Provider Enrollment:

Since the passage of the Affordable Care Act, the Medicare provider enrollment process has expanded to include additional methods of screening practitioners enrolling in the Medicare program. The Centers for Medicare and Medicaid Services (CMS) is required to conduct licensure checks, which may be conducted across multiple states. Additionally, CMS is permitted to conduct criminal background checks, fingerprinting, unscheduled and unannounced site visits, and other mechanisms that can be used to screen potential providers of Medicare services for fraudulent or otherwise criminal behavior. While originally, the law also required the collection of an application fee for both individual and institutional providers, such as hospitals or skilled nursing facilities, the fee is no longer required for individual providers.

Additionally, the ACA permits CMS to require certain sectors or categories of enrolled providers to establish compliance programs as a condition of Medicare enrollment. CMS is also allowed to establish temporary moratoria on the enrollment of different provider types if it determines that it is necessary to combat fraud and abuse.

The law also dictated that these new measures be included as part of provider enrollment in state Medicaid programs. In addition to the requirements detailed above, state Medicaid programs now also require that ordering and referring physicians be enrolled in their program and that the National Provider Identifier (NPI) of ordering or referring physicians be included on claims.

More information on Medicare provider enrollment is available on the CMS website.

Claims Submission:

The ACA requires that all claims for services be filed within one calendar year after the date of service, unless an exception is made by CMS. View more information on the CMS website.