Provider Enrollment

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42 CFR § 424.205

Requirements for Medicare Diabetes Prevention Program suppliers.

This provision establishes the enrollment, operational, documentation, and coach eligibility standards for suppliers participating in the Medicare Diabetes Prevention Program.

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42 CFR § 424.500

Scope.

This provision outlines the requirements for provider enrollment, revalidation, and reporting changes to enrollment information for Medicare billing purposes.

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42 CFR § 424.502

Definitions.

As used in this subpart, unless the context indicates otherwise—

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42 CFR § 424.505

Basic enrollment requirement.

This provision mandates that providers and suppliers must be enrolled in the Medicare program to receive payment for covered items or services.

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42 CFR § 424.506

National Provider Identifier (NPI) on all enrollment applications and claims.

This provision requires providers to report their National Provider Identifier (NPI) on enrollment applications and all submitted claims to ensure proper identification.

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42 CFR § 424.507

Ordering covered items and services for Medicare beneficiaries.

This provision establishes the requirements for physicians and eligible professionals to be enrolled in Medicare to order covered imaging, clinical laboratory services, DMEPOS, home health, and hospice services.

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42 CFR § 424.510

Requirements for enrolling in the Medicare program.

This provision details the enrollment requirements for providers and suppliers, including application submission, documentation, signature authority, and on-site review processes.

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42 CFR § 424.514

Application fee.

This provision establishes the requirement for institutional providers to submit an application fee or a hardship exception request when enrolling or revalidating Medicare billing privileges.

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42 CFR § 424.515

Requirements for reporting changes and updates to, and the periodic revalidation of Medicare enrollment information.

To maintain Medicare billing privileges, a provider or supplier (other than a DMEPOS supplier) must resubmit and recertify the accuracy of its enrollment information every 5 years.

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42 CFR § 424.516

Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program.

This provision outlines requirements for providers to certify compliance, report changes in enrollment information, and maintain documentation for seven years.

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42 CFR § 424.517

Onsite review.

This provision authorizes CMS to conduct onsite reviews of providers to verify enrollment information and ensure compliance with Medicare requirements.

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42 CFR § 424.518

Screening levels for Medicare providers and suppliers.

A Medicare contractor is required to screen all initial applications, revalidation applications, change of ownership applications pursuant to 42 CFR 489.18, applications to add a new practice location, and applications to report any new...

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42 CFR § 424.519

Disclosure of affiliations.

This provision requires providers to disclose affiliations with other entities that have had disclosable events to allow CMS to assess potential risks of fraud, waste, or abuse.

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42 CFR § 424.520

Effective date of Medicare billing privileges.

This section specifies the effective dates for Medicare billing privileges for various provider and supplier types, including hospitals and clinical labs.

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42 CFR § 424.521

Request for payment by certain provider and supplier types.

This section outlines the conditions under which certain providers and suppliers may retrospectively bill for services provided prior to their Medicare enrollment effective date.

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42 CFR § 424.522

Additional effective dates.

This section specifies the effective dates for reassignment of benefits and Form CMS-855O enrollment.

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42 CFR § 424.525

Rejection of a provider's or supplier's application for Medicare enrollment.

This section details the reasons CMS may reject a Medicare enrollment application and the process for resubmission.

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42 CFR § 424.526

Return of a provider's or supplier's enrollment application.

This section lists the specific reasons CMS may return a Medicare enrollment application without processing.

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42 CFR § 424.527

Provisional period of enhanced oversight.

This section defines the criteria for a provisional period of enhanced oversight for new providers or suppliers and the effective date of such oversight.

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42 CFR § 424.530

Denial of enrollment in the Medicare program.

This provision outlines the specific grounds upon which CMS may deny a provider or supplier's enrollment in the Medicare program, including noncompliance, criminal history, financial debt, and false information, while detailing the processes for reapplication and potential reapplication bars.

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42 CFR § 424.535

Revocation of enrollment in the Medicare program.

This provision outlines the specific grounds, processes, and consequences for the revocation of a provider or supplier's Medicare enrollment, including reenrollment bars and the impact on provider agreements.

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42 CFR § 424.540

Deactivation of Medicare billing privileges.

CMS may deactivate a provider's Medicare billing privileges for reasons such as inactivity, failure to update enrollment information, or non-compliance.

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42 CFR § 424.541

Stay of enrollment.

CMS may impose a stay on a provider's enrollment for non-compliance, which results in the rejection of claims during the stay period.

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42 CFR § 424.545

Provider and supplier appeal rights.

Providers may appeal CMS decisions regarding enrollment denial or revocation, with specific procedures for handling billing privilege and provider agreement terminations.

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42 CFR § 424.546

Deactivation rebuttals.

Providers have 15 days to submit a written rebuttal to CMS following the deactivation of their Medicare billing privileges.

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42 CFR § 424.547

Deactivation based on ordering, certifying, or referring services and items.

CMS may deactivate a practitioner's ability to order, certify, or refer Medicare services if they have not been listed on a claim in the previous 12 months.

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42 CFR § 424.550

Prohibitions on the sale or transfer of billing privileges.

This provision prohibits the sale or unauthorized use of Medicare billing numbers and mandates specific enrollment procedures during changes of ownership.

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42 CFR § 424.551

DMEPOS supplier changes in majority ownership.

This provision defines requirements for DMEPOS suppliers undergoing changes in majority ownership, including mandatory re-enrollment and accreditation.

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42 CFR § 424.57

Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges.

This provision establishes the enrollment, accreditation, surety bond, and operational standards that DMEPOS suppliers must meet to maintain Medicare billing privileges and receive payment.

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42 CFR § 424.570

Moratoria on newly enrolling Medicare providers and suppliers.

CMS may impose temporary moratoria on the enrollment of new Medicare providers or suppliers in specific geographic areas or categories to mitigate risks of fraud, waste, or abuse.

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42 CFR § 424.575

Rural emergency hospitals.

Rural emergency hospitals must comply with Medicare enrollment requirements and may convert existing hospital or critical access hospital enrollment via a change of information application.

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42 CFR § 424.67

Enrollment requirements for opioid treatment programs (OTP).

This provision establishes the Medicare enrollment requirements, screening standards, and compliance obligations for opioid treatment programs.

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42 CFR § 424.68

Enrollment requirements for home infusion therapy suppliers.

This provision defines the requirements for home infusion therapy suppliers to enroll in and receive payment from the Medicare program.

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42 CFR § 424.74

Termination of provider agreement.

This provision outlines the grounds for terminating a provider agreement if a provider violates payment assignment prohibitions.