Medicare Revalidation

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Disruption to Medicare billing privileges can have a significant impact on a practice’s patient volume and income. Medicare requires certain providers and suppliers to revalidate upon request. Revalidation requires providers and suppliers to recertify the accuracy of their enrollment data. While enrolled providers and suppliers are required to report changes in enrollment data to Medicare, this is not always done. (See Medicare Reporting Obligations.)

With revalidation, Medicare seeks to ensure that the enrollment data is complete and up-to-date, including commonly inaccurate data regarding practice locations, reassignments, and final adverse legal actions.

Revalidation is required in order to maintain billing privileges. Failure to revalidate is grounds for revocation from the program. Likewise, providers or suppliers who report events that affect enrollment eligibility during revalidation may face revocation of their billing privileges.

Who is Required to Revalidate?

Providers and suppliers enrolled in the Medicare program are subject to revalidation requests. Providers and suppliers that have opted-out of the program are not subject to revalidation. Providers or suppliers who are required to revalidate will receive a revalidation notice. Only providers or suppliers who receive notice of revalidation are required to revalidate.

How Often is Revalidation Required?

Providers and groups are required to revalidate every five years. Suppliers of durable medical equipment, prosthetics, orthotics and supplies are required to revalidate every three years. However, CMS can conduct off-cycle revalidations. Off-cycle revalidation is often triggered by receipt of a complaint, local health fraud problems and other reasons that cause CMS to question a provider or supplier’s compliance with Medicare enrollment requirements.

What is the Revalidation Process?

Providers and suppliers required to revalidate will receive notice from their Medicare contractor (MAC). Notices are sent via email or mail to the provider or supplier’s special payment and correspondence address on file with Medicare. DMEPOS will receive notice via the National Supplier Clearinghouse (NSC). Providers and suppliers will have 60 days to complete the revalidation process. The due date will be in the revalidation notice. Providers and suppliers with current and upcoming revalidation requirements may also find their revalidation due date at the CMS Revalidation List.

Revalidation applications should be submitted via PECOS or mailing a copy of the enrollment application to the appropriate MAC. Providers and suppliers must complete the revalidation by the due date or they may face revocation of their Medicare billing privileges and other sanctions. Extensions will no longer be issued by MACs.

If the MAC reviews the revalidation application and determines that additional information is needed in order to process the revalidation, MAC will request such additional information from the provider or supplier.

Providers and suppliers must submit the requested information within 30 days of notice or their Medicare billing privileges will be temporarily suspended.

Upon completion of a revalidation application, MAC will review the revalidation application and determine enrollment eligibility. If MAC determines that the provider or supplier does not meet all requirements for enrollment, they can revoke the provider or supplier’s billing privileges.

What About Onsite Inspections?

CMS may inspect a provider, supplier or group to determine the accuracy of submitted enrollment information and compliance with enrollment requirements before revalidating. If CMS determines during an on-site inspection that the provider or supplier cannot furnish the required services or items, or has failed to satisfy any enrollment requirements, CMS can deactivate and seek revocation of the provider or supplier’s Medicare billing privileges. (See Medicare Revocations)

What Happens in a Failure to Revalidate?

Providers or suppliers who fail to timely revalidate may face the following sanctions:

    • Deactivation of Medicare billing privileges
    • Revocation of Medicare billing privileges
    • A hold on pending Medicare payments
    • Loss of ability to bill Medicare during the cap in billing privileges
    • A bar on re-enrollment

Failure to submit a timely revalidation application or required information may result in deactivation of billing privileges. Providers or suppliers who are deactivated will need to submit a new full CMS-855 application to reactivate their enrollment.

Deactivation will result in a gap in coverage. Payment will not be made for services performed during the deactivation period. Any payments made will be subject to overpayment action. Medicare may also suspend payment on claims pending during the deactivation period.

Additionally, Medicare may seek revocation of a provider or supplier’s billing privileges for noncompliance found during a revalidation.

If Medicare revokes a provider or supplier’s Medicare billing privileges for failure to revalidate, the provider or supplier is barred from re-enrollment for one year. If CMS revokes a provider or supplier’s billing privileges for noncompliance and other issues discovered during revalidation, the provider or supplier may be barred from re-enrollment for up to three years.  Medicare Revocations

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