforts

Afterwards, there will be an opportunity for the public to ask questions.

May 19, 2010
3:00PM – 5:00PM ET
2:00 PM – 4:00 PM CT

Open Door Forum Instructions:

Capacity is limited so dial in early. You may begin dialing into this forum as early as 2:45 PM ET.

Dial: 1-800-603-1774

Reference Conference ID 61448973

Read my post on the date change for PECOS enrollment that relates to CMS-6010-IFC here.

Posted in: Medicare & Reimbursement, PECOS

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CMS Announces Delay in PECOS Use Until January 3, 2011

NOTE: The date has been changed to July 5, 2011.delayed indefinitely.

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A collective sigh of relief was heard across the land as it was revealed today during the CMS Open Door Forum that the requirement for providers to be enrolled in PECOS has been delayed until January 3, 2011.

Part B MACs (Medicare Administrative Contractors) will be sending revalidation letters to all providers who have not updated their Medicare enrollment since November of 2003, asking them to submit a paper enrollment form or to use the electronic enrollment system PECOS (Provider Enrollment, Chain and Ownership System.) This proactive stance on the part of CMS should help the many managers who have been desperately trying to determine if their providers are in PECOS or not.

An audio recording of today’s call will be available on the ODF website here and will be accessible for downloading on or around Monday March 1, 2010 and available for 30 days.

For automatic emails of Open Door Forum schedule updates (E-Mailing list subscriptions) and to view Frequently Asked Questions click here.

Posted in: Headlines, Medicare & Reimbursement, PECOS

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