• New User & User Access

UnitedHealthcare Community Plan: What to expect during a site visit

Health care professionals who wish to contract with UnitedHealthcare Community Plan may need a site visit as part of the credentialing process. Requirements for site visits are determined by state Medicaid contracts and by NCQA and Centers for Medicare & Medicaid Services (CMS) requirements for facilities.

Site visit requirements are outlined in the UnitedHealthcare Credentialing Plan and State and Federal Regulatory Addendum .

Who requires a site visit? As part of the credentialing process, site visit requirements for health care professionals vary depending on the state and specialty. Some states require visits for initial credentialing only, and others require them for recredentialing as well (every 36 months). 

Here are the requirements for Arizona, Florida, Indiana, Maryland, Mississippi, New Jersey and Pennsylvania :

  • Health care professional types/specialties that require a site visit: family practice, geriatric medicine, internal medicine, pediatrics, general practice, obstetrics and gynecology, nurse practitioner, physician assistant
  • Note: nurse practitioners and physician assistants will only need a site visit if they work in a primary care physician (PCP) or obstetrics and gynecology office
  • Health care professional types/specialties that require a site visit: family practice, geriatric medicine, internal medicine, pediatrics, general practice
  • Health care professional types/specialties that require a site visit: family practice, geriatric medicine, internal medicine, pediatrics, general practice, obstetrics and gynecology, nurse practitioner, physician assistant, certified nurse midwife
  • Health care professional types/specialties that require a site visit: family practice, geriatric medicine, internal medicine, pediatrics, general practice, adolescent medicine, obstetrics and gynecology 
  • Note: nurse practitioners will only need a site visit if they’ve indicated on the application that they are acting as a PCP
  • Health care professional types/specialties that require a site visit: family practice, geriatric medicine, internal medicine, pediatrics, general practice, obstetrics and gynecology
  • Health care professional types/specialties that require a site visit: family practice, geriatric medicine, internal medicine, pediatrics, general practice, dentist 
  • Note: site visits include verifying that the facility complies with Americans with Disabilities Act requirements

What are the site visit requirements for facilities? There are different site visit requirements for facilities. If the facility is not accredited or certified by a recognized agency, a site visit is required. A site visit is not required if CMS or state quality review was conducted within the last 3 years.

What can I expect during the site visit? Site visits are conducted by United Language Group (ULG), a third-party vendor. ULG will call you to schedule the visit. Please ensure the contact information in your application is accurate. Once the visit has been scheduled, ULG will send you a confirmation email and an auditor from ULG will arrive to conduct the visit. 

When the auditor arrives, they’ll use a check list to determine whether your facility complies. Items on the check list include – but are not limited to – physical accessibility, appearance, waiting and examining room cleanliness, record keeping, and policies and procedures.

  • Call Provider Services at 877-842-3210
  • For state specific contact information, visit UHCprovider.com/contactus

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Tools and Checklists for States

Tools and checklists for states seeking greater flexibility.

  • Medicaid and CHIP Telework Playbook  (PDF, 1.6 MB)
  • Medicaid & CHIP Telehealth Toolkit Checklist for States  (DOCX, 47.36 KB)
  • Medicaid and CHIP Telehealth Toolkit Supplement 1  (PDF, 700.4 KB)
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  • Inventory of Medicaid and CHIP Flexibilities and Authorities in the Event of a Disaster  (PDF, 1.66 MB)
  • Section 1135 Information & Waiver Checklist
  • Section 1115 Waiver Checklist
  • Home and Community-Based Section 1915(c) Waiver Information
  • Section 1915(c) Appendix K Template
  • CMS-179 Form: Transmittal of State Plan Material
  • CHIP Disaster State Plan Amendment

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florida medicaid site visit checklist

SOP - 12. Site Visits and Inspections

Petroleum restoration program quick links.

  • Petroleum Restoration Program
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  • Announcements & Upcoming Events
  • Administrative Guidance
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  • Monthly Dashboard Update
  • Petroleum Cleanup Programs
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  • Related Links
  • Remediation Guidance
  • Rules and Statutes
  • Templates, Forms, Tools and Guidance
  • Webpage Updates History
  • Weekly Encumbrance Approval
  • All Petroleum Restoration Program Content

Site Visits

Purpose of site visits.

Site Managers (SM) visit sites to gain an understanding of site‑specific conditions including logistics and constraints that may affect the petroleum cleanup work at a site. Site visits help a SM gain a better understanding of fieldwork methods and equipment used and to learn more cost‑effective methods of accomplishing work at the sites they oversee. SMs are not limited to visiting their assigned sites; they can also coordinate visits to sites assigned to other SMs.

Ideally, site visits should be scheduled when the contractor is performing work at the site. However, site visits are also useful for the following purposes:

  • Conducting a site walk-over to observe and document current site conditions including source area locations, monitoring well locations, buildings and structures, traffic, right-of-ways and other logistical concerns.
  • Confirming previous work performed at the site.
  • Conducting on site meetings with a site owner, operator, contractor or subcontractor to discuss the field work and concerns the parties may have.

Notifications

The Owner/RP or tenant/operator should be contacted when scheduling a site visit. If fieldwork will be occurring during a planned site visit, the SM may want to coordinate with the Contractor.

Contractors are required to notify the SM and the site owner/operator of scheduled field work at least seven calendar days prior to conducting on-site field activities in accordance with the Specifications of the purchase order Attachment A - Scope of Work.

Office Preparation

Before a SM travels to a site, permission to travel which may include a Travel Authorization form must be approved. In addition, the SM should gather pertinent information that will assist with conducting the site visit. This includes, but is not limited to, the following:

  • Site Inspection Form (see below);
  • Personal Protective Equipment (see Health & Safety below);
  • Cell phone/camera;
  • Work Plan/Scope of Work (if observing field work); and
  • Maps or Figures: current site map/vicinity, map/contaminant plume, maps/elevation contour map.
  • Tabulated data if available: Soil and Groundwater Analytical Tables, Groundwater Elevation Tables.

Health & Safety

SMs are observers and do not actively participate in field work. Site control is maintained by the contractor performing the work and is not the responsibility of the SM. If the site is visited during field activities, SMs should note designated work zones or exclusion zones and request to see the Contractor’s Health and Safety Plan (HASP). Signing the HASP is not a requirement for a SM.

OSHA Requirements

  • As observers, SMs must have a minimum of 24 hours of OSHA health and safety training. Many have the full 40-hour OSHA training. An annual eight-hour refresher course is required to keep this training current. 

Personal Protective Equipment (PPE)

  • SMs must wear appropriate PPE during site visits when work is performed. This includes hardhat, safety glasses and earplugs. Appropriate attire includes long pants and comfortable shirt. Steel‑toed shoes and safety vest are recommended. Water, sunscreen and bug spray may also be warranted.

Traffic Control

  • SMs should always be observant of the flow of traffic when conducting a site visit, particularly if visiting an active service station. SMs should make note of the contractor's traffic-control measures with respect to the work zones.

Site Inspection Form

Site Managers shall complete a Site Inspection Form for every site visit they make. A new Site Inspection Form is required to be filled out even if there are several site visits for the same site. The form is designed to be filled in with basic site information before the SM leaves for the field. 

Site Visit/Inspection

Always check in with the site owner or facility operator upon arrival to the site.

If the purpose of the site visit is to conduct a site walkover, note the following:

  • Confirm locations of on-site gasoline or petroleum product tanks and dispensers;
  • Identify buildings, structures and aboveground utilities located on site;
  • Note location and condition of remedial system equipment compound, if applicable;   
  • Confirm apparent property boundaries and right-of-way;
  • Confirm monitoring well or soil boring locations;
  • Take photographs, both general view and close-up shots, from all four compass directions for buildings, canopies, driveways, sidewalks, landscaping, etc., and any visible specific pre-existing damage or issues noted in the description; and
  • Record observations.

If observing field work during the site visit:

  • Review the scope of work prior to arrival;
  • Check in with the contractor’s on-site supervisor when it is safe to do so;
  • Make note of the contractor’s staff and any subcontractors working on-site;
  • Identify designated work areas and staging areas. Note where contaminated soil and groundwater are being removed, discharged, containerized or stockpiled;
  • Observe activities from a safe distance and record observations in field notebook or on the inspection form; 
  • Take relevant photos; and
  • Note any observed health and safety issues.

Upon return to the office, finalize the inspection form and attach relevant photos for upload to OCULUS. Discuss findings with PE or PG or the consultant as needed.

Inspector Program

The PRP utilizes dedicated inspectors to monitor work performed at state-funded sites. In general, contracted Local Programs are responsible for inspections at sites they manage within their respective geographic areas, while Teams 5 and 6 are responsible for inspecting sites managed by Tallahassee program staff. Overall, site inspections help to provide accountability and document that trust fund cleanup dollars are appropriately spent.

The two general categories of site inspections are described below.

Field Inspections

Field Inspections provide documentation of site conditions and the field work performed by state contractors. Field Inspectors are observers only and do not direct the contractors performing the work. Field Inspectors observe activities common to petroleum cleanup work including groundwater sampling, well construction, soil sampling, SRs, RAC and other activities. Field inspectors provide several important benefits to the petroleum program, including:

  • Confirmation that the scope of work is completed as required in the PO or WO.
  • Confirmation of field methods used and contractor’s conformance with established SOPs and guidelines.
  • Provide real-time feedback of work progress to the site managers and technical reviewers, and confirm logistical problems and necessary changes in SOW.
  • Document personnel, equipment, and subcontractors mobilized to a site for approval of payment.
  • Provide photographic documentation of baseline site conditions, site restoration and work in progress. 
  • Document that contractors have a HASP available for viewing when work is performed. Emergency contact information, route to hospital and sign-in sheet must be onsite in paper format.

O&M Inspections

O&M Inspections involve all aspects of remedial systems including system startup and routine operation and maintenance. The O&M Inspector documents operational status of remedial systems including system parameters and operating efficiencies. Inspections are completed with and without contractors present at the site. Inspectors do not make system adjustments or repairs to equipment. 

O&M inspections can include, but are not limited to, the following:

  • Confirmation of system “Run times” and reasons for system downtime.
  • Review of maintenance history and whether it was performed in accordance with the manufacturer’s specifications.
  • Verify that remediation system components are installed in accordance with the approved RAP or RAP Mod and the as-built drawings.
  • Verify that the system equipment and components are operating properly, and record all observations and system performance parameter measurements at the equipment, manifolds and wellheads/treatment points, as applicable
  • Verify that the remediation system performance measurement devices are installed in accordance with the approved RAP/RAP Modification and that they are operable and capable of measuring the required parameters, including hour meters, electric meters, flow meters and totalizers, pressure gauges, vacuum gauges, liquid level indicators, etc.
  • Verify that the critical fail-safe/interlock mechanisms are installed in accordance with the approved RAP/RAP Modification and ask the contractor to demonstrate that they are functioning properly, where possible. Examples include high liquid level sensor/cutoff, high pressure sensor/cutoff, air sparge shut off if VES fails, low oil level sensor/shut off, high temp sensor/cut off, power supply monitor/cut off, etc.
  • Observe and record general site conditions and any factors affecting site safety or cleanup efficiency.
  • Conduct state-owned equipment inventory verification for program SMs and inventory coordinators. 

Scheduling Inspections

Inspections at petroleum cleanup sites are scheduled based on field work notifications from contractors and requests from program staff as follows:

  • Field work notification from the contractors: Contractors are required to send notification of scheduled field work to the centralized e-mail address, [email protected]  in addition to the site manager at least seven calendar days prior to conducting on-site field activities. The scheduling coordinators and inspectors monitor the field notifications that are submitted in order to develop inspection schedules. 
  • Direct request from program staff: For Tallahassee program staff, requests can be made to the scheduling coordinator or Team Leader for Teams 5 and 6. local Programs have internal inspectors and requests should be handled internally. Requests should include the basic information used for field notifications along with the specific reason for the request and any expectations they have for the inspection. For complex or lengthy projects, requests can be made for regular visits to the site for the duration of the project. 

Coordinators and Inspectors typically develop a weekly schedule in a logical and efficient manner focusing on geographic areas of the state. Schedules are adjusted during the week based on actual field work being performed and any additional site inspection requests. The frequency and specific scope of any given inspection is determined by the inspector, coordinator and the PRP Team making the request.

Inspection Reports and Communication

Inspectors contact the assigned SM during the inspection to provide feedback and make SMs aware of important observations including changes to the SOW. Inspectors can also facilitate coordination and communication between a SM and field supervisor if problems or issues arise.

For O&M inspections, a post-inspection meeting between inspector, SM, and PE can be coordinated to discuss the inspection findings and operational data observed.

Field inspectors and O&M inspectors utilize different standardized report templates optimized for the type of inspection. Inspection reports are completed by the inspectors either in real time or upon return to the office or hotel. Copies of reports are uploaded to OCULUS (Profile: Discovery_Compliance; Document Type: Inspection Related) and emailed to the SMs. Site managers should carefully read the inspection reports and confirm if there is anything that requires follow-up discussion with the contractor or within their team or section. Site managers are encouraged to contact the inspector if they have questions about the information presented in the inspection report.

  • Field Inspection Summary form
  • O&M Inspection form

Return to: PRP Site Manager Standard Operating Procedures (SOP) webpage.

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National Credentialing Solutions

Medicare Provider Enrollment – Site Verification

by nCred | Medicare Provider Enrollment | 0 comments

Medicare Provider Enrollment News

CMS contracts with a third party to provide site visit services as an integral part of the Medicare Provider Enrollment process.  The National Sive Visit Contractor (NSVC) will conduct site visits for all providers and suppliers except for Durable Medical Equipment (DMEPOS) which will continue to be inspected by the National Supplier Clearinghouse.  MSM Security Services, LLC has the national site visit contract.  MSM, or one of its subcontractors, will conduct a site verification and screening process according to Medicare guidelines to prevent questionable providers and suppliers from enrolling in the Medicare program.  When an inspector shows up, he or she will have valid ID and a letter of authorization to begin the inspection.  You may not copy or retain the ID or letter of authorization.  You may contact MSM at any point if you have questions at 855-220-1074.

The site verification may be as quick as verifying your business location, or an inspector may physically show up to tour your clinic.  The process ensures that providers aren’t able to Enroll as participating Medicare providers without an appropriate service location.

You may see full details in section 10.6.20 of the Medicare Program Integrity Manual .

Call nCred today at (423) 443-4525 to discuss your Medicare Provider Enrollment needs.  We work with all specialties and have extensive experience processing Medicare applications.

From the Medicare Program Integrity Manual:

10.6.20 – Screening: On-site Inspections and Site Verifications (Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23) 

The contractor shall review section 10.3 of this chapter for special instructions regarding site visits. In the event of a conflict, those instructions take precedence over those in this section 10.6.20.

A. DMEPOS Suppliers and IDTFs

The scope of site visits of DMEPOS suppliers and IDTFs shall continue to be conducted in accordance with existing CMS instructions and guidance. (For purposes of this section 10.6.20, the term “contractor” refers to the Medicare Administrative Contractor; the term “SVC” refers to the site visit contractor.)

B. Provider and Supplier Types Other Than DMEPOS Suppliers and IDTFs

For provider/supplier types other than DMEPOS suppliers and IDTFs – that must undergo a site visit pursuant to this section 10.6.20 and § 424.518, the SVC will perform such visits consistent with the procedures in this section 10.6.20. This includes all of the following:

(1) Documenting the date and time of the visit, and including the name of the individual attempting the visit.

(2) Photographing the provider/supplier’s business for inclusion in the provider/supplier’s file. All photographs will be date/time stamped.

(3) 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.

(4) Writing a report of the findings regarding each site verification.

(5) Including a signed site visit report stating the facts and verifying the completion of the site verification.

In terms of the extent of the visit, the SVC will determine whether the following criteria are met: (i) the facility is open; (ii) personnel are at the facility; (iii) customers are at the facility (if applicable to that provider or supplier type); and (iv) the facility appears to be operational. This will require the site visitor(s) to enter the provider/supplier’s practice location/site rather than simply conducting an external review. If any of the four elements ((i) through (iv)) listed above are not met, the contractor will, as applicable – and using the procedures outlined in this chapter and in existing CMS instructions – 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).

C. Operational Status

When conducting a site verification to determine whether a practice location is operational, the SVC shall make every effort to limit its verification to an external review of the location. If the SVC cannot determine whether the location is operational based on this external review, it shall conduct an unobtrusive site verification by limiting its encounter with provider or supplier personnel or medical patients.

The contractor must review and evaluate the site visit results received from the SVC prior to making a final determination. If it is determined (during the review and evaluation process) that the location is non-operational based on the site visit results but there is reason to proceed with the enrollment, the contractor shall provide the appropriate justification in the comment section of the Validation Checklist in PECOS. (For example, a second site visit determined the location to be operational; the provider only renders services in patient’s homes; etc.).

If the contractor is unsure of how to proceed based on its evaluation of the site visit results, it shall contact its PEOG BFL and copy its contracting officer’s representative (COR).

Site verifications should be done Monday through Friday (excluding holidays) during their posted business hours. If there are no hours posted, the site verification should occur between 9 a.m. and 5 p.m. If, during the first attempt, there are obvious signs that the facility is no longer operational, no second attempt is required. If, on the first attempt, the facility is closed but there are no obvious indications that the facility is non-operational, a second attempt on a different day during the posted hours of operation should be made.

E. Documentation

As indicated previously, when conducting site verifications to determine whether a practice location is operational, the SVC shall:

(i) Document the date and time of the attempted visit and include the name of the individual attempting the visit.

(ii) As appropriate, photograph the provider/supplier’s business for inclusion in the provider/supplier’s file on an as-needed basis. All photographs should be date/time stamped.

(iii) Fully document all observations made at the facility (e.g., the facility was vacant and free of all furniture, a notice of eviction or similar documentation was posted at the facility, the space is now occupied by another company, etc.).

(iv) Write a report of its findings regarding each site verification.

F. Determination

(In the event an instruction in this subsection F is inconsistent with guidance in section 10.6.6, 10.4.7 et seq., or 10.4.8, the latter three sections of instructions shall take precedence.)

If a provider/supplier is determined not to be operational or in compliance with the regulatory requirements for its provider/supplier type, the contractor shall revoke the provider/supplier’s Medicare billing privileges – unless the provider/supplier has submitted a change of information request that notified the contractor of a change in practice location. Within 7 calendar days of CMS or the contractor determining that the provider/supplier is not operational, the contractor shall update PECOS or the applicable claims processing system (if the provider/supplier does not have an enrollment record in PECOS) to revoke Medicare billing privileges and issue a revocation notice to the provider/supplier. The contractor shall afford the provider/supplier applicable appeal rights in the revocation notification letter.

For non-operational status revocations , the contractor shall use either 42 CFR § 424.535(a)(5)(i) or 42 CFR § 424.535(a)(5)(ii) as the legal basis for revocation. Consistent with 42 CFR § 424.535(g), the date of revocation is the date on which CMS or the contractor determines that the provider/supplier is no longer operational. The contractor shall establish a 2-year reenrollment bar for providers/suppliers that are not operational.

For regulatory non-compliance revocations , the contractor shall use 42 CFR § 424.535(a)(1) as the legal basis for revocation. Consistent with 42 CFR § 424.535(g), the date of revocation is the date on which CMS or the contractor determines that the provider/supplier is no longer in compliance with regulatory provisions for its provider/supplier type. The contractor shall establish a 2-year enrollment bar for providers/suppliers that are not in compliance with provisions for their provider/supplier type.

G. Multiple Site Visits

Notwithstanding any other instruction to the contrary in this chapter, the contractor shall not order a site visit if the specific location to be visited has already undergone a successful site visit within the last 12 months and the applicable provider/supplier is in an approved status.

Consider the following illustrations:

Example 1  – A single-site home health agency (HHA) undergoes a revalidation site visit on February 1. The HHA submits a change of information request on July 1 to add a branch location. The contractor shall order this site visit because the visit will occur at a location (i.e., the branch location) different from the main location (i.e., the location that underwent the February 1 revalidation visit).

Example 2  – A DMEPOS supplier undergoes a revalidation site visit on April 1. It submits an initial Form CMS-855S application on May 1 to enroll a second location. The new location shall undergo a site visit because: (1) it is different from the first (revalidated) location; and (2) it is/will be separately enrolled from the first location.

Example 3  – A physical therapy (PT) group has three locations – X, Y, and Z. As part of a revalidation, the contractor elects to order a site visit of Location Y rather than X or Z. The visit was performed on June 1. On October 4, the group submits a Form CMS-855B to report a change of ownership, thus requiring a site visit under this chapter. However, the contractor shall not order a visit for Location Y because this site has been visited within the past 12 months. Location X or Location Z must instead be visited.

Example 4  – An IDTF undergoes an initial enrollment site visit on July 1. On September 24, it submits a Form CMS-855B application to change its practice location; this mandates a site visit under this chapter. The site visit shall be performed even though the initial visit took place within the past 12 months. This is because the second visit will be of the new location, whereas the first visit was of the old location.

H. Certified Providers/Suppliers – Address Validation Error

Notwithstanding any other instruction to the contrary in this chapter, the contractor need not order a site visit for a certified provider/supplier prior to making a recommendation to the state if an address validation error is received in PECOS. The contractor shall override the error message and notate in the referral package that the address was unverifiable. This avoids multiple site visits being performed (that is, pre-enrollment, survey, and post enrollment).

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Credentialing Resources

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Medicare Provider Enrollment Print

florida medicaid site visit checklist

What’s Changed?

  • Updated the enrollment application fee amount for 2024
  • Added marriage and family therapists, mental health counselors, and certain dental specialties to the Part B suppliers list
  • Merged Form CMS-855R into the CMS-855I paper enrollment application
  • Added new provider specialty code information for dentists

Substantive content changes are in dark red.

Application Fee

Physicians, non-physician practitioners, physician organizations, non-physician organizations, and Medicare Diabetes Prevention Program suppliers don’t pay a Medicare enrollment application fee.

Generally, institutional providers and suppliers like DMEPOS suppliers and opioid treatment programs pay an application fee when enrolling, re-enrolling, revalidating, or adding a new practice location.

Enrollment Application Fee

The 2024 enrollment application fee is $709.

Whether you apply for Medicare enrollment online or use the paper application, you can pay the Medicare application fee online through:

  • PECOS: During the application process, PECOS prompts you to pay the application fee
  • CMS Paper Application: Go to PECOS Application Fee Information to submit the application fee

A hardship exception exempts you from paying a current application’s fee. If you request a hardship exception, submit a written request and supporting documentation describing the hardship and justifying an exception to paying the application fee with your PECOS or CMS paper application. We grant exceptions on a case-by-case basis.

Medicare Administrative Contractors (MACs) will only process applications with the proper application fee payment or an approved hardship exception.

If you don’t pay the fee or submit a hardship exception request, your MAC will send a letter allowing you 30 days to pay the fee. If you don’t pay the fee on time, the MAC may reject or deny your application or revoke your existing billing privileges, as appropriate.

florida medicaid site visit checklist

Providers must enroll in the Medicare Program to get paid for providing covered services to Medicare patients. Determine if you’re eligible to enroll and how to complete enrollment.

We list institutional providers on the Medicare Enrollment Application: Institutional Providers (CMS-855A) , which include:

  • Community mental health centers
  • Comprehensive outpatient rehabilitation facilities
  • Critical access hospitals
  • ESRD facilities
  • Federally Qualified Health Centers
  • Histocompatibility labs
  • Home health agencies
  • Hospice organizations
  • Indian Health Service facilities
  • Organ procurement organizations
  • Opioid treatment programs
  • Outpatient physical therapy, occupational therapy, speech pathology services
  • Religious nonmedical health care institutions
  • Rural emergency hospitals
  • Rural health clinics
  • Skilled nursing facilities (SNFs)

Physicians, non-physician practitioners (NPPs), clinics or group practices, and specific suppliers who can enroll as Medicare Part B providers are defined in enrollment forms Medicare Enrollment Application: Physicians and Non-Physician Practitioners (CMS-855I) and Medicare Enrollment Application: Clinics/Group Practices and Other Suppliers (CMS-855B) .

Who’s an NPP?

NPPs include nurse practitioners, clinical nurse specialists, and physician assistants who practice with or under a physician’s supervision.

Physicians, NPPs, & Suppliers (CMS-855I)

  • Anesthesiology assistants
  • Audiologists
  • Certified nurse-midwives
  • Certified registered nurse anesthetists
  • Clinical nurse specialists
  • Clinical psychologists
  • Clinical social workers
  • Marriage and family therapists
  • Mass immunization roster billers (individuals)
  • Mental health counselors
  • Nurse practitioners
  • Occupational or physical therapists in private practice
  • Dental anesthesiology
  • Dental public health
  • Endodontics
  • Oral and maxillofacial surgery
  • Oral and maxillofacial pathology
  • Oral and maxillofacial radiology
  • Oral medicine
  • Orofacial pain
  • Orthodontics and dentofacial orthopedics
  • Pediatric dentistry
  • Periodontics
  • Prosthodontics
  • Physician assistants
  • Psychologists billing independently
  • Registered dietitians or nutrition professionals
  • Speech-language pathologists

Clinics, Group Practices, & Specific Suppliers (CMS-855B)

  • Ambulatory surgical centers (ASCs)
  • Clinics and group practices
  • Home infusion therapy suppliers
  • Hospital departments
  • Independent clinical labs
  • Independent diagnostic testing facilities
  • Intensive cardiac rehabilitation suppliers
  • Mammography centers
  • Mass immunization roster billers (entities)
  • Physical or occupational therapy groups in private practice
  • Portable X-ray suppliers
  • Radiation therapy centers

Medicare Diabetes Prevention Program Suppliers

Potential suppliers must use Medicare Enrollment Application: Medicare Diabetes Prevention Program (MDPP) Suppliers (CMS-20134) to enroll in the Medicare Program.

Beginning January 1, 2024, we established new provider specialty codes for dentists.

If you don’t see your provider type listed, contact your MAC’s provider enrollment center before submitting a Medicare enrollment application.

Medicare provider and supplier organizations have business structures, like corporations, partnerships, professional associations, or limited liability companies, which meet the provider and supplier definitions. Provider and supplier organizations don’t include organizations the IRS defines as sole proprietorships.

Provider and supplier organizations include:

  • Medical group practices and clinics

You must have a provider or supplier employer identification number (EIN) to enroll in Medicare. An EIN is the same as the provider or supplier organization’s IRS-issued tax identification number (TIN).

Sole Proprietorships & Disregarded Entities

Sections 10.6.4 and 10.6.7.1(D)(5) of Medicare Program Integrity Manual, Chapter 10 have more information about sole proprietorships and disregarded entities.

Medicare participation means you agree to accept claims assignment for all covered patient services. By accepting assignment, you agree to accept Medicare-allowed amounts as payment in full. You can’t collect more from the patient than the deductible and coinsurance or copayment . The Social Security Act says you must submit patient Medicare claims whether or not you participate.

You have 90 days after we send your initial enrollment approval letter to decide if you want to be a participating provider or supplier. To participate as a Medicare Program provider or supplier, submit the Medicare Participating Physician or Supplier Agreement (CMS-460) upon initial enrollment. The only other time you may change your participation status is during the open enrollment period, generally from mid-November–December 31 each year.

Participating Provider or Supplier

  • We pay 5% more to participating physicians and other suppliers
  • Because these are assigned claims, we pay you directly
  • We forward claim information to Medigap (Medicare supplement coverage) insurers

Non-Participating Provider or Supplier

  • We pay 5% less to non-participating physicians and other suppliers
  • You can’t charge patients more than the limiting charge, 115% of the Medicare Physician Fee Schedule amount
  • You may accept assignment on a case-by-case basis
  • You have limited appeal rights

Medicare Claims Processing Manual, Chapter 12 has more information.

Step 1: Get an NPI

To enroll in the Medicare Program, get an NPI through:

  • Online Application: Get an Identity & Access Management (I&A) System user account. Then apply for an NPI in NPPES .
  • Call 1-800-465-3203 (TTY 1-800-692-2326)
  • Email [email protected]
  • Bulk Enumeration: Apply for Electronic File Interchange access and upload your own CSV or XML files.

Not Sure If You Have an NPI?

Search for your NPI on the NPPES NPI Registry .

CMS Provider Enrollment Systems:

  • I&A System
  • Electronic Health Record (EHR) Incentive Payments

Multi-Factor Authentication

To better protect your information, we implemented I&A System multi-factor authentication for the provider enrollment systems listed above.

Step 2: Complete Proper Medicare Enrollment Application

After you get an NPI, you can complete Medicare Program enrollment, revalidate your enrollment, or change your enrollment information. Before applying, get the necessary enrollment information , and complete the actions using PECOS or the paper enrollment form.

A. Online PECOS Application

After we approve your I&A System registration, submit your PECOS application.

PECOS offers a scenario-driven application, asking questions to recover the information for your specific enrollment scenario. You can use PECOS to submit all supporting documentation. Follow these instructions:

  • Log in to PECOS .
  • Continue with an existing enrollment or create a new application.
  • When PECOS determines your enrollment scenario and you confirm it’s correct, you’ll see the topics for submitting your application. To complete each topic, enter the necessary information.
  • Confirms you entered all necessary data
  • Lists MAC documents to submit for review
  • Gives the option to electronically sign and certify
  • Shows your MAC’s name and mailing address
  • Lets you print your enrollment application for your records (don’t submit a paper copy to your MAC)
  • Sends the application electronically to your MAC
  • Emails you to confirm your MAC got the application

PECOS 2.0 Enhancements

PECOS will have enhanced features to better meet your needs. Watch this 2-minute video or read these FAQs to learn more about:

  • A single application for multiple enrollments
  • Data pre-population and an application that’s tailored to you
  • Enhanced capability to add or delete group members
  • Real-time processing checks and status updates
  • Revalidation reminders

Visit Introducing PECOS 2.0 for more information.

PECOS Scroll Functionality

PECOS validates that you’ve read and acknowledged certification terms and conditions before you electronically submit your Medicare enrollment application. Review and scroll through each text box with certification requirements before you can select accept on these pages:

  • Remote E-sign

Enrolling physicians, NPPs, or other Part B suppliers must choose 1 of the application descriptions below.

  • You’re the only owner of a business, set up as a corporation, where you provide health care services
  • Your business is legally separate from your personal assets
  • You provide all health care services from a facility you own, lease, or rent
  • You’re the only owner of a business that provides health care services
  • You and your business are legally 1 and the same
  • You’re personally responsible for the business’ financial obligations, and you report business income and losses on your personal tax return
  • You provide all health care services as an employee of a group practice or clinic
  • You arrange with your employer to submit claims and get paid for your services
  • Choose Group Member Only if you’re reassigning all your benefits to a group practice or clinic
  • You provide health care services as a group practice or clinic employee
  • You agree with your employer to submit claims and get paid for your services
  • You also provide health care services from a facility that you own, lease, or rent
  • Your income through self-employment is part of your personal assets
  • Your corporation doesn’t file taxes; instead, you file corporate taxes on your personal tax filing

B. Paper Medicare Enrollment Applications

Submit the appropriate paper enrollment application if you’re unable to use PECOS. Carefully review the paper application instructions to decide which form is right for your practice. The paper enrollment application collects your information, including documentation verifying your Medicare Program enrollment eligibility.

If you submit a paper application, your MAC processes your application and creates a Medicare enrollment record by entering the data into PECOS.

Medicare Enrollment Application: Institutional Providers (CMS-855A) : Institutional providers use this form to begin the Medicare enrollment or revalidation process or to change enrollment information.

Most physicians and NPPs complete the CMS-855I to begin the enrollment process. You can also use the CMS-855I if you reassign your benefits to another entity, like a medical group or group practice that gets paid for your services. We’ve merged the CMS-855R into the CMS-855I paper enrollment application.

  • Medicare Enrollment Application: Clinics/Group Practices and Other Suppliers (CMS-855B) : Group practices and other organizational suppliers, except DMEPOS suppliers, use this form to begin the Medicare enrollment or revalidation process or to change enrollment information.
  • Medicare Enrollment Application: Enrollment for Eligible Ordering/Certifying Physicians and Other Eligible Professionals (CMS-855O) : Physicians and other eligible NPPs use this form to enroll in Medicare solely to order or certify items or services for Medicare patients. This includes those physicians and other eligible NPPs who don’t send billed services claims to a MAC.
  • Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers (CMS-855S) : DMEPOS suppliers use this form to begin the Medicare enrollment or revalidation process or to change enrollment information.
  • Medicare Enrollment Application: Medicare Diabetes Prevention Program (MDPP) Suppliers (CMS-20134) : MDPP suppliers use this form to begin the Medicare enrollment or revalidation process or to change enrollment information.

After you submit an enrollment application and all required supporting documentation to your MAC, they’ll send their recommendations to the State Survey Agency . The State Survey Agency then decides if specific providers meet Medicare enrollment conditions.

After a MAC makes a recommendation, the State Survey Agency or a CMS-recognized accrediting organization conducts a survey. Based on the survey results, the agency or organization recommends that we approve or deny the enrollment (certification of compliance or non-compliance).

Certain institutional provider types may elect voluntary accreditation by a CMS-recognized accrediting organization instead of a State Survey Agency. The accrediting organization will notify the State Survey Agency of their decision.

The State Survey Agency forwards us the survey results. We assign the CMS Certification Number and effective date, sign the provider agreement, and update the certification database. Your MAC will issue your final approval or denial letter.

If approved, you’ll get a fully executed provider agreement.

Electronic Funds Transfer

If enrolling in Medicare, revalidating, or making certain changes to your enrollment, we require you to set up an electronic funds transfer (EFT). Enroll in EFT by completing the PECOS EFT information section. When submitting a PECOS application:

  • Complete the EFT information for your organization (if appropriate) or yourself
  • Include a copy of a voided check or bank letter that has your individual or business legal name and applicable account and routing numbers

Step 3: Respond to Requests for More Information

MACs pre-screen and verify enrollment applications for completeness. If the MAC needs more information, respond to information requests within 30 days. If you don’t, the MAC may reject your enrollment .

Your MAC won’t fully process your PECOS enrollment application without your electronic or uploaded signature, application fee (if applicable), and necessary supporting documentation. The enrollment application filing date is when the MAC gets your enrollment application.

You can check your PECOS enrollment application status 2 ways:

  • Log in to PECOS and select the View Enrollments link. In the Existing Enrollments section, find the application. The system shows the application status.
  • To see your enrollment status without logging in, go to PECOS and, under Helpful Links , select Application Status.

When your MAC approves your application, it switches the PECOS record to an approved status and sends you an approval letter.

Provider Enrollment Site Visits

We conduct a site visit verification process using National Site Visit Contractors (NSVCs). A site visit helps prevent questionable providers and suppliers from enrolling or staying enrolled in the Medicare Program.

The NSVCs conduct unannounced site visits for all Medicare Part A and B providers and suppliers, including DMEPOS suppliers. The NSVCs may conduct an observational site visit or a detailed review to verify enrollment-related information and collect other details based on pre-defined CMS checklists and procedures.

During an observational visit, the inspector has minimal contact with the provider or supplier and doesn’t hinder the facility’s daily activities. The inspector will take facility photos as part of the site visit. During a detailed review, the inspector enters the facility, speaks with staff, and collects information to confirm the provider’s or supplier’s compliance with our standards.

Inspectors performing site visits will carry a photo ID and a CMS-issued, signed authorization letter the provider or supplier may review. If the provider or its staff want to verify we ordered a site visit, contact your MAC .

Make your office staff aware of the site visit verification process. An inspector’s inability to perform a site visit may result in denial of your Medicare enrollment application or revocation of your Medicare billing privileges.

Step 4: Use PECOS to Keep Enrollment Information Current

Report a Medicare enrollment change using PECOS. Physicians, NPPs, and physician and NPP organizations must report a change of ownership or control (including a change in authorized or delegated official), a change in practice location, and any final adverse legal actions (like a felony or suspension of a federal or state license) within 30 days of the change and report all other changes within 90 days of the change.

DMEPOS suppliers must report changes in their enrollment application information within 30 days of the change.

Independent diagnostic testing facilities must report changes in ownership, location, general supervision, and adverse legal actions within 30 days of the change and report all other changes within 90 days of the change.

Medicare Diabetes Prevention Program suppliers must report changes in ownership, including AO or Access Manager; location; coach roster; and adverse legal actions within 30 days of the change and report all other changes within 90 days of the change.

PECOS Users

We allow various organizations and users to work in our systems. The type of user depends on their relationship with you and the duties they perform in your practice.

You may choose other users to act for your organization to manage connections and staff, including appointing and approving other system-authorized users. Depending on your professional relationships with other providers, the CMS External User Services Help Desk may ask you for additional validation information.

One Account, Multiple Systems

We use several provider enrollment systems. Organizational providers and suppliers must use the Identity & Access Management (I&A) System to name an AO to work in CMS systems. The I&A System allows you to:

  • Use NPPES to apply for and manage NPIs
  • Use PECOS to enroll in Medicare or update or revalidate your current enrollment information
  • Register to get electronic health record (EHR) incentive payments for eligible professionals and hospitals that adopt, use and upgrade, or show meaningful use of EHR technology

Authorized Officials, Access Managers, Staff End Users, & Surrogates

Organizational providers or suppliers must appoint and authenticate an Authorized Official (AO) through the I&A System to work in PECOS for them. That person must meet the AO regulatory definition. For example, an AO is a chief executive officer, chief financial officer, general partner, chair of the board, or direct owner who can legally enroll in the Medicare Program.

Respond to your employer’s AO invitation or initiate the request yourself. After you’re the confirmed AO, use PECOS for your provider or supplier organization. As an AO, you’re responsible for approving PECOS user system requests to work on behalf of the provider or supplier organization. Regularly check your email and take the requested actions.

AOs may delegate their responsibilities to an Access Manager who can also initiate or accept connections and manage staff for their organizations.

AOs or Access Managers may invite a Staff End User (SEU) or Surrogate to access PECOS for their organization. Once registered, an SEU or Surrogate may log in to access, view, and modify CMS system information, but they can’t represent the practice, manage staff, sign enrollment applications, or initiate or accept connections.

We recommend using the same I&A System-appointed AO and PECOS Access Managers. The assigned AO and Access Managers must have the right to legally bind the company and be responsible for approving the system staff and be CMS-approved in the I&A System.

Only AOs can sign an initial organization enrollment application. An Access Manager can sign changes, updates, and revalidations.

The I&A System Quick Reference Guide has detailed instructions on managing system users.

PECOS Technical Help

Using PECOS may require technical support. The first step toward a solution is knowing which CMS contractor to contact.

Common Problems & Who to Contact

You experience system-generated error messages, have trouble navigating through or accessing PECOS screens, encounter printing problems, or your valid I&A System user ID and password won’t allow PECOS access because of a malfunction (for example, the website operates slowly or not at all or a system-generated error message prevents you from entering data).

A system-generated error message doesn’t include messages created when you enter data incorrectly or ignore system prompts.

Solution: Contact the CMS External User Services Help Desk

The External User Services website has information on common problems and allows you to ask questions, chat live with a support team member, or look up previous support history.

Phone: 1-866-484-8049 (TTY 1-866-523-4759)

Email: [email protected]

EUS Hours of Operation:

  • Monday–Friday: 6 am–6 pm CT
  • Saturday–Sunday: Closed

Before you log in to PECOS, you need a valid I&A System user ID and password.

Passwords expire every 60 days. The I&A System tells you the number of days until your password expires. If you attempt to log in to PECOS with an expired password, the system redirects you to the I&A System to reset it.

Solution: Access I&A System or Contact I&A System Help

The I&A System website lets you create an I&A System user ID and password, change your password, and recover forgotten login information. You can also access several resources:

  • The I&A FAQs helps you resolve common I&A System problems
  • The I&A System Quick Reference Guide provides step-by-step instructions, including screenshots, and information about I&A System features and tools

On the I&A System website, select the Help button in the upper right corner of any webpage for more information on that webpage’s topic.

While using PECOS, you may have questions, experience problems enrolling, or need help completing specific PECOS enrollment application sections.

Solution: Contact Your Medicare Enrollment Contractor

Find detailed enrollment contact information in the Medicare Provider Enrollment Contact List . If you have questions, find your MAC’s website .

Solution: Refer to the CMS Provider Enrollment Assistance Guide

If you don’t know who to call for help, refer to the “Who should I call?” CMS Provider Enrollment Assistance Guide .

Find detailed enrollment contact information in the Medicare Provider Enrollment Contact List .

Organizational providers and suppliers must designate a provider enrollment AO to work in CMS systems, including the I&A System , NPPES , and PECOS . The AO may also authorize Access Managers, Surrogates, and SEUs to use PECOS. Individual providers and suppliers don’t require an AO but can authorize Surrogates and SEUs to work in PECOS. Refer to the I&A System Quick Reference Guide and I&A FAQs for more information on registering for an I&A System account or enrolling as an AO.

We use several provider enrollment systems. Specifically, the I&A System allows you to:

  • Use PECOS to enroll in Medicare or to update or revalidate your current enrollment information
  • Register to get EHR incentive payments for eligible professionals and hospitals that adopt, use and upgrade, or show meaningful use of certified EHR technology

Before completing PECOS enrollment, create an I&A System account. Organizational providers and suppliers must designate an AO to work in these systems.

Use the same information to enroll in Medicare using PECOS as you would for a paper enrollment application.

  • If you don’t have an I&A System account, create your username and password
  • Use your username and password to log in to NPPES to register for an NPI
  • All Medicare provider enrollees must have an active NPI

Based on your provider type, you may also need this information:

  • Personal identifying information, including your legal name on file with the Social Security Administration, date of birth, and SSN
  • Legal business name of the provider or supplier organization
  • Provider or supplier organization’s TIN; if any person or organization has 5% or more partnership interest or ownership (direct or indirect), you must list them on all enrollment records under your TIN
  • Professional license information
  • School degrees
  • Certificates
  • W-2 employees and contracted individuals and organizations with managerial control of the provider or supplier
  • Accreditation information
  • Surety bond information
  • Providers self-designate their Medicare specialty on the Medicare enrollment application (CMS 855-I or CMS 855-O) or PECOS when they enroll in the Medicare Program
  • Beginning January 1, 2024, we established new provider specialty codes for dentists
  • Current medical practice location
  • Federal, state, and local (city or county) business and professional licenses, certificates, and registrations specifically required to operate as a health care facility
  • Medical record storage information
  • Special payment information
  • Bank account information
  • Suspension, termination, or revocation of a license to provide health care by a state licensing authority or the Medicaid Program
  • Conviction of a federal or state felony within 10 years before enrollment, revalidation, or re-enrollment
  • Exclusion or debarment from federal or state health care program participation by the Office of Inspector General (OIG) or other federal or state offices with authority to exclude or sanction a provider (or those listed above)

An application is the paper or electronic form you submit for Medicare Program enrollment approval. After the MAC processes the application, PECOS keeps the enrollment record, which includes all your enrollment application data.

You can’t use PECOS to:

  • Change your SSN
  • Change a provider’s or supplier’s TIN
  • Solely owned PA, PC, or LLC can’t be changed to a sole proprietorship
  • Sole proprietorship can’t be changed to a PA, a PC, or an LLC

Submit changes noted above using the appropriate paper Medicare enrollment application .

No. All Fee-for-Service (FFS) providers can apply in PECOS.

PECOS is available 24 hours a day, Monday–Saturday, with scheduled downtime on Sunday. We offer technical support daily, 5 am–8 pm CT.

We encourage you to submit your enrollment application through PECOS because it’s faster and easier, but you may complete and mail the appropriate paper Medicare enrollment application to the address on the Medicare Fee-for-Service Provider Enrollment Contact List :

  • Parts A and B Providers: Send forms to your Part A or Part B MAC.
  • Home Health and Hospice Providers: Send forms to the Home Health and Hospice Contractor.
  • DMEPOS Suppliers Send forms to the National Provider Enrollment (NPE) DMEPOS contractor in your region. Find your NPE contractor .

Even if you submit your application on a paper form, your MAC creates an enrollment record in PECOS.

When you electronically submit your Medicare enrollment application, you’ll get a Submission Confirmation page, which will remind you that the individual provider, or the provider or supplier organization AO or Access Manager must electronically sign the application or upload their signature. You’ll be able to see which MAC is processing your application, your unique application tracking number, and real-time information about your application.

PECOS emails the web tracking ID for the submitted application to each address in the Contact Person section of the application. Remember to verify all your completed signatures with either an electronic signature or uploading certification. Mail any required supporting documentation you didn’t upload during submission to the MAC, and include the PECOS tracking ID.

Create a new enrollment:

  • If you change your services, like changing specialties
  • If you change your location, causing your MAC to need new state surveys and other documentation (your MAC can determine this)
  • If you have a change of ownership
  • If a provider is creating a new TIN because of a change of ownership
  • If you have provider-based vs. freestanding requirements (find your MAC’s website for more information)

Application Fee & Supporting Documentation

Generally, institutional providers and suppliers, like DMEPOS suppliers and opioid treatment programs, pay an application fee when enrolling, re-enrolling, revalidating, or adding a new practice location.

MACs will only process applications with the proper application fee payment or an approved hardship exception.

If you pay the fee during the 30-day period, the MAC processes the application in the usual manner.

No. When you electronically submit the Medicare enrollment application, a page appears that lists the supporting documentation to complete the enrollment. You can submit all this documentation electronically through PECOS.

Yes, either is acceptable. You must send this information electronically (as supporting documentation uploaded into PECOS).

During the PECOS application process, the Penalties for Falsifying Information page has the same text as the paper Medicare enrollment application and lists the consequences for providing false information. These consequences include criminal and civil penalties, fines, civil monetary penalties, exclusion from federal health care programs, and imprisonment, among others. You must acknowledge this page by selecting the Next Page button before continuing the PECOS submission process.

Enrollment Application Issues

First, make sure you entered your correct SSN, legal name, and date of birth. If you believe you entered the correct information but PECOS doesn’t accept this information, contact the Social Security Administration .

You must report an SSN to enroll in Medicare. If you don’t want to report your SSN over the web, use the appropriate paper Medicare enrollment application .

An Invalid Address error indicates the address entered doesn’t comply with the U.S. Postal Service address standards. This page lets you continue by either saving the address you entered or selecting the address PECOS displays.

As a security feature, PECOS will time out if you’re inactive (you don’t hit any keys on your computer keyboard) for 15 minutes. The system warns you of inactivity after 10 minutes. If it gets no response after 5 additional minutes, the system automatically times you out. Save your work if you anticipate inactivity while applying in PECOS. If you don’t save your work and the system times out, you must start from the beginning.

Submitting Reportable Events

No. If you report a change to existing information, check Change , include the effective date of change, and complete the appropriate fields in the impacted sections.

Yes. Following your initial enrollment, report certain changes (reportable events) to your MAC within 30 calendar days of the change. Report all other changes to your MAC within 90 days.

Report a Medicare enrollment change using PECOS. Physicians and NPPs must report a change of ownership or control (including a change in authorized or delegated official), a change in practice location, and any final adverse legal actions (like a felony or suspension of a federal or state license) within 30 days of the change and report all other changes within 90 days of the change.

Since Medicare pays claims by EFT, the Special Payments address should indicate where all other payment information must go (for example, paper remittance notices or special payments).

Providers and suppliers should report most changes using PECOS or the applicable paper Medicare enrollment application .

No. If you have a new business location, complete a new PECOS or paper application. Each DMEPOS enrollment record can only have 1 current business location.

Revalidations

Revalidation means resubmitting and recertifying your enrollment information.

DMEPOS suppliers must revalidate every 3 years, while all other providers and suppliers generally revalidate every 5 years. We can also conduct off-cycle revalidations . You can revalidate using PECOS or by submitting the appropriate paper Medicare enrollment application .

If you’re currently enrolled, check the Medicare Revalidation List to find your revalidation due date. If you see a due date, submit your revalidation before that date. Your MAC will also send you a revalidation notice.

Due dates are:

  • Updated in the Medicare Revalidation List every 60 days at the beginning of the month
  • Listed up to 7 months in advance or listed as to be determined (TBD) if the due date is more than 7 months away

Yes. Your MAC will send a revalidation notice 90–120 days before your revalidation due date.

If there’s no due date listed on the Medicare Revalidation List or you didn’t get a MAC letter requesting revalidation, don’t submit your revalidation application. Your MAC will return it to you.

However, if you’re within 2 months of the due date listed on the Medicare Revalidation List and didn’t get a MAC notice to revalidate, submit your revalidation application.

Yes. PECOS lets you review information on file and update and electronically submit your revalidation. If you use PECOS, you need to update only changed information.

If you submit your revalidation after its due date, your MAC may place a hold on your Medicare payments or deactivate your Medicare billing privileges. If the MAC requests additional documentation, respond within 30 days. If you don’t, they may deactivate your Medicare billing privileges.

Revalidation ensures all provider enrollment records are accurate and current. Generally, we don’t take administrative action against a provider or supplier for updating their records even though it wasn’t timely. However, we could take administrative actions, including recovering previous Medicare payments, when a provider or supplier that fails to report the change causes their Medicare enrollment to become ineligible.

PECOS users can’t mail documents that require a signature. When submitting your application, be prepared to send an e-signature or upload your signed documents.

Protect Your Identity & Privacy

You can help protect your professional medical identifiers from identity thieves attempting to defraud the Medicare Program.

Keep PECOS Enrollment Information Current

Log in to PECOS and review your Medicare enrollment information several times a year to ensure no unauthorized changes were made.

PECOS Provides Security

Only you, authorized surrogates, authorized CMS officials, and MACs may enter and view your Medicare PECOS enrollment information. CMS officials and MACs get security standards training and must protect your information. We don’t disclose your Medicare enrollment information to anyone, except when authorized or required by law.

Review & Protect Enrollment Information

Review your Medicare enrollment information in PECOS frequently to ensure it’s accurate, current, and unaltered.

Use your I&A System user ID and password to access PECOS. Keep your ID and password secure.

Protect Yourself & CMS Programs from Fraud

Your NPI and TIN are publicly available information. Use extra caution to monitor and protect your professional and personal information to help prevent fraud and abuse. Also ensure your patients’ personal health information is secure. Refer to these resources:

  • Medicare Fraud & Abuse: Prevent, Detect, Report
  • Office of Inspector General
  • Reporting Medicare fraud & abuse

Take these steps to verify your Medicare enrollment information:

PECOS Login Webpage

If you suspect your PECOS profile is incorrect due to unauthorized account access, contact your MAC, law enforcement authorities, and your bank. Your MAC and bank can flag your respective accounts for possible fraudulent activity, and law enforcement can begin investigating if and how your accounts were compromised.

Additional Privacy Tips

Take these additional actions to protect your Medicare enrollment information:

  • Change your password in the I&A System before accessing PECOS the first time. You can’t change your user ID, but you must change your password every 60 days.
  • Review your Medicare enrollment information several times a year to ensure no one changed information without your knowledge. Immediately report changes you didn’t submit.
  • Maintain your Medicare enrollment record. Report Medicare enrollment changes known as reportable events, including change of ownership or control , change in practice location, banking arrangements, and any final adverse legal actions.
  • Store PECOS copies or paper enrollment applications in a secure location. Don’t allow others access to this information as it contains your personal information, including your date of birth and SSN. Don’t leave copies in a public workspace.
  • Enroll in electronic Medicare payments, and ensure they deposit directly into your bank account. We require all providers to use electronic funds transfer (EFT) when enrolling in Medicare, revalidating, or making changes to their enrollment. The most efficient way to enroll in EFT is to complete the EFT information section in PECOS and provide the required supporting documentation. Using EFT allows us to send payments directly to your bank account.

DMEPOS Supplier Requirements

Dmepos supplier standards, accreditation, & surety bond.

To enroll or keep your Medicare billing privileges, all DMEPOS suppliers (except certain exempted professionals) must meet supplier and DMEPOS Quality Standards to become accredited. Certain DMEPOS suppliers must also submit a surety bond .

DMEPOS suppliers (except those exempted eligible professionals and other persons) must be accredited by a CMS-approved accrediting organization before submitting a Medicare enrollment application to the National Provider Enrollment (NPE) DMEPOS contractors .

Each enrolled DMEPOS supplier covered under the Health Insurance Portability and Accountability Act (HIPAA) must name each practice location (if it has more than 1) as a sub-part and make sure each sub-part gets its own NPI.

Individual DMEPOS Suppliers (for example, sole proprietorships)

Physicians, NPPs, and DMEPOS suppliers may use their I&A System user ID and password to access PECOS . If you don’t already have an I&A System account, refer to the I&A System User Registration page and enter the information to open an account. For help, refer to the How to Setup Your Account if you are a Sole Owner section in the I&A System Quick Reference Guide .

As an individual DMEPOS supplier, you don’t need an AO or another authorized user.

Organizational DMEPOS Suppliers System Users

A DMEPOS supplier organization must appoint an AO to manage connections and staff, including appointing and approving other authorized PECOS users. The organization must identify the AO in the enrollment application. The AO must have ownership or managing control in the DMEPOS supplier organization.

Providers Who Solely Order or Certify

Physicians and other eligible professionals must enroll in the Medicare Program or have a valid opt-out affidavit on file to solely order or certify Medicare patient items or services.

Those physicians and other eligible professionals enrolled solely as ordering/certifying providers don’t send billed service claims to a MAC.

Ordering/Certifying Terms

Part B claims use the term ordering/certifying provider to identify the professional who orders or certifies an item or service reported in a claim. These are technically correct terms:

  • Providers order non-physician patient items or services, like DMEPOS, clinical lab services, or imaging services
  • Providers certify patient home health services

The health care industry uses the terms ordered , referred , and certified interchangeably .

Who Are Eligible Ordering/Certifying Providers?

Physicians or eligible professionals who order or certify Part A or Part B services but don’t want to submit Medicare claims are eligible ordering/certifying providers.

A person already enrolled as a Part B provider may submit claims listing themselves as the ordering/certifying provider without re-enrolling using Medicare Enrollment Application: Enrollment for Eligible Ordering/Certifying Physicians and Other Eligible Professionals (CMS-855O) .

Note: Those who enroll as eligible providers using CMS-855O can’t bill Medicare, and we can’t pay for their services because they have no Medicare billing privileges.

Organizational NPIs don’t qualify, and you can’t use them to order or certify.

Eligible providers must meet these basic conditions:

  • Have an individual NPI
  • Be enrolled in Medicare in either an approved or opt-out status
  • Be an eligible specialty type to order or certify

Denial of Ordering/Certifying Claims

If claims lack a valid individual NPI, MACs deny them if they’re from:

  • Clinical labs for ordered tests
  • Imaging centers for ordered imaging procedures
  • DMEPOS suppliers for ordered DMEPOS
  • Part A home health agencies that aren’t ordered or certified by a Doctor of Medicine, Osteopathy, or Podiatric Medicine

If you bill a service that needs an eligible provider and they aren’t on the claim, the MAC will deny the claim. The claim must have a valid NPI and the eligible provider’s name as it appears in PECOS.

If a provider who’s on the Preclusion List prescribes a Medicare Part D drug, drug plans will deny it.

Requirement 1: Get an Individual NPI

The 2 types of NPIs are: Type 1 (individual) and Type 2 (organizational). Medicare allows only Type 1 NPIs to solely order items or certify services. Apply for an NPI through:

  • Online Application: Get an I&A System user account. Then apply for an NPI in NPPES .

Requirement 2: Enroll in Medicare in an Approved or Opt-Out Status

Once you have an NPI, use PECOS to verify current Medicare enrollment record information, including your NPI and that you’re approved, or go to the Opt Out Affidavits list to check your status. To opt out of Medicare, submit an affidavit expressing your decision to opt out of the program.

Part C and Part D providers don’t have to enroll in Medicare in an approved or opt-out status.

*We deny certain power mobility device claims if the ordering provider isn’t on our eligible providers list.

Requirement 3: Be Eligible to Order or Certify

The physicians and eligible professionals who may enroll in Medicare solely for ordering or certifying include, but aren’t limited to, physicians and eligible professionals who are:

  • Department of Veterans Affairs employees
  • Public Health Service employees
  • Department of Defense or TRICARE employees
  • Indian Health Service or Tribal Organization employees
  • Federally Qualified Health Center, Rural Health Clinic, or Critical Access Hospital employees
  • Licensed Residents in an approved medical residency program defined in 42 CFR 413.75(b)
  • Dentists, including oral surgeons
  • Pediatricians
  • Retired, licensed physicians

If you’re unsure whether your specific provider specialty qualifies to enroll as an ordering/certifying provider, refer to Section 4 of CMS-855O or find your MAC’s website before submitting a Medicare enrollment application.

Interns & Residents

Claims for items or services ordered or certified by licensed or unlicensed interns and residents must specify a teaching physician’s NPI and name. State-licensed residents may enroll to order or certify and can be listed on claims. If states offer provisional licenses or otherwise permit residents to order/certify, we allow interns and residents to enroll consistent with state law.

Requirement 4: Respond to Requests for More Information

  • To see your enrollment status without logging in, go to PECOS and, under Helpful Links , select Application Status .

Requirement 5: Use PECOS to Keep Enrollment Information Current

Report a Medicare enrollment change using PECOS. Providers and suppliers must report a change of ownership or control (including a change in authorized or delegated official), a change in practice location, and any final adverse legal actions (like revocation or suspension of a federal or state license) within 30 days of the change and must report all other changes within 90 days of the change.

Revalidation

Revalidation, or re-submitting and recertifying your enrollment information accuracy, is an important anti-fraud tool. All Medicare-enrolled providers and suppliers must periodically revalidate their enrollment information .

Generally, physicians, including physician organizations, opioid treatment programs, Medicare Diabetes Prevention Program suppliers, and institutional providers, revalidate enrollment every 5 years or when we request it. DMEPOS suppliers must revalidate their enrollment information every 3 years.

PECOS is the most efficient way to revalidate information.

If you’re actively enrolled, go to the Medicare Revalidation List to find your revalidation due date. If you see a due date, submit your revalidation before that date. Your MAC notifies you when it’s time to revalidate. If you submit your revalidation application after the due date, your MAC may hold your Medicare payments or deactivate your billing privileges.

Rebuttal Process

MACs issue Medicare billing privilege deactivations. We permit providers and suppliers to file a rebuttal .

Get more information:

  • 42 CFR 424.515
  • Provider Enrollment Revalidation Cycle 2 FAQs
  • Revalidations (Renewing Your Enrollment)

Large Group Coordination

Groups with more than 200 members can use the Medicare Revalidation List and search by their organization’s name to download group information. Their MAC will send them a letter and spreadsheet that lists the providers linked to their group who must revalidate within 6 months. Large groups should work together to ensure they submit only 1 application from each provider or supplier.

Use these resources to learn how to enroll in the Medicare Program, revalidate your enrollment, or change your enrollment information. Enroll in the Medicare Program to get paid for providing covered patient services. Enroll if you solely order items or certify services.

You can enroll online by using PECOS or the appropriate paper enrollment application you submit to your MAC.

  • Get an I&A System user account
  • Apply for your NPI in the NPPES
  • Enroll in PECOS

Enrollment Forms

If you enroll using a paper application instead of PECOS , search the CMS Forms List to find the form you need and read on page 1, Who Should Submit This Application .

Commonly Used Terms

View the Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure .

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

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Florida’s Medicaid Redetermination Plan

Since the beginning of the Public Health Emergency (PHE), as a requirement to receive additional funding from the federal government, Florida has provided continuous Medicaid coverage and has not disenrolled ineligible recipients. As a result of this policy, Florida saw a significant increase in the number of individuals and families seeking Medicaid assistance, from 3.8 million enrolled in March 2020 to 5.5 million in November 2022. Medicaid eligibility in Florida is determined either by the Department of Children and Families (DCF) or the Social Security Administration (for SSI recipients) while the Agency for Health Care Administration (AHCA) administers the Medicaid Program. Each month the Department processes, on average, 220,658 Medicaid applications, redeterminations, or requests for additional assistance.

As a result of legislative changes in the Consolidated Appropriations Act, 2023, the continuous coverage provision will end on March 31, 2023, and is untied from the end of the PHE. The Department will follow federal guidance to restore Medicaid eligibility through normal processing while working to ensure eligible recipients remain enrolled. The Centers for Medicare and Medicaid Services (CMS) allows state agencies up to 12 months to complete Medicaid reviews once the continuous coverage period ends. Florida will undertake this task by scheduling and conducting redeterminations in a manner that will meet federal regulatory requirements while minimizing the impact on families.

Florida's economy has rebounded quickly and continues to outperform the nation in economic and labor market metrics. With our robust economic environment, many families have had an increase in income and the ability to obtain insurance through employment. This is welcome news for many families, and the Department will work with them to ensure a smooth transition. Over the next 12 months, the Department will work to notify and communicate to all current Medicaid recipients their redetermination timeframes and next steps.

             •   Updated Medicaid Redetermination Information

             •   Medicaid Redetermination Information Flyer (PDF)

             •   Florida's Medicaid Redetermination Plan (PDF)

             •   Florida Medicaid Redetermination Partner Packet (PDF)

                              •   Florida's Medicaid Redetermination Partner Packet - Spanish (PDF)

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Are You Ready for a CMS Site Visit?

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Whether you are a new provider or you have been in practice for some time, the Centers for Medicare & Medicaid Services (CMS) may pay enrolled providers a visit for a medical record review and audit.

Would you be prepared if this audit were to happen next week?

The goal of CMS onsite audits is to find any fraud or abuse in the healthcare payment system. Some insurance payers are now joining in on-site audit visits. During the visit, CMS will make sure that your physical address matches the address on your electronic records and that your business is clearly labeled with street and number signs. They will also check that the proper licensed staff is providing professional services and that medical records are unaltered.

Checklist To Prepare for CMS Onsite Visit

You will receive a warning letter from CMS or from an insurance payer announcing your site visit . An unannounced visit may occur as well. Take action right away:

Check the credentials and photo ID of the auditors.

Let your attorney know about the audit and ask if they have any preparation advice or if they want to be present.

You may request that the appointment be rescheduled to a less busy time for your office.

Determine the exact purpose of the office visit and what issues they have observed in other providers.

Ask in advance whether any of your staff will be interviewed. If yes, brief them on how to answer questions accurately – but don’t volunteer any additional information.

Prepare a secure room in which the auditors can work.

If the audit is for only for medical records, ask for a patient list in advance.

Keep copies of all material that you supply to the auditors.

As a good practice drill for your staff, do a self-audit. Make sure that HIPAA standards are being met and that certificates are properly displayed. While you are at it, include safety standards in your audit for both OSHA and health department standards.

The auditors are only doing their jobs! Healthcare providers and suppliers must have policies and procedures in place for full compliance. When you are prepared for an audit at any time, you and your staff are confident that all proper HIPAA and other mandates are in place.

Let Us Manage All Your Payer Enrollment and Credentialing Services

If you require medical credentialing and payer enrollment needs for your practice or medical facility, please contact 1st Assistant. Our experienced and dedicated specialists will provide all credentialing and enrollment services quickly and will monitor your account for ongoing updates and re-attestations. Heidi Henderson , Vice President of Credentialing, is eager to meet you and discuss your payer enrollment needs. Please call us at 512.201.2668 or contact us via the website .

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Patients struggle to get lifesaving medication after cyberattack on a major health care company

Desperate patients around the country have been forced to choose between paying out of pocket for essential medications or forgoing them entirely as the aftermath of a cyberattack on a major health care company stretches into its third week. 

Change Healthcare, a little-known but critical subsidiary of UnitedHealth Group, detected the attack on Feb. 21. Since then, pharmacies, doctors offices and patients say their lives and work have been upended by widespread outages in systems commonly used for medical billing and insurance claims. 

Disruptions to copay assistance and coupon card processing at pharmacies, in particular, have highlighted key vulnerabilities in a system on which people’s lives depend.

Ronda Miller, 54, said she and her husband rely on a discount card to afford his insulin — he has Type 2 diabetes and congestive heart failure. But when she tried to pick up his medication at her pharmacy in Deadwood, South Dakota, on Feb. 22, the card could not be processed. Without it, the medications would cost hundreds of dollars.

“When you are diabetic, whether it’s Type 1 or Type 2, without insulin they’re going to die,” Miller said.

Ronda Miller and her husband John Paul Miller.

Change Healthcare’s technology is involved in transactions throughout the industry — beyond those involving United Healthcare insurance. The company says it completes 15 billion transactions a year, amounting to $1.5 trillion in health claims. On its website, Change said the hack affected 21 parts of its business, including many that providers use to receive payments, get reimbursed by insurers and process patients’ insurance eligibility.

“Anything that requires interaction between health plans, a pharmacy, a facility, an office has been disrupted,” said Dr. Jesse Ehrenfeld, the president of the American Medical Association. “That has far-reaching implications, whether you’re on routine, standard medications, whether you rely on a rebate program from a pharmaceutical company, whether you’re just trying to get clearance to have routine elective surgery.” 

UnitedHealth Group said in a statement that it took “immediate action to disconnect Change Healthcare’s systems to prevent further impact” and that the services would “remain offline until we are certain we can turn them back on safely.”

The company said Tuesday that a new network connecting pharmacies to benefit managers could come online as soon as Thursday.

Laura Lester, who owns Marion Family Pharmacy in Marion, Virginia, said the biggest effect in her community has been on patients who can’t afford their medications without copay assistance cards.

“We’ve got people walking away from diabetes medicines, antipsychotics, ADHD medications,” she said. 

“We had one woman yesterday who had to pay $1,100 out of pocket because the copay card wasn’t working,” she added. The patient needed the medication for her irritable bowel syndrome, she said.

Even patients who don’t use copay assistance have faced immense challenges. Donna Hamlet, 73, a breast cancer patient at Florida Cancer Specialists & Research Institute, takes a medication called IBRANCE that would cost her around $16,000 a month without insurance. But on Feb. 23, she said, a pharmacy told her it couldn’t process her refill through insurance because of the cyberattack.

Donna Hamlet, a 16-year breast cancer survivor.

Without the drug, Hamlet said, “the cancer would fill up my body, and I guess I would die.”

After four or five days of phone calls, she got her prescription filled via OptumRx, a UnitedHealth Group pharmacy benefit manager. 

Nathan Walcker, the CEO of the Florida institute treating Hamlet, estimates that $350 million worth of the practice’s charges have been affected by billing delays due to the cyberattack.

But Walcker said he worries most about patients who can’t get prior authorizations processed — many insurance companies require them for cancer treatments, which can cost up to $100,000 per course. 

“We have no ability today to even know if we have a prior authorization in hand for a new patient,” he said. 

The Centers for Medicare and Medicaid Services on Tuesday encouraged Medicare and Medicaid programs to remove or relax prior authorizations during the outage and to consider giving health care providers advance funding. Hospitals can submit accelerated payment requests, CMS said, and Medicare providers struggling to submit claims can send paper versions and may be eligible for exceptions or extensions.

UnitedHealth Group said that as of Tuesday, around 90% of claims were “flowing uninterrupted,” with pharmacy claims “flowing at near-normal levels,” thanks to temporary fixes or systems’ coming back online.

The company has encouraged health care providers to switch to an Optum system to expedite submitting claims and receiving payments. Meanwhile, the new network connection that the company expects Thursday should address “the majority of the coupon volume” managed by Change Healthcare, it said.

Optum is also offering temporary loans to medical practices, but providers say they’re insufficient.

Dr. Christine Meyer, who owns an internal medicine practice in Exton, Pennsylvania, said her office submits up to $600,000 a month in claims but was offered only a monthly loan of $4,000.

Amid the sudden halt in revenue, Meyer said, the small offer was “an emotional slap in the face.”

Her practice is manually submitting some claims to insurance websites, she said, and her staff printed around 1,000 paper claims and FedExed them to Medicare. 

“The next thing I have to do is start to cut expenses, stop buying supplies and vaccines, then reduce our staff, then reduce our hours and then, God forbid, the unthinkable: just shut our doors,” Meyer said.

Doctors, pharmacists and industry experts say the hack has exposed major vulnerabilities in the health sector, particularly given Change Healthcare’s dominance. 

“How do you have a system where it has this big of a leak and almost two weeks later, you’re leaving the small pharmacy owners to try to figure out a solution?” asked Dr. Mayank Amin, the owner of Skippack Pharmacy in Skippack, Pennsylvania.

Amin said he and his staff have spent hours calling insurance companies to find out patients’ eligibility manually, one at a time. The work has kept him up until 2 a.m every night, he said. He even plans to pick up free samples of a blood-thinner medication from a local doctor’s office to distribute to a patient.

“What do I get out of this? Zero profit but the feeling that you’re able to help somebody who relies on you,” he said.

Ronda Miller said that her pharmacy in South Dakota gave her husband a free box of his diabetes medication for now and that his doctor also provided a sample. But for families like hers, she said, the disruption has meant “playing with people’s lives.”

Change Healthcare said the perpetrator of the cyberattack “represented itself to us as ALPHV/Blackcat.” Alphv was involved in the attack on MGM Resorts last year, costing the company $100 million. It is developed and maintained by a group of Russian-speaking cybercriminals.

In total last year, victims of cybercrime sent a record $1 billion in extortion payments to ransomware criminals, according to Chainalysis , a company that tracks cryptocurrency payments.

UnitedHealthcare didn’t answer questions about whether it paid a ransom. But experts at the cybersecurity company Recorded Future and the cryptocurrency analytics company Tenable pointed to a bitcoin wallet that received a payment of more than $22 million Friday. The companies say the wallet, which was viewed by NBC News, belonged to Alphv. Wired first reported the news.

The sum has since been doled out, mostly in $3.2 million portions that the two companies haven’t been able to trace fully. Alphv’s site on the dark web claims it is no longer operational.

Cybersecurity expert Eric Noonan, the CEO of CyberSheath, said that if UnitedHealth did pay a ransom, “it’s a terrible precedent, because what it now does is say this is a viable market.”

Change Healthcare was “a very attractive target,” Noonan said, because it runs critical infrastructure and the attack has had visible consequences.

Noonan said UnitedHealth needs to address whether patients’ personal information has been compromised. Thus far, the company has said only that its teams are “actively engaged and working to understand the impact.” 

Noonan also called for the federal government to require mandatory minimum cybersecurity for all critical infrastructure sectors, including health care.

“Americans, I think, are somewhat defenseless in this regard, because they’re relying on the companies to implement the right levels of cybersecurity, and that’s largely not happening,” he said.

florida medicaid site visit checklist

Daniella Silva is a reporter for NBC News, focusing on education and how laws, policies and practices affect students and teachers. She also writes about immigration.

florida medicaid site visit checklist

Aria Bendix is the breaking health reporter for NBC News Digital.

IMAGES

  1. Site Visit Checklist Template

    florida medicaid site visit checklist

  2. Florida Medicaid Web Portal

    florida medicaid site visit checklist

  3. Medicaid application checklist in Word and Pdf formats

    florida medicaid site visit checklist

  4. Florida Medicare: The Ultimate Guide

    florida medicaid site visit checklist

  5. Site Visit Checklist: 18 Ways Properties Can Close More

    florida medicaid site visit checklist

  6. Free Florida Medicaid Prior (Rx) Authorization Form

    florida medicaid site visit checklist

COMMENTS

  1. PDF Home

    Policy. On-site reviews are conducted for currently enrolled providers, those re-enrolling, and those enrolling for the first time in Florida Medicaid. Virtual Site Visits Begin September 8: Beginning September 8, 2020, the Agency will conduct site reviews of behavior analysis lead analysts who enrolled in Florida Medicaid as a behavior

  2. UnitedHealthcare Community Plan: What to expect during a site visit

    Health care professionals who wish to contract with UnitedHealthcare Community Plan may need a site visit as part of the credentialing process. Requirements for site visits are determined by state Medicaid contracts and by NCQA and Centers for Medicare & Medicaid Services (CMS) requirements for facilities. Site visit requirements are outlined ...

  3. Tools and Checklists for States

    Medicaid & CHIP Telehealth Toolkit Checklist for States (DOCX, 47.36 KB) Medicaid and CHIP Telehealth Toolkit Supplement 1 (PDF, 700.4 KB) Disaster Preparedness Toolkit for State Medicaid Agencies (PDF, 369.77 KB) Inventory of Medicaid and CHIP Flexibilities and Authorities in the Event of a Disaster (PDF, 1.66 MB)

  4. Learning Resources: What to Expect from a Site Visit (video)

    Having these copies ready to go will speed up your site visit. During the site visit you can expect that we'll tour your facility. We'll interview you according to the checklist. And we'll obtain the required copies. We'll let you know if you've met all the requirements for the site visit. Otherwise, you'll correct any outstanding items and ...

  5. SOP

    Site Inspection Form. Site Managers shall complete a Site Inspection Form for every site visit they make. A new Site Inspection Form is required to be filled out even if there are several site visits for the same site. The form is designed to be filled in with basic site information before the SM leaves for the field.

  6. PDF Florida Medicaid Provider Enrollment Application Guide

    application process. To access the Interactive Enrollment Checklist, visit mymedicaid-florida.com. From the homepage, hover over the Provider Services tab, and click Enrollment. Once at the Provider Enrollment page, look under the New Medicaid Providers section, and click Interactive Enrollment Checklist. 5.

  7. Medicaid Provider Enrollment Requirements

    a site visit. What is the purpose of a site visit? A site visit is required for moderate-risk category : and high-risk category providers.[15] The purpose of the visit is to verify the accuracy of the information submitted with the application and to determine compliance with enrollment requirements.[16] For revalidations, site visits are also ...

  8. Medicaid

    In Florida, the Agency for Health Care Administration (Agency) is responsible for Medicaid. The Agency successfully completed the implementation of the Statewide Medicaid Managed Care (SMMC) program in 2014. Under the SMMC program, most Medicaid recipients are enrolled in a health plan. Nationally accredited health plans were selected through a ...

  9. PDF Florida Medicaid Provider Enrollment Policy January 2022

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  10. PDF SOLO PROVIDER ENROLLMENT CHECKLIST Items with an asterisk ...

    waiver individuals. Please visit www.dms.myflorida.com for more details. 10. Copy of "Declaration Page" of General or Professional Liability business Insurance* Instructions: APD must be listed at the 'certificate holder' on the declaration page. Proof of liability insurance does not need to be provided until execution of the MWSA. 11.

  11. PDF SITE VISIT REVIEW CHECKLIST

    Adam Miller, Executive Director Office of Independent Education & Parental Choice 325 W. Gaines Street, Suite 1044 | Tallahassee, FL 32399-0400 | 850-245-0502

  12. PDF Florida Department of Health

    The CMS Plan Provider Manual is a comprehensive guide for health care providers who serve children with special health care needs in Florida. It covers topics such as eligibility, enrollment, benefits, prior authorization, claims, reimbursement, and quality improvement. Download the PDF to learn more about the CMS Plan and how to participate.

  13. Provider Screening and Onsite Visits

    PCG has conducted over 10,000 Medicaid provider site visits to proactively verify provider qualifications and protect public agencies and taxpayers from fraud, waste, and abuse by unscrupulous providers. More than 50 percent of unscheduled site visits result in noncompliance findings. PCG Provider Screening Services.

  14. Medicare Site Visits during Provider Enrollment

    The process ensures that providers aren't able to Enroll as participating Medicare providers without an appropriate service location. You may see full details in section 10.6.20 of the Medicare Program Integrity Manual. Call nCred today at (423) 443-4525 to discuss your Medicare Provider Enrollment needs. We work with all specialties and have ...

  15. PDF Medicaid Provider Enrollment

    Medicaid Provider Enrollment Requirements. CMS promulgated requirements via regulations at. 42 CFR: − 455 Subpart B (Disclosures) − 455 Subpart E (Screening and Enrollment) The federal regulations became effective March 25, 2011 (except FCBC) These requirements mirror those implemented in Medicare—with a few exceptions.

  16. MLN9658742

    A site visit helps prevent questionable providers and suppliers from enrolling or staying enrolled in the Medicare Program. The NSVCs conduct unannounced site visits for all Medicare Part A and B providers and suppliers, including DMEPOS suppliers. The NSVCs may conduct an observational site visit or a detailed review to verify enrollment ...

  17. Medicaid Redetermination Plan

    As a result of this policy, Florida saw a significant increase in the number of individuals and families seeking Medicaid assistance, from 3.8 million enrolled in March 2020 to 5.5 million in November 2022. Medicaid eligibility in Florida is determined either by the Department of Children and Families (DCF) or the Social Security Administration ...

  18. PDF Enrolling as a Florida Medicaid Behavior Analysis Provider

    Enrolling in the Florida Medicaid Behavior Analysis Program April 25, 2019 6. Before You Get Started. Enrolling providers are highly encouraged to access the Interactive Enrollment Checklist tool found on the Provider Enrollmentpage before starting their application. To access the Interactive Enrollment Checklist, visit . mymedicaid-florida.com.

  19. Are You Ready for a CMS Site Visit?

    Schedule your free consultation. Our credentialing experts are here to help you assess exactly which solutions you need to put you on the right track. 1ˢᵗ Credentialing includes payor enrollment for all insurance networks. Don't wait another minute, contact our team today! Call us at (512) 201-2668 or email us at [email protected].

  20. PDF Medicaid Survey Results

    Medicaid Survey Results 1 The Communications Committee of the Florida Children and Youth Cabinet has collaborated with a state Medicaid workgroup and the Agency for Healthcare Administration to identify topics and questions from professionals in the field related to Medicaid and available services. A five question survey was

  21. PDF Guide for Completing a Medicaid Provider Enrollment Application

    Florida Medicaid Provider Applicant's Responsibility To Comply With Section 409.907, ... Application Checklist Are you a: 9 1. PA, ARNP, RN, CRNA, or RNFA applicant? (Complete Question 16.) ... form visit the fiscal agent Medicaid web site listed below to download the form from the Internet or call the Medicaid fiscal

  22. Adult Wellness Visits

    Annual wellness visits can help: Manage an ongoing condition, such as diabetes. Avoid preventable diseases. Detect and treat health problems before they become serious illnesses. Prevent hospitalizations. Annual wellness visits are a great way to: Have your weight and blood pressure checked. Review your medical and family history.

  23. AHCA

    December 27, 2023. Agency for Health Care Administration Delivers Quality and Transparency to Florida's Health Care System in 2023 [ 170.7 kB ] December 5, 2023. Governor DeSantis' Focus on Florida's Future Budget Provides Innovation and Transparency, Strengthening Florida's Health Care System for Generations [ 181.4 kB ] April 25, 2023.

  24. Florida's Medicaid call center's wait times, disconnection rates

    Florida's Medicaid call center is experiencing long wait times and high rates of disconnection that could be preventing families from renewing or accessing healthcare coverage, according to a ...

  25. Patients struggle to get medication after cyberattack on Change Healthcare

    After a cyberattack on Change Healthcare, patients are struggling to access and afford essential medication. Outages persist in systems used for medical billing and insurance claims.