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MEDICARE
A CMS Medicare Administrative Contractor
http://www.NGSMedicare.com
Jurisdiction B Supplier Manual: Chapter 2
September 2014 Update
Enrollment Process
Overview
A supplier is an entity or individual, which provides, sells or rents DMEPOS to Medicare beneficiaries. The
National Supplier Clearinghouse is the organizational entity contracted by CMS to issue Medicare billing
privileges to suppliers of DMEPOS and to maintain a supplier file that contains information collected via the CMS­
855S enrollment form.
Medicare requires that all suppliers of DMEPOS who serve Medicare beneficiaries must meet the supplier
standards outlined in the Code of Federal Regulations and must enroll and obtain a PTAN with the NSC.
Before enrolling with the NSC, you must follow the process below:
1.
2.
3.
4.
5.
Apply for and obtain an NPI from NPPES.
Complete the DMEPOS accreditation process, if applicable and comply with DMEPOS Quality Standards.
Obtain a surety bond, if applicable.
Comply with the DMEPOS Supplier Standards outlined in 42 CFR. Section 424.57(c).
Complete the CMS-855S Medicare Enrollment Application – Durable Medical Equipment, Prosthetics,
Orthotics and Supplies (DMEPOS) Suppliers
6. Complete the CMS-460 Medicare Participating Supplier Agreement form.
7. Complete the Authorization Agreement for Electronic Funds Transfer (CMS-588) form.
8. Remit payment of the required application fee, if applicable.
Questions regarding the enrollment process and obtaining and maintaining DMEPOS Medicare billing privileges
should be directed to the National Supplier Clearinghouse.
National Provider Identifier
The Administrative Simplification provisions of the HIPAA, mandated the adoption of standard unique identifiers
for health care providers, as well as the adoption of standard unique identifiers for health plans. For health care
providers, the NPI is the standard unique identifier. The CMS has developed the NPPES to assign the NPIs. You
can apply for an NPI one of three ways.
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For the most efficient application processing and the fastest receipts of NPIs, use the web-based
application process. Simply log onto the NPPES website.
You can agree to have an EFIO submit application data on their behalf (i.e., through a bulk enumeration
process) if an EFIO requests their permission to do so.
You may wish to obtain a copy of the paper NPI Application/Update Form (CMS-10114) and mail the
completed, signed application to the NPI Enumerator. This form is available on the CMS website or by
requesting a copy from the NPI Enumerator. Suppliers who wish to obtain a copy of this form from the
NPI Enumerator may do so in any of these ways:
o Phone: 800-465-3203 or TTY 800-692-2326
132_0914 Supplier Manual Update
o Email: [email protected]
o Mail to:
NPI Enumerator
P.O. Box 6059
Fargo, ND 58108-6059
Note: You may only apply for an NPI using only one of the methods described above.
Visit the CMS website for more information about NPI enumeration.
Related Content
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National Provider Identifier (NPI) Application/Update Form
National Provider Identifier Standard (NPI) Website
NPPES Website
DMEPOS Accreditation
In order to enroll or retain Medicare billing privileges, certain DMEPOS suppliers need to complete the
accreditation process and be in compliance with the new quality standards prior to enrolling as a supplier.
The Quality Standards are a separate set of standards from the NSC Supplier Standards that are divided into the
following areas:
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Section I: Supplier Business Services Requirements
Section II: Supplier Product-Specific Service Requirements
Appendix A: Respiratory Equipment, Supplies and Services
Appendix B: Manual Wheelchairs, Power Mobility Devices, and Complex Rehabilitative Wheelchairs and
Assistive Technology
Appendix C: Custom Fabricated and Custom Fitted Orthoses, Prosthetic Devices, External Breast
Prostheses, Therapeutic Shoes and Inserts, and their Accessories and Supplies, Custom-Made Somatic,
Ocular, and Facial Prostheses
Further information on the DMEPOS accreditation requirements along with a list of the accreditation organizations
and guidance regarding the DMEPOS Quality Standards for DMEPOS suppliers is located in the Downloads
section of the CMS DMEPOS Accreditation web page. Suppliers can also find additional information related to the
Quality Standards in a Medicare Learning Networks article titled, “Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) Quality Standards.”
Related Content
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DMEPOS Accreditation Website
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Quality Standards (3.47
MB)
Surety Bond Requirements
A DMEPOS surety bond is a bond issued by an entity (the surety) guaranteeing that a DMEPOS supplier will fulfill
an obligation or series of obligations to a third party (the Medicare Program). If the obligation is not met, the third
party will recover its losses via the bond.
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Suppliers enrolling in the Medicare Program for the first time, existing suppliers undergoing a change of
ownership, or existing suppliers establishing a new practice location are required to submit a surety bond to the
NSC with their CMS-855S Medicare Enrollment Application – Durable Medical Equipment, Prosthetics, Orthotics,
and Supplies (DMEPOS) Suppliers. Absent an exception to the bonding requirement, the NSC will reject a
pending supplier’s enrollment application if the supplier has not submitted a valid surety bond.
DMEPOS suppliers must submit a $50,000 surety bond for each assigned NPI for which the DMEPOS supplier is
seeking to obtain Medicare billing privileges. In addition, a DMEPOS supplier enrolling a new practice location
must submit to the NSC a new surety bond or an amendment or rider to the existing bond, showing the new
practice location is covered by an additional base surety bond of $50,000. Suppliers who have certain adverse
legal actions imposed against them in the past may be required to post a higher bond amount. The final
regulations permit the NSC to require DMEPOS suppliers to obtain a base surety bond of $50,000 and an
elevated surety bond of $50,000 for each occurrence of an adverse legal action within ten years preceding
enrollment, revalidation, or reenrollment in the Medicare Program.
Some companies or organizations that supply DMEPOS are exempt from the surety bond requirements. As noted
in the DMEPOS Accreditation section, an Accreditation & Surety Bond Exemption chart is available on the NSC
website. This chart includes details on DMEPOS supplier exemptions from the surety bond
For additional information or to view the regulation in its entirety, access the CMS DMEPOS Surety Bond web
page. You can access a list of Surety Bond Requirement for Suppliers of Durable Medical Equipment,
Prosthetics, Orthotics and Supplies (DMEPOS) FAQs on the NSC website.
Related Content
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Accreditation & Surety Bond Exemption Chart
CMS-855S Medicare Enrollment Application – Durable Medical Equipment, Prosthetics, Orthotics, and
Supplies (DMEPOS) Suppliers. (1.4 MB)
DMEPOS Surety Bond
Surety Bond Requirement for Suppliers of Durable Medical Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) FAQs
Obtaining and Retaining Medicare DMEPOS Billing Privileges
Under DME jurisdictional processing, every supplier of DMEPOS must obtain billing privileges from the NSC.
A supplier is an entity or individual, which provides, sells or rents DMEPOS to Medicare beneficiaries. The NSC is
the organizational entity contracted by CMS to issue Medicare billing privileges to suppliers of DMEPOS and to
maintain a supplier file that contains information collected via the CMS-855S enrollment form.
Online enrollment is now available for all DMEPOS suppliers. The PECOS allows you to enroll, make changes to
existing enrollment records, reenroll, and check the status of products, services and company officials. For more
information, view the CMS PECOS website.
The NSC verifies data submitted through PECOS or on the CMS-855S enrollment application, issues billing
privileges to approved suppliers and maintains a national DMEPOS supplier file. The NSC must process supplier
data and issue billing privileges before a supplier may start submitting claims to a DME MAC. The NSC will verify
all information submitted.
You must submit information using Internet-based PECOS or on the CMS-855S application and meet one of the
following conditions if you plan to bill Medicare for DMEPOS:
•
Enroll in Medicare for the first time as a DMEPOS supplier
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•
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Currently enrolled in Medicare as a DMEPOS supplier and need to report changes to their business,
other than enrolling a new business location (e.g., they are adding, deleting or changing existing
information under this Medicare PTAN)
Currently enrolled in Medicare as a DMEPOS supplier but need to enroll a new business location. Note:
This is to add a new location to an organization with a tax identification number already listed with the
NSC (this differs from changing information on an already existing location).
Note: 42 CFR 424.57(b)(1) requires suppliers to enroll separate physical locations other than warehouses or
repair facilities.
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•
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Currently enrolled in Medicare as a DMEPOS supplier and have been asked to reenroll in order to verify
or update their information (includes situations where the supplier has been asked to attest that their
organization is still eligible to receive Medicare payments)
Reactivating their Medicare DMEPOS supplier billing privileges (e.g., their Medicare supplier billing
privileges were deactivated because of no billing activity and they wish to receive payment from Medicare
for future claims)
Voluntarily terminating their Medicare DMEPOS supplier billing privileges
Instructions on how to obtain and complete the CMS-855S may be found under the Supplier
Enrollment/Forms/CMS-855S Form section of the NSC website or on the CMS website. The supplier is
accountable for the accuracy of the information on the CMS-855S form. Any deliberate misrepresentation or
concealment of material information may subject the supplier to liability under civil and criminal laws.
Application Fee
Section 6401(a) of the ACA requires the secretary to impose a fee on each ‘institutional provider of medical or
other items or services and suppliers.’ The fee is to be used by the secretary to cover the cost of program integrity
efforts including the cost of screening associated with provider enrollment processes, including those under
section 1866(j) and section 1128J of the Social Security Act. The application fee is $505 for CY 2011. The
application fee is to be imposed on institutional providers that are newly-enrolling, reenrolling/revalidating or
adding a new practice location for applications received on and after Friday, 03/25/11. CMS has defined
‘institutional provider’ to mean any provider or supplier that submits a paper Medicare enrollment application using
the CMS-855A, CMS-855B (except physician and nonphysician practitioner organizations), or CMS-855S forms
or associated Internet-based PECOS enrollment application.
If suppliers have any questions regarding enrollment application fees, please contact the National Supplier
Clearinghouse.
Incomplete or Inconsistent Application Information
The NSC will contact a supplier via email or fax, or mail if the enrollment application form is incomplete or has
inconsistent information. Suppliers will be allowed 30 days from the date of notification to return all required
information. If the information is not received within the 30-day time frame, the application will be closed.
Participation Program
Suppliers with Medicare have the option to participate in the program. Suppliers who agree to the Medicare
participation guidelines will be required to complete the CMS-460 Medicare Participating Supplier Agreement
form.
Supplier Standards
Further, all suppliers are subject to a site visit in order to determine compliance with the supplier standards.
Suppliers found in noncompliance with the supplier standards are subject to denial or revocation of their NSC
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issued billing privileges. The denial/revocation notification outlines the appeals process available to suppliers,
including instructions on requesting an appeal.
Enrollment Denial
According to the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 10, Section 6.2, a
supplier that is denied enrollment in the Medicare Program cannot submit a new enrollment application until one
of the following has occurred:
•
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If the denial was not appealed, the provider or supplier may reapply 90 days after the denial/revocation
date.
If the denial was appealed, the provider or supplier may reapply after it received notification the
determination was upheld.
On 06/27/08, CMS published a final rule titled, “Appeals of CMS or CMS Contractor Determinations When a
Provider or Supplier Fails to Meet the Requirements for Medicare Billing Privileges (CMS 6003-F)” in the Federal
Register. This final rule establishes an enrollment bar for those providers and suppliers whose billing privileges
are revoked. The enrollment bar will require that providers and suppliers whose billing privileges are revoked wait
from one to three years before reapplying to participate in the Medicare Program—depending on the severity of
the infraction.
CMS-855S Terminology
Each DMEPOS supplier applying for Medicare billing privileges must disclose ownership on the CMS-855S form
in accordance with Section 1124A of the Social Security Act and Section 4313 of the Balanced Budget Act of
1997, by including the following information:
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•
The names and social security numbers of the owners, managing employees, those with controlling
interest of five percent or more, and/or authorized representatives/members of the board of directors
(including nonprofit corporations) as well as any partnership regardless of the percentage of ownership.
The names of all owners, managing employees and/or authorized representatives/members of the board
of directors who have received penalties, been sanctioned, or excluded by the Medicare, Medicaid and/or
other federal and state authorities or programs.
The term managing employee is defined as any individual, including a general manager, business manager, or
administrator, who exercises operational or managerial control over the DMEPOS supplier, or who conducts the
day-to-day operations of the DMEPOS supplier. For Medicare enrollment purposes, “managing employee” also
includes individuals who are not actual employees of the DMEPOS supplier but, either under contract or through
some other arrangement, manage the day-to-day operations of the DMEPOS supplier.
An authorized official must be an owner, general partner, chairman of the board, chief financial officer, chief
executive officer, or president or must hold a position of similar status and authority within the supplier’s
organization. This individual must have the authorization to legally bind the organization to a contract.
The authorized official has the authority to sign the initial CMS-855S application on behalf of the supplier and to
notify the NSC of any change or that the billing privileges are no longer valid due to sale of the entity. Only the
authorized official can add, change or delete delegated officials or sign off on the change of the authorized official.
Adding delegated officials is an option and is not required. Delegated officials may either be a managing
employee of the supplier, or hold a five percent direct-ownership interest or partnership interest in the supplier.
Managing employees include general managers, business managers, or administrators—individuals who exercise
operational or managerial control over the supplier, or who conduct the day-to-day operations of the supplier. A
delegated official must be an employee of the supplier, and proof, such as a W-2 form, may be requested.
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Delegated officials may not delegate their authority to any other individual. Once a delegated official has been
designated, he/she may make any changes and/or updates to the provider status including enrolling additional
locations, reenrolling the supplier, reactivating the supplier, or adding new part-owners.
Suppliers may have as many authorized and delegated officials as desired as long as the individual meets the
respective definition. These officials are not location specific, but rather are supplier specific. For example, if a
supplier has multiple locations under one tax ID number, the authorized and delegated officials appointed will be
the authorized signers for all locations.
On 05/01/06, CMS issued the revised CMS-855 Medicare enrollment applications. Listed below are changes and
enhancements made specifically to the CMS-855S. You should review and become familiar with this information.
•
Requires the submission of the NPI and a copy of the NPI notification furnished by the NPPES. Suppliers
should provide their NPI where requested and submit a copy of the notification verifying the NPI.
Suppliers unable to locate their NPI notification should contact the NPPES at 800-465-3203 or send an
email to [email protected].
Note: Each enrolled supplier of DMEPOS that is a covered entity under HIPAA must designate each practice
location (if they have more than one) as a subpart and ensure that each subpart obtains its own unique NPI.
Federal regulations require that each location of a Medicare DMEPOS supplier have its own unique billing
number. In order to comply with that regulation, each location must have its own unique NPI.
In addition, the address listed on the NPI notification must match the address listed on the CMS-855S. CMS
requires a copy of the notification to be submitted with all enrollment documentation, which includes initial
applications, changes of information, reenrollments and reactivations.
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Requires suppliers to complete the Authorization Agreement for Electronic Funds Transfer (CMS-588).
With regards to DMEPOS enrollment, suppliers should submit the CMS-588 EFT form when initially
enrolling or submitting an application for an additional location. Suppliers must list the proper Medicare
contractor and ensure the form has the original signature of the authorized or delegated official. Also,
suppliers should submit a separate form for each Medicare contractor where it submits claims. (Effective
04/01/10, the CMS-588 EFT agreement form no longer requires the listing of the Medicare contractor.)
Along with the completed form, suppliers must include one of the following verifying the account information:
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Voided check
Bank affidavit
Notification on bank letterhead verifying the account information
The role of the NSC is to verify the form is complete, confirm the correct DME MAC has been indicated (based on
the information the supplier has provided on the CMS-855S) and to ensure the agreement is signed properly.
Once verified, the NSC will send the agreements to the appropriate DME MAC for processing.
Again, suppliers should only submit the CMS-588 form to the NSC when submitting the CMS-855S for initial
enrollment when enrolling an additional location or reenrolling and not currently enrolled in the EFT program. The
NSC does not enroll suppliers into the EFT program. Any changes to EFT information should be submitted
following existing procedures.
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A new section was added for suppliers to provide a specific address of where the NSC should mail their
revalidation packages. If a supplier would like to receive their revalidation at an address other than the
address where correspondences are received, the supplier should list this address in Section 4C. This
enhancement was made to provide all suppliers, especially those suppliers with multiple locations, a
single address where they would like their revalidation packages mailed.
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Requires suppliers to provide the name and phone number of the insurance underwriter. The NSC is
required by CMS to verify coverage. Section 5 requires suppliers to provide identifying information for
both the insurance agent and the underwriter. Providing this information will assist in facilitating the
verification process. (Effective January 2013, section 3D of the revised CMS-855S is where suppliers will
list products and services.)
On 04/02/07, CMS issued a Final Rule on accreditation for DMEPOS suppliers. Because of the Final
Rule, Section 3B was added for suppliers to provide information concerning accreditation.
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As of 05/07/13, DMEPOS suppliers must submit all initial enrollment, change of information, or
revalidation requests on the revised CMS-855S enrollment application (version 01/13).
All DMEPOS suppliers must submit accreditation information and/or a surety bond to the NSC to
obtain/maintain Medicare billing privileges unless the supplier type has been exempted by CMS.
Requires suppliers list the state(s) where items or services are being provided. Section 4 is where
suppliers will indicate what jurisdiction the majority of claims will be submitted and list the individual states
where items and services are provided. This information is being collected in order to ensure suppliers
are properly licensed in the states where they provide Medicare-covered items to beneficiaries.
Related Content
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CMS-460 Medicare Participating Supplier Agreement form (217 KB)
CMS 855S Enrollment Application
CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 10, Section 6.2 (653 KB)
CMS PECOS Website
National Supplier Clearinghouse
NSC Website
Application Fees
Providers and suppliers that are (1) initially enrolling in Medicare, (2) adding a practice location, or (3) revalidating
their enrollment information, must submit with their application:
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An application fee in an amount prescribed by CMS, and/or
A request for a hardship exception to the application fee
This requirement applies to applications received on or after 03/25/11. The fee for 01/01/14 through 12/31/14, is
$542.00. Fee amounts for future years will be adjusted by the percentage change in the consumer price index (for
all urban consumers) for the 12-month period ending on June 30 of the prior year. CMS will give Medicare
contractors and the public advance notice of any change in the fee amount for the coming calendar year.
Providers or suppliers who submit enrollment applications using Internet-based PECOS pay the application fee
during the online submission process. Providers or suppliers who submit the paper CMS-855 application form will
pay the fee on the Medicare Enrollment site.
CMS will regularly send a listing of providers and suppliers (the “Fee Submitter List”) who paid an application fee
to the contractors. However, you are strongly encouraged to submit a copy of your receipt of payment with the
enrollment/reenrollment application. This may enable the contractor to more quickly verify that payment has been
made.
Exceptions to the Application Fee Requirements
This does not apply to physicians, nonphysician practitioners, physician group practices and nonphysician group
practices unless enrolling/revalidating as DMEPOS suppliers via the CMS-855S application.
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Hardship Exceptions
A provider or supplier requesting a hardship exception from the application fee must include with its enrollment
application a letter (and supporting documentation) that describes the hardship and why the hardship justifies an
exception. If a paper CMS-855 application is submitted, the hardship exception letter must accompany the
application. If the application is submitted via the Internet-based Provider Enrollment (PECOS), accompany the
certification statement. Hardship exception letters will not be considered if they were submitted separately from
the application or certification statement, as applicable. If your Medicare contractor receives a hardship exception
request separately from the application or certification statement, it will: (1) return it to you, and (2) notify you via
letter, email, or telephone, that it will not be considered.
Upon receipt of a hardship exception request with the application or certification statement, the contractor will
send the request and all documentation accompanying the request to CMS. CMS will determine if the request
should be approved. During this review period, the contractor will not begin processing the provider’s
application. CMS will communicate its decision to the institutional provider and the contractor via letter.
Important Note: The contractor will not begin to process the provider’s/supplier’s application until the following
has occurred:
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The fee has been paid, or
The hardship exception request has been approved
Once processing commences, the application will be processed in the order in which it was received.
We highly recommend that you review CMS Medicare Learning Network (MLN) Matters article MM7350
“Implementation of Provider Enrollment Provisions in CMS-6028-FC” to gain a better understanding of
this new requirement.
Related Content
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MM7350 Revised – Implementation of Provider Enrollment Provisions in CMS-6028-FC
Medicare Enrollment site
Change of Information
Any changes or updates to information provided on the CMS-855S form must be reported to the NSC within 30
days after such changes have taken place. Updated information should be submitted on the CMS-855S or
through Internet-based PECOS. Suppliers found noncompliant are subject to the revocation or inactivation of their
Medicare billing privileges. In order to receive timely information from the DME MAC, the NSC must have the
supplier’s correct address. The NSC maintains the supplier’s correspondence address information and transmits
this information to the DME MAC. All changes, including changes in address, must be reported to the NSC.
Be sure to attach all location specific licenses to any change of information form that includes a change of
physical location. This will be required before any changes can be made to the supplier file. This serves as notice
to suppliers that they should apply for any new location-specific licenses from the specific licensing board (e.g.,
the Board of Pharmacy, business license offices, etc.) as quickly as possible to ensure compliance with supplier
standard #1.
Further instructions on how to complete a change of information for various reasons may be found in the Supplier
Enrollment/Change of Information section of the NSC Web site.
All CMS-855S forms and changes to previously submitted information must be sent to:
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Regular Mail Address
Overnight Mail Address
National Supplier Clearinghouse
AG-495
P.O. Box 100142
Columbia, SC 29202-3142
National Supplier Clearinghouse
AG-495
2300 Springdale Drive, Bldg. 1
Camden, SC 29020
The NSC isn’t the only company that should be notified in the event of an address change. A checklist titled
“Address Change Checklist for DME MAC Suppliers” was developed to assist suppliers that have a location
change and need to complete a change of address and can be found in the Resources section of our website
under Tools and Materials.
Related Content
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NSC Website
Directory of Medicare Suppliers
The CMS is responsible for producing a directory of all Medicare suppliers. This directory will not include
physicians or ambulatory surgical centers that furnish supplies, except optometrists.
Related Content
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Supplier Directory
Supplier Standards
Medicare regulations have defined standards a supplier must meet to receive and maintain billing privileges.
These standards can be found in the Supplier Enrollment/Standards & Compliance/Supplier Standards section of
the NSC website.
The Medicare DMEPOS supplier standards were finalized and became effective 12/11/00.
You may download the abbreviated or the full version of the supplier standards on the NSC website.
The abbreviated version of the supplier standards are listed below. These standards, in their entirety, are listed in
42 CFR 424.57(c).
If suppliers have any questions regarding these standards, please contact the National Supplier Clearinghouse.
1. A supplier must be in compliance with all applicable federal and state licensure and regulatory
requirements.
2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any
changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
3. An authorized individual (one whose signature is binding) must sign the application for billing privileges.
4. A supplier must fill orders from its own inventory or must contract with other companies for the purchase
of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded
from the Medicare program, any state health care programs or from any other Federal procurement or
non-procurement programs.
5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased
durable medical equipment and of the purchase option for capped rental equipment.
6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State
law and repair or replace free of charge Medicare covered items that are under warranty.
7. A supplier must maintain a physical facility on an appropriate site.
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8. A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the supplier's
compliance with these standards. The supplier location must be accessible to beneficiaries during
reasonable business hours and must maintain a visible sign and posted hours of operation.
9. A supplier must maintain a primary business telephone listed under the name of the business in a local
directory or a toll free number available through directory assistance. The exclusive use of a beeper,
answering machine or cell phone is prohibited.
10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers
both the supplier's place of business and all customers and employees of the supplier. If the supplier
manufactures its own items, this insurance must also cover product liability and completed operations.
11. A supplier must agree not to initiate telephone contact with beneficiaries with a few exceptions allowed.
This standard prohibits suppliers from calling beneficiaries in order to solicit new business.
12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items
and maintain proof of delivery.
13. A supplier must answer questions and respond to complaints of beneficiaries and maintain
documentation of such contacts.
14. A supplier must maintain and replace at no charge or repair directly or through a service contract with
another company Medicare-covered items it has rented to beneficiaries.
15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable
items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
16. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicarecovered item.
17. A supplier must disclose to the government any person having ownership, financial or control interest in
the supplier.
18. A supplier must not convey or reassign a supplier number (e.g., the supplier may not sell or allow another
entity to use its Medicare billing number).
19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that
relate to these standards. A record of these complaints must be maintained at the physical facility.
20. Complaint records must include the name, address, telephone number and health insurance claim
number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.
21. A supplier must agree to furnish CMS any information required by the Medicare statute and implementing
regulations.
22. All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and
retain a supplier billing number. The accreditation must indicate the specific products and services for
which the supplier is accredited in order for the supplier to receive payment of those specific products and
services (except for certain exempt pharmaceuticals). Implementation date—October 1, 2009.
23. All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and
be separately accredited in order to bill Medicare.
25. All suppliers must disclose upon enrollment all products and services, including the addition of new
product lines for which they are seeking accreditation.
26. Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c). Implementation date—May 4,
2009.
27. A supplier must obtain oxygen from a state–license oxygen supplier.
28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42
C.F.R. 424.516(f).
29. DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers
and suppliers.
30. DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain
exceptions.
Related Content
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National Supplier Clearinghouse Website
National Supplier Clearinghouse Contact Information
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Change of Ownership
When there is a change of ownership, new billing privileges must be issued unless the new owners assume all
liabilities and the tax identification number of the existing supplier. Otherwise, the new owner may not use the
existing supplier’s billing privileges (supplier standard #18). The new owner must submit form CMS-855S to the
NSC within 30 days of the change of ownership, along with a bill of sale, articles of incorporation filed with the
state and any other documents that show the exact nature of the transaction.
If there is a change in the tax identification number, the outgoing owner must notify the NSC by completing the
CMS-855S as a “Voluntary Termination of Billing Number.” The request to voluntarily terminate the supplier’s
billing privileges must be submitted on the CMS-855S. Per the CMS IOM Publication 100-08, Medicare Program
Integrity Manual, Chapter 10, Section 7 all changes must be reported on the CMS-855S.
The old billing privileges will be deactivated. If the NSC determines the new owners have met all requirements,
the new privileges will be effective from the date of the change of ownership. Claims for items furnished between
the date of the change of ownership and the issuance of the new privileges may be submitted to the DME MAC
once the supplier has received the new privileges.
Further information about change in ownership, including instructions on how to submit a voluntary termination,
may be found in the Supplier Enrollment/Standards & Compliance/Change of Information Guide section of the
NSC website.
Related Content
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CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 10, Section 7
NSC Website
Participation Program
(CMS-460 Medicare Participating Supplier Agreement)
The Medicare participation program involves a voluntary agreement between a supplier and Medicare. Under the
agreement, the supplier agrees to accept assignment for all services rendered to Medicare beneficiaries and to
accept the Medicare-allowed amount as the total charge for any covered item and not to collect any more than the
Medicare unmet deductible and coinsurance from the beneficiary.
Any Medicare-enrolled supplier may choose to participate in the program. Participation is not automatic; the
assignment of a DMEPOS PTAN does not enroll a supplier in the program. A separate participation agreement,
the CMS-460 form, must be filed with the NSC.
Once a supplier is enrolled in the program, the agreement applies to locations enrolled under the same tax
identification number. Participation is not location specific. This is true whether the supplier is an individual,
partnership or corporation.
Enrollment
The participation enrollment form is available on the NSC Web site or on the CMS website.
Suppliers may also obtain an enrollment form by calling the NSC toll free at 866-238-9652 or by writing to:
National Supplier Clearinghouse
Palmetto GBA—AG-495
P.O. Box 100142
Columbia, SC 29202-3142
National Government Services, Inc.
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If preferred, suppliers can email their questions to [email protected]. Questions received will
be answered within a reasonable time frame. The NSC suggests that suppliers refrain from submitting protected
healthcare information via email.
The CMS offers an open-enrollment period each year when suppliers may enroll in the program or provide notice
of the termination of their participation agreement. The open enrollment period usually takes place mid-November
to the end of December. The NSC notifies suppliers of the specific dates for the enrollment period each year.
In order to terminate a participation agreement, the supplier must notify the NSC in writing during the enrollment
period. The written notice must be postmarked before the end of the enrollment period and have the original
signature of the authorized official. The termination will be effective January 1 of the following year.
The NSC will acknowledge receipt of a request, which has been appropriately completed and has the proper
original signature, to enroll or to terminate enrollment in the participation program. Suppliers who do not receive
an acknowledgement within a reasonable time should contact the NSC.
Related Content
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Medicare Participating Physician or Supplier Agreement Form CMS-460 (217 KB)
National Supplier Clearinghouse Website
Benefits of Participation
By agreeing to accept assignment on all claims, a participating provider receives certain advantages. By
accepting assignment, a supplier:
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requests direct payment from Medicare for covered items;
accepts the Medicare-allowed amount as the full charge for the item or service; and
has the right to appeal claim determination by the DME MAC.
Medicare also advertises the participation status of providers to beneficiaries by providing a directory of
participating providers to senior citizens groups and, upon request, to individual Medicare beneficiaries. The
Medicare Supplier Directory is available on the Medicare.gov website.
Medicare provides for the automatic crossover of claims to Medigap insurers for participating providers. In other
words, when a participating supplier provides the appropriate information on a claim for a beneficiary who has a
Medigap insurance policy, Medicare will transfer the claim information to the Medigap insurer after processing,
reducing paperwork for the supplier. Refer to the Claim Submission Chapter of this manual for CMS-1500 claim
form completion instructions to ensure automatic crossover.
Related Content
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Supplier Directory
Nonparticipating Suppliers
DMEPOS suppliers who do not sign an agreement to accept assignment on all Medicare claims are
nonparticipating suppliers. Physicians billing nonassigned claims are limited to charging 15 percent above the
approved amount. However, DMEPOS suppliers do not have a limit on the amount they may charge above the
Medicare allowable. They may accept assignment on a claim-by-claim basis.
National Government Services, Inc.
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Assignment of Claims
It should be noted that the terms participating and nonparticipating refer to suppliers. The terms assigned and
nonassigned refer to claims.
By accepting assignment on a claim a supplier agrees to accept Medicare’s allowed amount as the full charge for
the items or services provided. This means that for covered services, the supplier may collect only the deductible
and remaining coinsurance amounts from the beneficiary. A claim for an assigned item is considered paid in full
when the DME MACs allowed amount is paid.
On an assigned claim that was denied because the beneficiary did not meet Medicare’s medical necessity criteria,
the beneficiary may be held financially responsible for Medicare’s allowed amount if an acceptable ABN was
obtained. Refer to the Advanced Beneficiary Notice of Noncoverage chapter of this manual for detailed ABN
requirements.
For noncovered items, the beneficiary may be held financially responsible for the supplier’s entire charge
regardless of whether the claim is filed assigned or nonassigned.
Assignment for Nonparticipating Suppliers
Suppliers who have not enrolled in the participation program (i.e., nonparticipating suppliers) may accept
assignment on a claim-by-claim basis. On a nonassigned claim that was denied because the beneficiary did not
meet Medicare’s medical necessity criteria, the beneficiary may be held financially responsible for the supplier’s
entire charge if an acceptable ABN was obtained prior to rendering the services.
Once a claim has been filed as assigned, it may not be changed to nonassigned without the consent of both the
beneficiary and the supplier. The notice to rescind must be received by the DME MAC prior to payment
determination.
Mandatory Assignment for Covered Drugs Billed to Medicare
Section 114 of the BIPA states, in part, “Payment for a charge for any drug or biological for which payment may
be made under this part may be made only on an assignment-related basis.” Mandatory assignment applies only
to those drugs “for which payment may be made”, i.e., Medicare-covered drugs. Drugs that would never be paid,
e.g., no benefit category, never medically necessary, are not subject to mandatory assignment.
A supplier may not render a charge or bill to anyone for these drugs and biologicals for any amount other than the
Medicare Part B deductible and coinsurance. Mandatory assignment does not apply to dispensing fees for drugs.
If a supplier submits an unassigned claim for a drug or biological, the DME MAC will process the claim as though
the supplier accepted assignment.
Assignment Violation
When an assignment violation is noted by the DME MAC through the review of a claim or through a beneficiary
complaint, the DME MAC will educate the supplier on the terms of the assignment agreement. The supplier may
be required to return a refund and provide a corrected statement to the beneficiary.
Where there are repeated violations of the assignment agreement, the DME MAC may suspend further payment
to the supplier on assigned claims as directed by the CMS. For payable claims, payment will be made directly to
the beneficiary. The beneficiary will be advised that the supplier has not complied with the requirements for
receiving payment from Medicare.
National Government Services, Inc.
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Resources Available to Assist Suppliers with the Enrollment Process
The NSC Website
http://www.PalmettoGBA.com/NSC
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Numerous FAQs regarding the enrollment process
Information regarding the NSC site visit process
Licensure information
A checklist to ensure the CMS-855S was completed properly and that all required documentation has
been provided
NSC Customer Service Line
866-238-9652
The NSC analysts are available Monday through Friday from 9:00 a.m. until 5:00 p.m. ET to answer questions
regarding the enrollment process. If you have questions regarding supplier-specific information, please be sure
the caller is listed on the supplier file. NSC analysts will not be able to give supplier-specific information to
someone who is not listed on the supplier file. The NSC also has a voice mailbox available to Spanish-speaker
suppliers who do not speak English.
NSC Email Address
[email protected]
If preferred, you can email your questions to this address. Questions received will be answered within a
reasonable time frame. The NSC suggests you do not submit protected health care information via email.
NSC Interactive Voice Response Unit
The NSC IVR unit allows suppliers to obtain:
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General information regarding the enrollment process
Information on the appeals process
Status of a new application, reenrollment, reactivation or change of information
Instructions on how to obtain a CMS-855S
Contact information for the NSC, DME MACs and CMS
The IVR is available 24-hours a day, seven days a week (except for routine system maintenance) and can be
accessed by calling the NSC Customer Service line at 866-238-9652.
National Government Services, Inc.
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