CMS-10357.Transmittal 371

CMS Manual System

Department of Health &
Human Services (DHHS)

Pub 100-08 Medicare Program Integrity

Centers for Medicare &
Medicaid Services (CMS)

Transmittal 371

Date: March 23, 2011

Change Request 7350
NOTE: This instruction is being re-issued to correct Business Requirements references which
inadvertently referred to chapter 15, section 17 to chapter 15, section 19. The references have been
revised to correctly reflect chapter 15, section 19. The transmittal number, date issued and all other
information remain the same.
SUBJECT: Implementation of Provider Enrollment Provisions in CMS-6028-FC
I. SUMMARY OF CHANGES: In the February 2, 2011 edition of the Federal Register, the Centers for
Medicare and Medicaid Services (CMS) published a final rule with comment period entitled: “Medicare,
Medicaid, and Children’s Health Insurance Programs; Additional Screening Requirements, Application
Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and
Suppliers” (CMS-6028-FC). This rule finalized, among other things, provisions related to the: (1)
submission of application fees as part of the provider enrollment process, (2) establishment of provider
enrollment screening categories, and (3) imposition of a temporary moratorium on the enrollment of new
Medicare providers and suppliers of a particular type (or the establishment of new practice locations of a
particular type) in a geographic area. This change request implements said provisions.
EFFECTIVE DATE: March 25, 2011
IMPLEMENTATION DATE: March 25, 2011
Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized
material. Any other material was previously published and remains unchanged. However, if this revision
contains a table of contents, you will receive the new/revised information only, and not the entire table of
contents.
II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated)
R=REVISED, N=NEW, D=DELETED-Only One Per Row.

R/N/D

CHAPTER / SECTION / SUBSECTION / TITLE

N

15/Table of Contents

N

15/19/Application Fees and Additional Screening Requirements

N

15/19.1/Application Fees

N

15/19.2/Screening Categories

N

15/19.2.1/Background

N

15/19.2.2/Scope of Site Visit

N

15/19.2.3/Changes of Information

N

15/19.2.4/Reactivations

N

15/19.2.5/Movement of Providers and Suppliers into the High Level

N

15/19.3/Temporary Moratoria

N

15/19.4/Tracking

III. FUNDING:
For Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs) and/or Carriers:
Funding for implementation activities will be provided to contractors through the regular budget process.
For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined
in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is
not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically
authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to
be outside the current scope of work, the contractor shall withhold performance on the part(s) in question
and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions
regarding continued performance requirements.

IV. ATTACHMENTS:
Business Requirements
Manual Instruction

*Unless otherwise specified, the effective date is the date of service.

Attachment - Business Requirements
Pub. 100-08

Transmittal: 371

Date: March 23, 2011

Change Request: 7350

NOTE: This instruction is being re-issued to correct Business Requirements references which
inadvertently referred to chapter 15, section 17 to chapter 15, section 19. The references have been
revised to correctly reflect chapter 15, section 19. The transmittal number, date issued and all other
information remain the same.
SUBJECT: Implementation of Provider Enrollment Provisions in CMS-6028-FC

Effective Date: March 25, 2011
Implementation Date: March 25, 2011

I.

GENERAL INFORMATION

A. Background: In the February 2, 2011 edition of the Federal Register, the Centers for Medicare and
Medicaid Services (CMS) published a final rule with comment period entitled: “Medicare, Medicaid, and
Children’s Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary
Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers” (CMS-6028FC). This rule finalized, among other things, provisions related to the: (1) submission of application fees as
part of the provider enrollment process, (2) establishment of provider enrollment screening categories, and (3)
imposition of a temporary moratorium on the enrollment of new Medicare providers and suppliers of a
particular type (or the establishment of new practice locations of a particular type) in a geographic area. This
change request implements said provisions.
B. Policy: The purpose of this change request is to implement the provider enrollment-related provisions in
CMS-6028-FC.
Please note that under 42 CFR §424.518(c)(2)(ii), providers and suppliers in the “high” level of categorical
screening are subject to a fingerprint-based criminal background check. This requirement is not being
implemented at the current time.

II.

BUSINESS REQUIREMENTS TABLE

Use “Shall" to denote a mandatory requirement
Number

Requirement

Responsibility (place an “X” in each
applicable column)
A D F C R SharedOTHER
/ M I A H System
B E
R H Maintain
R I
ers
M M
I
F M V C
A A
E
I C MW
C C
R
S S S F
S

Responsibility (place an “X” in each
applicable column)
A D F C R SharedOTHER
/ M I A H System
B E
R H Maintain
R I
ers
M M
I
F M V C
A A
E
I C MW
C C
R
S S S F
S
X
X X X
National
Supplier
Clearinghous
e (NSC)

Number

Requirement

7350.1

If the contractor receives a hardship exception
request separately from the paper Form CMS-855
application or the Internet-based Provider
Enrollment, Chain and Ownership System (PECOS)
certification statement, it shall: (1) return the
hardship exception request to the provider, and (2)
notify the provider via letter, e-mail or telephone that
it will not be considered.

7350.2

Upon receipt of a paper Form CMS-855 application
(or Internet-based PECOS certification statement)
from a provider or supplier that is otherwise required
to submit an application fee, the contractor shall first
determine whether the application is an initial
enrollment, a revalidation, or involves the addition of
a practice location.

X

X X X

NSC

7350.2.1

If the application does not fall within any of the
categories identified in business requirement 7350.2,
the contractor shall process the application as normal.

X

X X X

NSC

7350.2.2

If the application falls within any of the categories
identified in business requirement 7350.2, the
contractor shall determine whether the provider has:
(1) paid the application fee via Pay.gov, and/or (2)
included a hardship exception request with the
application or certification statement.

X

X X X

NSC

7350.2.3

If the provider has neither paid the fee nor submitted
a hardship exception request, the contractor shall
send a letter to the provider notifying it that it has 30
days from the date of the letter to pay the application
fee via Pay.gov, and that failure to do so will result in
the rejection of the provider’s application (for initial
enrollments and new practice locations) or revocation
of the provider’s Medicare billing privileges (for
revalidations); the letter shall also state that because a
hardship exception request was not submitted with
the original application, such a request will not be
considered in lieu of the fee.

X

X X X

NSC

Responsibility (place an “X” in each
applicable column)
A D F C R SharedOTHER
/ M I A H System
B E
R H Maintain
R I
ers
M M
I
F M V C
A A
E
I C MW
C C
R
S S S F
S
X
X X X
NSC

Number

Requirement

7350.2.4

During the 30-day period described in business
requirement 7350.2.3, the contractor shall review
each updated Fee Submitter List to determine if the
fee has been paid.

7350.2.4.1

If the fee is paid within the 30-day period described
in business requirement 7350.2.3, the contractor shall
begin processing the application as normal.

X

X X X

NSC

7350.2.4.2

If the fee is not paid within the 30-day period
described in business requirement 7350.2.3, the
contractor shall reject the application (initial
enrollments and new locations) under
42 CFR
§424.525(a)(3) or revoke the provider’s Medicare
billing privileges under 42 CFR §424.535(a)(6)
(revalidations).

X

X X X

NSC

7350.2.5

If the provider has paid the fee but has not submitted
a hardship exception request, the contractor shall
begin processing the application as normal.

X

X X X

NSC

7350.2.6

If the provider has submitted a hardship exception
request but has not paid the fee, the contractor shall
send the request and all documentation
accompanying the request to its Provider Enrollment
Operations Group (PEOG) liaison.

X

X X X

NSC

7350.2.6.1

If PEOG denies the hardship exception request, the
contractor shall – during the following 30-day period
- review each updated Fee Submitter List to
determine if the fee has been paid.

X

X X X

NSC

7350.2.6.1.1

If the fee is not paid within the 30-day period
described in 7350.2.6.1, the contractor shall deny the
application (initial enrollments and new locations)
pursuant to 42 CFR §424.530(a)(9) or revoke the
provider’s Medicare billing privileges under 42 CFR
§424.535(a)(6) (revalidations).

X

X X X

NSC

7350.2.6.2

If PEOG approves the hardship exception request, the X
contractor shall begin processing the application as

X X X

NSC

Number

Requirement

Responsibility (place an “X” in each
applicable column)
A D F C R SharedOTHER
/ M I A H System
B E
R H Maintain
R I
ers
M M
I
F M V C
A A
E
I C MW
C C
R
S S S F
S

normal.
7350.2.7

If, at any time during the 30-day periods referred to
in business requirements 7350.2.3 and 7350.2.6.1, the
provider submits a Pay.gov receipt as proof of
payment, the contractor shall begin processing the
application as normal.

7350.2.8

If the provider has submitted a hardship exception
request and has paid the fee, the contractor shall: (1)
send the request and all documentation
accompanying the request to its PEOG liaison, and
(2) begin processing the application as normal.

X

X X X

NSC

7350.2.9

In all cases, the contractor shall not begin processing
the provider’s application until: (1) the fee has been
paid, or (2) the hardship exception request has been
approved.

X

X X X

NSC

7350.3

If PEOG approves a provider’s hardship exception
reconsideration request, the contractor shall process
the application as normal, or, to the extent applicable:
(a) if the application has already been rejected,
request that the provider resubmit the application
without the fee, or (b) if Medicare billing privileges
have already been revoked, reinstate said billing
privileges in accordance with existing instructions
and request that the provider resubmit the application
without the fee.

X

X X X

NSC

7350.3.1

If the Administrative Law Judge (ALJ) reverses
PEOG’s reconsideration decision and approves the
hardship exception request, and the application has
already been rejected, the contractor – once PEOG
informs it of the ALJ’s decision - shall notify the
provider via letter, e-mail or telephone that it may
resubmit the application without the fee; if the
provider’s Medicare billing privileges have already
been revoked, the contractor shall reinstate said
billing privileges in accordance with existing
instructions and request that the provider resubmit

X

X X X

NSC

Number

Requirement

Responsibility (place an “X” in each
applicable column)
A D F C R SharedOTHER
/ M I A H System
B E
R H Maintain
R I
ers
M M
I
F M V C
A A
E
I C MW
C C
R
S S S F
S

the application without the fee.
7350.3.2

If the Departmental Appeals Board (DAB) reverses
the ALJ’s decision and approves the hardship
exception request, and the application has already
been rejected, the contractor - once PEOG informs it
of the DAB’s decision - shall notify the provider via
letter, e-mail or telephone that it may resubmit the
application without the fee; if the provider’s
Medicare billing privileges have already been
revoked, the contractor shall reinstate said billing
privileges in accordance with existing instructions
and request that the provider resubmit the application
without the fee.

X

X X X

NSC

7350.3.3

Should the provider submit an application with a
paper check or any other hard copy form of
payment (e.g., money order), the contractor shall
treat this as a non-submission of the fee and
follow the instructions in Publication 100-08,
Chapter 15, section 19.1(D)(b)(i) or (iii)
(depending on whether a hardship exception
request was submitted); when sending the
applicable letter requesting payment within 30
days, the contractor shall explain that all
payments must be made via.Pay.gov and shall
include the submitted check with the letter.

X

X X X

NSC

7350.4

The contractor shall utilize the screening procedures
outlined in Publication 100-08, Chapter 15, sections
19.2 through 19.2.5 for applications it receives on or
after March 25, 2011.

X

X X X

NSC

7350.5

For providers and suppliers in the “limited” category,
the contractor shall (unless Publication 100-08,
Chapter 15, section 19.2.5 applies) process initial,
revalidation, and new location applications in
accordance with existing instructions.

X

X X X

7350.6

For providers and suppliers in the “moderate” level
of categorical screening, the contractor shall (unless

X

X X X

NSC

Number

Requirement

Responsibility (place an “X” in each
applicable column)
A D F C R SharedOTHER
/ M I A H System
B E
R H Maintain
R I
ers
M M
I
F M V C
A A
E
I C MW
C C
R
S S S F
S

Publication 100-08, Chapter 15, section 19.2.5
applies): (1) process initial, revalidation, and new
location applications in accordance with existing
instructions; and (2) perform a site visit in
accordance with Publication 100-08, Chapter 15,
sections 19.2 through 19.2.5.
7350.6.1

For ambulance suppliers, independent clinical
laboratories, physical therapists, and physical
therapist groups, the contractor shall conduct a site
visit prior to the contractor’s final decision regarding
the application.

X

X

7350.6.2

For initially enrolling community mental health
X
centers (CMHCs) – and in addition to the site visit
that is currently performed for CMHCs - the
contractor shall conduct another site visit after
receiving the tie-in notice from the regional office but
before the contractor conveys Medicare billing
privileges to the CMHC.

X

7350.6.3

For revalidating CMHCs, the contractor shall
conduct a site visit prior to making a final decision
regarding the revalidation application.

X

X

7350.6.4

For CMHCs that are adding a new practice location,
the contractor shall conduct a site visit of the new
location prior to making a recommendation for
approval.

X

X

7350.6.5

For initially enrolling comprehensive outpatient
rehabilitation facilities (CORFs), hospices and
portable x-ray suppliers (PXRSs), the contractor shall
conduct a site visit after receiving the tie-in notice
from the regional office but before the contractor
conveys Medicare billing privileges to the provider.

X

X X X

7350.6.6

For revalidating CORFs, hospices and PXRSs, the
contractor shall conduct a site visit prior to making a
final decision regarding the revalidation application.

X

X X X

Responsibility (place an “X” in each
applicable column)
A D F C R SharedOTHER
/ M I A H System
B E
R H Maintain
R I
ers
M M
I
F M V C
A A
E
I C MW
C C
R
S S S F
S
X
X X X

Number

Requirement

7350.6.7

For CORFs, hospices and PXRSs that are adding a
new location, the contractor shall conduct a site visit
of the new location prior to making a
recommendation for approval.

7350.6.8

For initially enrolling independent diagnostic testing
facilities (IDTFs), the contractor shall continue to
conduct site visits
in accordance with Publication 100-08, Chapter 10,
section 4.19.6.

X

X

7350.6.9

For revalidating IDTFs, the contractor shall (prior to
making a final decision regarding the revalidation
application) conduct a site visit in accordance with
Publication 100-08, Chapter 10, section 4.19.6.

X

X

7350.6.10

For revalidating home health agencies (HHAs), the
contractor shall conduct a site visit of the HHA prior
to making a final decision regarding the revalidation
application.

X

7350.6.11

For revalidating suppliers of durable medical
equipment, prosthetics, orthotics and supplies
(DMEPOS) – and to the extent that a site visit is not
currently required - the contractor shall conduct a site
visit of the DMEPOS supplier prior to making a final
decision regarding the revalidation application.

7350.7

For providers and suppliers in the “high” level of
categorical screening, the contractor shall: (1)
process initial, revalidation, and new location
applications in accordance with existing instructions;
and (2) perform a site visit to the extent that this is
not already required by CMS. (If a site visit is
currently required, the contractor shall continue this
activity in accordance with existing instructions.)

X

X X X

NSC

7350.8

Changes of information (including additions of
practice locations) submitted by providers and
suppliers in the “limited” level of categorical
screening shall be processed in accordance with

X

X X X

NSC

X

X

NSC

Number

Requirement

Responsibility (place an “X” in each
applicable column)
A D F C R SharedOTHER
/ M I A H System
B E
R H Maintain
R I
ers
M M
I
F M V C
A A
E
I C MW
C C
R
S S S F
S

existing instructions.
7350.9

With the exception of DMEPOS suppliers, if a
provider or supplier in the “moderate” level of
categorical screening submits a Form CMS-855
request to add a practice location (including an HHA
branch), the contractor shall: (1) process the
application in accordance with existing instructions,
and (2) conduct a site visit in accordance with
Publication 100-08, Chapter 15, sections 19.2
through 19.2.5.

X

X X X

7350.10

With the exception of DMEPOS suppliers and
HHAs, if a provider or supplier in the “moderate”
level of categorical screening undergoes a change of
ownership resulting in a new tax identification
number (TIN), the contractor shall:
(1) process the application in accordance with
existing instructions, and (2) conduct a site visit in
accordance with Publication 100-08, Chapter 15,
sections 19.2 through 19.2.5.

X

X X

7350.10.1

For ownership changes described in business
requirement 7350.10 that must be approved by the
regional office under current CMS instructions, the
contractor shall perform the site visit after it receives
the tie-in notice from the regional office but before
the contractor activates the new owner’s billing
privileges.

X

X X X

7350.10.2

For ownership changes described in business
requirement 7350.10 that do not require regional
office approval under current CMS instructions, the
contractor shall perform the site visit prior to making
its final decision regarding the application.

X

X X X

7350.10.3

For HHAs undergoing a change in majority
ownership, the contractor shall – consistent with
Publication 100-08, Chapter 15, section 15.26.1 –

X

X

X

Number

Requirement

Responsibility (place an “X” in each
applicable column)
A D F C R SharedOTHER
/ M I A H System
B E
R H Maintain
R I
ers
M M
I
F M V C
A A
E
I C MW
C C
R
S S S F
S

determine whether the provisions of 42 CFR
§424.550(b)(1) and (2) apply.
7350.10.4

For HHAs reporting an ownership change that is not
a change in majority ownership as that term is
defined in §424.502, the contractor shall process the
change in accordance with existing instructions.

X

X

X

7350.10.5

For HHAs seeking to reactivate their Medicare
billing privileges, the contractor shall process the
application under the “moderate” level of categorical
screening. (A site visit will be necessary prior to the
reactivation of the provider’s billing privileges.)

X

X

X

7350.10.6

Unless specified otherwise in Publication 100-08,
Chapter 15, sections 19.2 through 19.2.5, all other
changes of information for providers and suppliers in
the moderate level of categorical screening shall be
processed in accordance with existing instructions.

X

X X X

NSC

7350.11

The contractor shall process reactivation applications
submitted by providers and suppliers in the “limited”
level of categorical screening in accordance with
existing instructions.

X

X X X

NSC

7350.11.1

The contractor shall process reactivation applications
submitted by providers and suppliers in the
“moderate” level of categorical screening (including
existing DMEPOS suppliers and HHAs) in
accordance with the screening procedures for this
category. (A site visit will therefore be necessary
prior to the contractor’s final decision regarding the
application.)

X

X X X

NSC

7350.11.2

The contractor shall process reactivation applications
submitted by providers and suppliers in the “high”
level of categorical screening in accordance with the
screening procedures for this category. (A site visit
will therefore be necessary prior to the contractor’s
final decision regarding the application.)

X

X X X

NSC

Responsibility (place an “X” in each
applicable column)
A D F C R SharedOTHER
/ M I A H System
B E
R H Maintain
R I
ers
M M
I
F M V C
A A
E
I C MW
C C
R
S S S F
S
X
X X X
NSC

Number

Requirement

7350.12

Upon receipt of an initial, revalidation, or new
location application from a provider or supplier that
otherwise falls within the limited or moderate
screening category (and after the appropriate fee has
been paid, etc.), the contractor shall determine
whether the provider or supplier is on the bi-monthly
“high” screening list described in Publication 100-08,
Chapter 15, section 19.4.

7350.12.1

If the provider is on the bi-monthly “high” screening
list, the contractor shall process the application using
the procedures in the “high” screening category.

X

X X X

NSC

7350.12.2

If the provider is not on the bi-monthly “high”
screening list, the contractor shall process the
application in accordance with existing instructions.

X

X X X

NSC

7350.13

If the contractor receives an initial or new location
application from a provider or supplier: (a) that is of
a provider or supplier type that was subject to a
moratorium and (b) within 6 months after the
applicable moratorium was lifted, the contractor shall
process the application using the procedures in the
“high” screening category.

X

X X X

NSC

7350.14

As a moratorium will not apply to an application for
which an approval or a recommendation for approval
has been made as of the effective date of the
moratorium (even if the contractor has not yet
formally granted Medicare billing privileges), the
application can continue to be processed to
completion.

X

X X X

NSC

7350.15

As a moratorium will apply to an application that is
pending as of the effective date of the moratorium
and for which the contractor has not yet made a final
approval/denial decision or recommendation for
approval, the contractor shall deny said application,
using CFR §424.535(a)(10) as the basis.

X

X X X

NSC

Number

Requirement

7350.16

As a moratorium will apply to an application that the
contractor receives on or after the effective date of
the moratorium, the contractor shall deny said
applications, using CFR §424.535(a)(10) as the basis.

7350.17

The contractor shall submit the data referred to in
Publication 100-08, Chapter 15, section 19.4 to its
Provider Enrollment Operations Group liaison no
later than the 15th day of each month, with the first
report due on May 15, 2011.

III.

Responsibility (place an “X” in each
applicable column)
A D F C R SharedOTHER
/ M I A H System
B E
R H Maintain
R I
ers
M M
I
F M V C
A A
E
I C MW
C C
R
S S S F
S
X
X X X
NSC

X

X X X

NSC

PROVIDER EDUCATION TABLE

Number

Requirement

7350.18

A provider education article related to this instruction
will be available at
http://www.cms.hhs.gov/MLNMattersArticles/ shortly
after the CR is released. You will receive notification of
the article release via the established "MLN Matters"
listserv.
Contractors shall post this article, or a direct link to this
article, on their Web site and include information about it
in a listserv message within one week of the availability
of the provider education article. In addition, the
provider education article shall be included in your next
regularly scheduled bulletin. Contractors are free to
supplement MLN Matters articles with localized
information that would benefit their provider community

Responsibility (place an “X” in each
applicable column)
A D F C R
SharedOTH
/ M I A H
System
ER
B E
R H Maintainers
R I F M V C
M M
I
I C M W
A A
E
S S S F
C C
R
S
X
X X X

Number

Requirement

Responsibility (place an “X” in each
applicable column)
A D F C R
SharedOTH
/ M I A H
System
ER
B E
R H Maintainers
R I F M V C
M M
I
I C M W
A A
E
S S S F
C C
R
S

in billing and administering the Medicare program
correctly.

IV.

SUPPORTING INFORMATION

Section A: For any recommendations and supporting information associated with listed requirements,
use the box below: N/A
Use "Should" to denote a recommendation.
X-Ref
Recommendations or other supporting information:
Requireme
nt
Number

Section B: For all other recommendations and supporting information, use this space: N/A

V. CONTACTS
Pre-Implementation Contact: Frank Whelan, (410) 786-1302, frank.whelan@cms.hhs.gov.
Post-Implementation Contact(s): Contact your Contracting Officer’s Technical Representative (COTR) or
Contractor Manager, as applicable.

VI. FUNDING
Section A: For Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), and/or
Carriers:
Funding for implementation activities will be provided to contractors through the regular budget process.
Section B: For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in
your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not
obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically

authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be
outside the current scope of work, the contractor shall withhold performance on the part(s) in question and
immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding
continued performance requirements.

Medicare Program Integrity Manual
Chapter 15 - Medicare Enrollment
_________________________________________________
Table of Contents
(Rev.371, 03-23-11)

15.19 – Application Fees and Additional Screening Requirements
15.19.1 – Application Fees
15.19.2 – Screening Categories
15.19.2.1 – Background
15.19.2.2 – Scope of Site Visit
15.19.2.3 – Changes of Information
15.19.2.4 – Reactivations
15.19.2.5 - Movement of Providers and Suppliers into the High Level
15.19.3 – Temporary Moratoria
15.19.4 - Tracking

15.19 – Application Fees and Additional Screening Requirements
(Rev.371, Issued: 03-23-11, Effective: 03-25-11, Implementation: 03-25-11)

15.19.1 – Application Fees
(Rev.371, Issued: 03-23-11, Effective: 03-25-11, Implementation: 03-25-11)
A. Background
Pursuant to 42 CFR §424.514 - and with the exception of physicians, non-physician
practitioners, physician group practices and non-physician group practices – institutional
providers that are (1) initially enrolling in Medicare, (2) adding a practice location, or (3)
revalidating their enrollment information per 42 CFR §424.515, must submit with their
application:
An application fee in an amount prescribed by CMS, and/or
A request for a hardship exception to the application fee.
This requirement applies to applications that the contractor receives on or after March 25, 2011.
For purposes of this requirement, the term “institutional provider,” as defined in 42 CFR
§424.502, means any provider or supplier that submits a paper Medicare enrollment application
using the Form CMS-855A, Form CMS- 855B (not including physician and non-physician
practitioner organizations), Form CMS-855S or associated Internet-based Provider Enrollment,
Chain and Ownership System (PECOS) enrollment application. Note that a physician, nonphysician practitioner, physician group, or non-physician practitioner group that is enrolling as
a supplier of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) via the
Form CMS-855S application must submit the required application fee with its Form CMS-855S
form.

B. Fee
1.

Amount

The application fee must be in the amount prescribed by CMS for the calendar year in which the
application is submitted. The fee for March 25, 2011 through December 31, 2011 is $505.00.
Fee amounts for future years will be adjusted by the percentage change in the consumer price
index (for all urban consumers) for the 12-month period ending on June 30 of the prior year.
CMS will give the contractor and the public advance notice of any change in the fee amount for
the coming calendar year.

2. Non-Refundable

Per 42 CFR §424.514(d)(2)(v), the application fee is non-refundable, except if it was submitted
with one of the following:
a. A hardship exception request that is subsequently approved;
b. An application that was rejected prior to the contractor‟s initiation of the screening
process, or
c. An application that is subsequently denied as a result of the imposition of a temporary
moratorium under 42 CFR §424.570.
(For purposes of (B)(2)(b) above, the term “rejected” includes applications that are returned
pursuant to section 15.8.1 of this Chapter.)
In addition, the fee should be refunded if:
It was not required for the transaction in question (e.g., the provider submitted a fee with
its application to report a change in phone number).
It was not part of an application submission.

3. Format
The provider or supplier must submit the application fee electronically through Pay.gov, either
via credit card, debit card, or check. Note that CMS will send to the contractor on a regular
basis a listing of providers and suppliers (the “Fee Submitter List”) that have paid an
application fee via Pay.gov.

C. Hardship Exception
1. Background
A provider or supplier requesting a hardship exception from the application fee must include
with its enrollment application a letter (and any supporting documentation) that describes the
hardship and why the hardship justifies an exception. If a paper Form CMS-855 application is
submitted, the hardship exception letter must accompany the application; if the application is
submitted via Internet-based PECOS, the hardship exception letter must accompany the
certification statement. Hardship exception letters shall not be considered if they were submitted
separately from the application or certification statement, as applicable. If the contractor
receives a hardship exception request separately from the application or certification statement,
it shall: (1) return it to the provider, and (2) notify the provider via letter, e-mail or telephone
that it will not be considered.

2. Criteria for Determination
The application fee for Calendar Year 2011 is $505 and generally should not represent a
significant burden for an adequately capitalized provider or supplier. Hardship exceptions
should not be granted when the provider simply asserts that the imposition of the application fee
represents a financial hardship. The provider must instead make a strong argument to support
its request, including providing comprehensive documentation (which may include, without
limitation, historical cost reports, recent financial reports such as balance sheets and income
statements, cash flow statements, tax returns, etc.).
Other factors that may suggest that a hardship exception is appropriate include the following:
(a) Considerable bad debt expenses,
(b) Significant amount of charity care/financial assistance furnished to patients,
(c) Presence of substantive partnerships (whereby clinical, financial integration are
present) with those who furnish medical care to a disproportionately low-income
population;
(d) Whether an institutional provider receives considerable amounts of funding through
disproportionate share hospital payments, or
(e) Whether the provider is enrolling in a geographic area that is a Presidentiallydeclared disaster under the Robert T. Stafford Disaster Relief and Emergency Assistance
Act, 42 U.S.C. 5121-5206 (Stafford Act).
Upon receipt of a hardship exception request with the application or certification statement, the
contractor shall send the request and all documentation accompanying the request via regular
mail, fax, or e-mail to its Provider Enrollment Operations Group (PEOG) liaison. PEOG has
60 calendar days from the date of the contractor‟s receipt of the hardship exception request to
determine whether it should be approved; during this period, the contractor shall not commence
processing the provider‟s application. PEOG will communicate its decision to the provider and
the contractor via letter, after which the contractor shall carry out the applicable instructions in
section 19.1(D) below.
Note that if the provider fails to submit appropriate documentation to support its request, the
contractor is not required to contact the provider to request it. The contractor can simply
forward the request “as is” to its PEOG liaison. Ultimately, it is the provider‟s responsibility to
furnish the necessary supporting evidence at the time it submits its hardship exception request.

D. Receipt

Upon receipt of a paper application (or, if the application is submitted via Internet-based
PECOS, upon receipt of a certification statement) from a provider or supplier that is otherwise
required to submit an application fee, the contractor shall first determine whether the
application is an initial enrollment, a revalidation, or involves the addition of a practice
location. If the application does not fall within any of these categories, the contractor shall
process the application as normal. If it does fall within one of these categories, the contractor
shall undertake the following:
a. Determine whether the provider has: (1) paid the application fee via Pay.gov, and/or (2)
included a hardship exception request with the application or certification statement. The
contractor can verify payment of the application fee by checking:
Whether the provider has included with its application or certification statement a
Pay.gov receipt as proof of payment, and/or
The Fee Submitter List

b. If the provider:
i. Has neither paid the fee nor submitted the hardship exception request, the contractor
shall send a letter to the provider notifying it that it has 30 days from the date of the letter
to pay the application fee via Pay.gov, and that failure to do so will result in the rejection
of the provider‟s application (for initial enrollments and new practice locations) or
revocation of the provider‟s Medicare billing privileges (for revalidations). The letter
shall also state that because a hardship exception request was not submitted with the
original application, CMS will not consider granting a hardship exception in lieu of the
fee.
During this 30-day period, the contractor shall review each updated Fee Submitter List
to determine whether the fee has been paid via Pay.gov. If the fee is paid within the 30day period, the contractor may begin processing the application as normal. If the fee is
not paid within the 30-day period, the contractor shall reject the application (initial
enrollments and new locations) under 42 CFR §424.525(a)(3) or revoke the provider‟s
Medicare billing privileges under 42 CFR §424.535(a)(6) (revalidations).
Note that if, at any time during this 30-day period, the provider submits a Pay.gov receipt
as proof of payment, the contractor shall begin processing the application as normal.
ii. Has paid the fee but has not submitted a hardship exception request, the contractor shall
begin processing the application as normal.
iii. Has submitted a hardship exception request but has not paid a fee, the contractor shall
send the request and all documentation accompanying the request via regular mail, fax,
or e-mail to its PEOG liaison. If PEOG:

a. Denies the hardship exception request, it will notify the provider in the decision letter
(on which the contractor will be copied) that the application fee must be paid within
30 calendar days from the date of the letter. During this 30-day period, the
contractor shall review each updated Fee Submitter List to determine if the fee has
been submitted via Pay.gov. If the fee is not paid within 30 calendar days, the
contractor shall deny the application (initial enrollments and new locations) pursuant
to 42 CFR §424.530(a)(9) or revoke the provider‟s Medicare billing privileges under
42 CFR §424.535(a)(6) (revalidations).
If, at any time during this 30-day period, the provider submits a Pay.gov receipt as
proof of payment, the contractor shall begin processing the application as normal.
b. Approves the hardship exception request, it will notify the provider of such in the
decision letter (on which the contractor will be copied). The contractor shall begin
processing the application as normal.
iv. Has submitted a hardship exception request and has paid a fee, the contractor shall send
the request and all documentation accompanying the request via regular mail, fax, or email to its PEOG liaison. As the fee has been paid, the contractor shall begin
processing the application as normal.
In all cases, the contractor shall not begin processing the provider‟s application until: (1) the fee
has been paid, or (2) the hardship exception request has been approved.

E. Appeals of Hardship Determinations
A provider may appeal PEOG‟s denial of its hardship exception request via the procedures
outlined below:
1. If the provider is dissatisfied with PEOG‟s decision to deny a hardship exception request, it
may file a written reconsideration request with PEOG within 60 calendar days from receipt
of the notice of initial determination (e.g., PEOG‟s denial letter). The request must be signed
by the individual provider or supplier, a legal representative, or any authorized official
within the entity. Failure to file a reconsideration request within this timeframe is deemed a
waiver of all rights to further administrative review.
The reconsideration request should be mailed to:
Centers for Medicare & Medicaid Services
Provider Enrollment Operations Group
7111 Security Boulevard
Baltimore, MD 21244

Notwithstanding the filing of a reconsideration request, the contractor shall still carry out
the post-hardship exception request instructions in subsections (D)(b)(iii)(a) and (iv) above,
as applicable. A reconsideration request, in other words, does not stay the execution of the
instructions in section 19.1(D) above.
PEOG has 60 calendar days from the date of the reconsideration request to render a
decision. The reconsideration shall be:
(a) Conducted by a PEOG staff person who was independent from the initial decision to deny
the hardship exception request.
(b) Based on PEOG‟s review of the original letter and documentation submitted by the
provider.
Upon receipt of the reconsideration, PEOG will send a letter to the provider or supplier to
acknowledge receipt of its request. In its acknowledgment letter, PEOG will advise the
requesting party that the reconsideration will be conducted and a determination issued
within 60 days from the date of the request.
a. If PEOG denies the reconsideration, it will notify the provider of this via letter, with a
copy to the contractor. If PEOG approves the reconsideration request, it will notify the
provider of this via letter, with a copy to the contractor, after which the contractor shall
process the application as normal, or, to the extent applicable:
i. If the application has already been rejected, request that the provider resubmit the
application without the fee, or
ii. If Medicare billing privileges have already been revoked, reinstate said billing
privileges in accordance with existing instructions and request that the provider
resubmit the application without the fee.
Note that Corrective Action Plans (CAPs) may not be submitted in lieu of or in addition to a
request for reconsideration of a hardship exception request denial.

2. If the provider is dissatisfied with the reconsideration determination regarding the
application fee, it may request a hearing before an Administrative Law Judge (ALJ). Such
an appeal must be filed, in writing, within 60 days from receipt of the reconsideration
decision. ALJ requests should be sent to:
Department of Health and Human Services
Departmental Appeals Board (DAB)
Civil Remedies Division, Mail Stop 6132
330 Independence Avenue, S.W.
Cohen Bldg, Room G-644
Washington, D.C. 20201

ATTN: CMS Enrollment Appeal
Failure to timely request an ALJ hearing is deemed a waiver of all rights to further
administrative review.
If the ALJ reverses PEOG‟s reconsideration decision and approves the hardship exception
request, and the application has already been rejected, the contractor – once PEOG informs
it of the ALJ‟s decision - shall notify the provider via letter, e-mail or telephone that it may
resubmit the application without the fee. If the provider‟s Medicare billing privileges have
already been revoked, the contractor shall reinstate said billing privileges in accordance
with existing instructions and request that the provider resubmit the application without the
fee.
3. If the provider is dissatisfied with the ALJ‟s decision, it may request Board review by the
Departmental Appeals Board (DAB). Such request must be filed within 60 days after the
date of receipt of the ALJ„s decision. Failure to timely request a review by the DAB is
deemed a waiver of all rights to further administrative review.
If the DAB reverses the ALJ‟s decision and approves the hardship exception request, and the
application has already been rejected, the contractor - once PEOG informs it of the DAB‟s
decision - shall notify the provider via letter, e-mail or telephone that it may resubmit the
application without the fee. If the provider‟s Medicare billing privileges have already been
revoked, the contractor shall reinstate said billing privileges in accordance with existing
instructions and request that the provider resubmit the application without the fee.
To the extent permitted by law, a provider or supplier dissatisfied with a DAB decision may seek
judicial review by timely filing a civil action in a United States District Court. Such request
shall be filed within 60 days from receipt of the notice of the DAB„s decision.

F. Miscellaneous
The contractor shall abide by the following:
1. Paper Checks Submitted Outside of Pay.gov – As stated earlier, all payments must be made
via Pay.gov. Should the provider submit an application with a paper check or any other
hard copy form of payment (e.g., money order), the contractor shall not deposit the
instrument. It shall instead treat the situation as a non-submission of the fee and follow
the instructions in (D)(b)(i) or (iii) above (depending on whether a hardship exception
request was submitted). When sending the applicable letter requesting payment within
30 days, the contractor shall explain that all payments must be made via. Pay.gov , stamp
the submitted paper check "VOID," and include the voided paper check with the letter.
2. Practice Locations – DMEPOS suppliers, federally qualified health centers (FQHCs), and
independent diagnostic testing facilities (IDTFs) must individually enroll each site.
Consequently, the enrollment of each site requires a separate fee. For all other providers

and suppliers (except physicians, non-physician practitioners, and physician and nonphysician practitioner groups, none of which are required to submit the fee), a fee must
accompany any application that adds a practice location. If multiple locations are being
added on a single application, however, only one fee is required. The fee for providers and
suppliers other than DMEPOS suppliers, FQHCs, and IDTFs is based on the application
submission, not the number of locations being added on a single application.
3. Other Application Submissions – A provider or supplier need not pay an application fee if
the application is:
Reporting a change of ownership via the Form CMS-855B or Form CMS-855S. (For
providers and suppliers reporting a change of ownership via the Form CMS-855A, the
ownership change does not necessitate an application fee if the change does not require
the provider or supplier to enroll as a new provider or supplier.)
Reporting a change in tax identification number (whether Part A, Part B, or DMEPOS)
Requesting a reactivation of the provider‟s Medicare billing privileges

15.19.2 – Screening Categories
(Rev.371, Issued: 03-23-11, Effective: 03-25-11, Implementation: 03-25-11)

15.19.2.1 – Background
(Rev.371, Issued: 03-23-11, Effective: 03-25-11, Implementation: 03-25-11)
Consistent with 42 CFR §424.518, newly-enrolling and existing providers and suppliers will,
beginning on March 25, 2011, be placed into one of three levels of categorical screening:
limited, moderate, or high. The risk levels denote the level of the contractor‟s screening of the
provider when it initially enrolls in Medicare, adds a new practice location, or revalidates its
enrollment information.
The contractor shall utilize the screening procedures outlined below for applications it receives
on or after March 25, 2011.

A. Limited
The “limited” level of categorical screening consists of the following provider and supplier
types:
Physicians
Non-physician practitioners other than physical therapists
Physician group practices
Non-physician group practices other than physical therapist group practices
Ambulatory surgical centers
Competitive Acquisition Program/Part B Vendors

End-stage renal disease facilities
Federally qualified health centers
Histocompatibility laboratories
Hospitals (including critical access hospitals, Department of Veterans Affairs hospitals,
and other federally-owned hospital facilities.\
Health programs operated by an Indian Health Program (as defined in section 4(12)
of the Indian Health Care Improvement Act) or an urban Indian organization (as defined
in section 4(29) of the Indian Health Care Improvement Act) that receives funding from
the Indian Health Service pursuant to Title V of the Indian Health Care Improvement Act
Mammography screening centers
Mass immunization roster billers
Organ procurement organizations
Pharmacies that are newly enrolling or revalidating via the Form CMS-855B application
Radiation therapy centers
Religious non-medical health care institutions
Rural health clinics
Skilled nursing facilities
For providers and suppliers in the “limited” category, the contractor shall (unless section 19.2.5
of this Chapter applies) process initial, revalidation, and new location applications in
accordance with existing instructions.

B. Moderate
The “moderate” level of categorical screening consists of the following provider and supplier
types:
Ambulance service suppliers
Community mental health centers (CMHCs)
Comprehensive outpatient rehabilitation facilities (CORFs)
Hospice organizations
Independent clinical laboratories
Independent diagnostic testing facilities
Physical therapists enrolling as individuals or as group practices
Portable x-ray suppliers (PXRSs)
Revalidating home health agencies (HHAs)
Revalidating DMEPOS suppliers
For providers and suppliers in the “moderate” level of categorical screening, the contractor
shall (unless section 19.2.2 of this Chapter applies):
Process initial, revalidation, and new location applications in accordance with existing
instructions; and

Perform a site visit in accordance with the following:
Ambulance suppliers, independent clinical laboratories, physical therapists, and
physical therapist groups – The contractor shall conduct a site visit prior to the
contractor‟s final decision regarding the application.
CMHCs
Initial applications - In addition to the site visit that is currently performed, the
contractor shall conduct another site visit after receiving the tie-in notice from the
regional office but before the contractor conveys Medicare billing privileges to the
CMHC. This is to ensure that the provider is still in compliance with CMS‟s
enrollment requirements.
Revalidations – The contractor shall conduct a site visit prior to making a final
decision regarding the revalidation application.
New location – The contractor shall conduct a site visit of the new location prior to
making a recommendation for approval.
CORFs, hospices and PXRSs Initial applications - The contractor shall conduct a site visit after receiving the
tie-in notice from the regional office but before the contractor conveys Medicare
billing privileges to the provider. This is to ensure that the provider is still in
compliance with CMS‟s enrollment requirements.
Revalidations – The contractor shall conduct a site visit prior to making a final
decision regarding the revalidation application.
New location – The contractor shall conduct a site visit of the new location prior
to making a recommendation for approval.
IDTFs
Initial applications – The contractor shall conduct site visits of initially enrolling
IDTFs in accordance with Pub. 100-08, Chapter 10, section 4.19.6.
Revalidations - The contractor shall conduct site visits of revalidating IDTFs
(prior to making a final decision regarding the revalidation application) in
accordance with Pub. 100-08, Chapter 10, section 4.19.6.
Revalidating HHAs – The contractor shall conduct a site visit of the HHA prior to
making a final decision regarding the revalidation application.

Revalidating DMEPOS suppliers – The contractor shall conduct a site visit of the
DMEPOS supplier prior to making a final decision regarding the revalidation
application.

C. High
The “high” level of categorical screening consists of the following provider and supplier types:
Newly enrolling DMEPOS suppliers
Newly enrolling HHAs
For providers and suppliers in the “high” level of categorical screening, the contractor shall:
Process initial, revalidation, and new location applications in accordance with existing
instructions; and
Perform a site visit to the extent that this is not already required by CMS. If a site visit is
currently required, the contractor shall continue this activity in accordance with existing
instructions.
(NOTE: Enrolled DMEPOS suppliers that are adding another location will be classified as
“high” for screening purposes. In addition, newly-enrolling HHA sub-units fall within the
“high” level of categorical screening.)
See section 19.2.3 below for information regarding DMEPOS changes of ownership and TIN
changes.

15.19.2.2 - Scope of Site Visit
(Rev.371, Issued: 03-23-11, Effective: 03-25-11, Implementation: 03-25-11)
A. DMEPOS Suppliers and IDTFs
As stated above, site visits of DMEPOS suppliers and IDTFs shall continue to be conducted in
accordance with existing CMS instructions and guidance.

B. Other Provider and Supplier Types
For all provider and supplier types – other than DMEPOS suppliers and IDTFs – that are
subject to a site visit in accordance with this section, the contractor shall perform such visits
using the procedures outlined in sections 20 and 20.1 of this Chapter. This includes the
following:
• Documenting the date and time of the visit, and including the name of the individual
attempting the visit;

• Photographing the provider or supplier‟s business for inclusion in the provider/supplier‟s
file. All photographs should be date/time stamped;
• Fully documenting observations made at the facility, which could include facts such as:
(a) the facility was vacant and free of all furniture; (b) a notice of eviction or similar
documentation is posted at the facility, and (c) the space is now occupied by another
company;
•

Writing a report of the findings regarding each site verification; and

• Including a signed declaration stating the facts and verifying the completion of the site
verification. (The sample declaration identified in section 20.1 of this Chapter is
recommended.)
In terms of the extent of the visit, the contractor shall determine whether the following criteria
are met:
The facility is open
Personnel are at the facility
Customers are at the facility (if applicable to that provider or supplier type)
The facility appears to be operational
This will require the site visitor(s) to enter the provider or supplier‟s practice location/site,
rather than simply conducting an external review.
If any of the 4 elements listed above are not met, the contractor shall, as applicable - and using
the procedures outlined in Pub. 100-08, Chapters 10 and 15 - deny the provider‟s enrollment
application pursuant to §424.530(a)(5)(i) or (ii), or revoke the provider‟s Medicare billing
privileges under §424.535(a)(5)(i) or (ii).

15.19.2.3 – Changes of Information
(Rev.371, Issued: 03-23-11, Effective: 03-25-11, Implementation: 03-25-11)
1. Limited
Changes of information (including additions of practice locations) submitted by providers and
suppliers in the “limited” level of categorical screening shall be processed in accordance with
existing instructions.

2. Moderate

a.

Addition of Practice Location

With the exception of DMEPOS suppliers, if a provider or supplier in the “moderate” level of
categorical screening submits a Form CMS-855 request to add a practice location (including an
HHA branch), the contractor shall: (1) process the application in accordance with existing
instructions, and (2) conduct a site visit in accordance with the instructions in section 19.2.1(B)
above.
(As explained earlier, a DMEPOS supplier that is adding a new practice location falls within the
“high” screening category.)

b.

Change of Ownership

With the exception of DMEPOS suppliers and HHAs, if a provider or supplier undergoes a
change of ownership resulting in a new tax identification number (TIN), the contractor shall:
(1) Process the application in accordance with existing instructions, and
(2) Conduct a site visit in accordance with the following:
For ownership changes that must be approved by the regional office under current
CMS instructions, the site visit shall be performed after the contractor receives the
tie-in notice from the regional office but before the contractor activates the new
owner‟s billing privileges.
For ownership changes that do not require regional office approval under current
CMS instructions, the site visit shall be performed prior to the contractor‟s final
decision regarding the application.
A DMEPOS supplier that is:
Undergoing a change of ownership with a change in TIN falls within the “high”
screening category.
Undergoing a change of ownership with no change in TIN falls within the
“moderate” screening category.
Undergoing a change in TIN with no change in ownership falls within the “moderate
screening category.

With respect to HHAs:

For HHAs undergoing a change in majority ownership, the contractor shall – consistent
with section 15.26.1 of this Chapter – determine whether the provisions of 42 CFR
§424.550(b)(1) and (2) apply. If the contractor determines that a change in majority
ownership has occurred and that none of the exceptions in §424.550(b)(2) apply, the
HHA must enroll as a new entity, in which case the newly-enrolling HHA will be placed
into the “high” level of categorical screening. If the contractor determines that an
exception does apply, the transaction will be subject to the “moderate” level of
categorical screening; a site visit will be necessary.
For HHAs reporting an ownership change that is not a change in majority ownership as
that term is defined in §424.502, the contractor shall process the change in accordance
with existing instructions. A site visit is not necessary.
For HHAs seeking to reactivate their Medicare billing privileges, the transaction shall be
processed under the “moderate” level of categorical screening. A site visit will be
necessary prior to the reactivation of the provider‟s billing privileges.

c.

All Other Changes of Information

All other changes of information for providers and suppliers in the moderate level of categorical
screening shall be processed in accordance with existing instructions.

3.

High

Unless otherwise specified in sections 19.2.1 through 19.2.5, no changes of information will be
subject to the “high” level of categorical screening.

15.19.2.4 – Reactivations
(Rev.371, Issued: 03-23-11, Effective: 03-25-11, Implementation: 03-25-11)
A. Limited
Reactivation applications submitted by providers and suppliers in the “limited” level of
categorical screening shall be processed in accordance with existing instructions.

B. Moderate
Reactivation applications submitted by providers and suppliers in the “moderate” level of
categorical screening – including existing DMEPOS suppliers and HHAs – shall be processed in
accordance with the screening procedures for this category. A site visit will therefore be
necessary prior to the contractor‟s final decision regarding the application.

C. High
Reactivation applications submitted by providers and suppliers in the “high” level of categorical
screening shall be processed in accordance with the screening procedures for this category. A
site visit will therefore be necessary prior to the contractor‟s final decision regarding the
application.

15.19.2.5 – Movement of Providers and Suppliers into the High Level
(Rev.371, Issued: 03-23-11, Effective: 03-25-11, Implementation: 03-25-11)
Under §424.518©(3), CMS may adjust a particular provider or supplier‟s screening level from
“limited” or “moderate” to “high” if any of the following occur:
2. CMS imposes a payment suspension on a provider or supplier at any time within the last
10 years;
3. The provider or supplier:
a. Has been excluded from Medicare by the Office of Inspector General; or
b. Had billing privileges revoked by a Medicare contractor within the previous 10 years
and is attempting to establish additional Medicare billing privileges by:

i. Enrolling as a new provider or supplier; or
ii. Obtaining billing privileges for a new practice location
c. Has been terminated or is otherwise precluded from billing Medicaid
d. Has been excluded from any Federal health care program

e. Has been subject to any final adverse action (as defined in §424.502) within the previous
10 years

4. CMS lifts a temporary moratorium for a particular provider or supplier type, and a provider
or supplier that was prevented from enrolling based on the moratorium applies for
enrollment as a Medicare provider or supplier at any time within 6 months from the date the
moratorium was lifted.
CMS intends to send to the contractor on a bi-monthly basis a list of current and former
Medicare providers and suppliers within the contractor‟s jurisdiction that meet any of the
criteria in subsection (1) or (2) above. Upon receipt of an initial, revalidation, or new location

application from a provider or supplier that otherwise falls within the limited or moderate
screening category (and after the appropriate fee has been paid, etc.), the contractor shall
determine whether the provider or supplier is on the bi-monthly “high” screening list. If the
provider or supplier is, the contractor shall process the application using the procedures in the
“high” screening category. If the provider or supplier is not on said list, the contractor shall
process the application in accordance with existing instructions
With respect to subsection (3) above, if the contractor receives an initial or new location
application from a provider or supplier: (a) that is of a provider or supplier type that was
subject to a moratorium and (b) within 6 months after the applicable moratorium was lifted, the
contractor shall process the application using the procedures in the “high” screening category.

15.19.3 – Temporary Moratoria
(Rev.371, Issued: 03-23-11, Effective: 03-25-11, Implementation: 03-25-11)
Under §424.570(a), CMS may impose a moratorium on the enrollment of new Medicare
providers and suppliers of a particular type or the establishment of new practice locations of a
particular type in a particular geographic area. In general, a moratorium will not apply to:
Reactivations
Revalidations
A change in practice location
A change of ownership (with the exception of situations in which an HHA must enroll as
a new HHA in accordance with 42 CFR §424.550(b), in which case the new application
is treated as an initial enrollment and is therefore subject to the moratorium)
Any other change in the provider or supplier‟s enrollment information
The announcement of a moratorium will be made via the Federal Register, though the contractor
will also be separately notified of the moratorium. For initial and new location applications
involving the affected provider and supplier type, the moratorium:
Will not apply to applications for which an approval or a recommendation for approval
has been made as of the effective date of the moratorium, even if the contractor has not
yet formally granted Medicare billing privileges. Such applications can continue to be
processed to completion.
Will apply to applications that are pending as of the effective date of the moratorium and
for which the contractor has not yet made a final approval/denial decision or
recommendation for approval. The contractor shall deny such applications, using
§424.535(a)(10) as the basis.
Will apply to applications that the contractor receives on or after the effective date of the
moratorium, and for as long as the moratorium is in effect. The contractor shall deny
such applications, using §424.535(a)(10) as the basis.

If a particular moratorium is lifted, all applications pending with the contractor as of the
effective date of the moratorium‟s cessation are no longer subject to the moratorium and may be
processed. However, consistent with §424.518(a)(3), such applications shall be processed in
accordance with the “high” level of categorical screening. In addition, any initial application
received from a provider or supplier: (a) that is of a provider or supplier type that was subject to
a moratorium and (b) within 6 months after the applicable moratorium was lifted, the contractor
shall process the application using the “high” level of categorical screening.

15.19.4 – Tracking
(Rev.371, Issued: 03-23-11, Effective: 03-25-11, Implementation: 03-25-11)
In April 2011, PEOG will send to each contractor an Excel spreadsheet that the contractor shall
complete and submit to its PEOG liaison via e-mail no later than the 15th day of each month.
The first report will be due on May 15, 2011. The spreadsheet will contain data elements such
as, but not limited to:
Number of enrolled providers and suppliers in each risk category, broken down by
provider/supplier sub-type (e.g., hospital, HHA)
Amount of fees collected (i.e., fees that were cleared), broken down by provider and
supplier type