All DMEPOS suppliers who serve Medicare beneficiaries and meet the supplier standards listed in this chapter must enroll and obtain a Provider Transaction Access Number (PTAN) with the National Supplier Clearinghouse (NSC).

Before enrolling with the NSC, suppliers must obtain a National Provider Identifier (NPI). Applying for an NPI is a separate process from enrollment with NSC.

National Provider Identifier
The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (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 National Provider Identifier (NPI) is the standard unique identifier. The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign the NPIs. Suppliers can apply for an NPI one of three ways.

• For the most efficient application processing and the fastest receipts of NPIs, use the Web-based application process. Simply log onto the National Plan and Provider Enumeration System (NPPES) and apply online.
  
  
• Suppliers can agree to have an electronic file interchange (EFI) organization (EFIO) submit application data on their behalf (i.e., through a bulk enumeration process) if an EFIO requests their permission to do so.
  
  
• Suppliers may wish to obtain a copy of the paper CMS-10114 NPI Application/Update Form and mail the completed, signed application to the NPI Enumerator. This form is available on the CMS Web site 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:
  
  
  • Phone: 800-465-3203 or TTY 800-692-2326
    
    
  • E-mail: customerservice@npienumerator.com
    
    
  • Mail: NPI Enumerator
    P.O. Box 6059
    Fargo, ND 58108-6059
    

Note: Suppliers may only apply for an NPI using only one of the methods described above.

For more information about NPI enumeration, go to www.cms.hhs.gov/nationalprovidentstand/ .

Obtaining and Retaining Medicare DMEPOS Billing Privileges
Under durable medical equipment (DME) jurisdictional processing, every supplier of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) must obtain billing privileges from the National Supplier Clearinghouse (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 the Centers for Medicare & Medicaid Services (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 .

The NSC distributes enrollment supplier applications (Provider/Supplier Enrollment Application or CMS-855S form , verify the data, issue billing privileges to approved suppliers and maintain a national DMEPOS supplier file. The NSC must process supplier data and issue billing privileges before a supplier may start submitting claims to a durable medical equipment Medicare administrative contractor (DME MAC). The NSC will verify all information submitted.

The supplier must complete the CMS-855S application and meet one of the following conditions if they plan to bill Medicare for DMEPOS:

• Enrolling in Medicare for the first time as a DMEPOS supplier
  
  
• 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 Provider Transaction Access Number [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 C.F.R. 424.57(b)(1) requires suppliers to enroll separate physical locations other than warehouses or repair facilities.
  

• 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 Web site .

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.

The NSC will contact a supplier via e-mail or fax if the CMS-855S form is incomplete or has inconsistent information. Suppliers will be allowed 60 days from the date of notification to return all required information. If the information is not received within the 60-day time frame, the application will be closed.

Suppliers enrolling 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 . Additional information on participation with Medicare can be found in the Participation Program chapter of this manual.

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 issued billing privileges. The denial/revocation notification outlines the appeals process available to suppliers, including instructions on requesting an appeal.

According to the CMS Internet-Only Manual (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:

• 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.

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:

• 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.

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 May 1, 2006, CMS issued the revised CMS-855 Medicare enrollment applications. Listed below are changes and enhancements made specifically to the CMS-855S . DMEPOS suppliers should review and become familiar with this information.

• Requires the submission of the national provider identifier (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 e-mail to customerservice@npienumerator.com.

  Note: Each enrolled supplier of DMEPOS that is a covered entity under Health Insurance Portability and Accountability Act (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.

• Requires suppliers to complete the Authorization Agreement for Electronic Funds Transfer (CMS-588) . With regards to DMEPOS enrollment, suppliers should submit the CMS-588 electronic funds transfer (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.

  Note: Suppliers completing a reenrollment package, who are not currently enrolled in the EFT program, should submit the completed CMS-588 form along with the required attachment verifying the bank account information. The NSC will then forward the form to the appropriate DME MAC for processing.

  Along with the completed form, suppliers must include one of the following verifying the account information:

  • Voided check
  • Deposit slip
  • 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. The NSC does not enroll suppliers into the EFT program. Any changes to EFT information should be submitted following existing procedures.

• A new section was added for suppliers to provide a specific address of where the NSC should mail their reenrollment packages. If a supplier would like to receive their reenrollment at an address other than the address where correspondences are received, the supplier should list this address in Section 2.A.3. This enhancement was made to provide all suppliers, especially those suppliers with multiple locations, a single address where they would like their reenrollment packages mailed.
  
  
• Requires suppliers to provide the name and phone number of the insurance underwriter. The NSC is required by CMS to verify coverage. Section 2.D requires suppliers to provide identifying information for both the insurance agent and the underwriter. Providing this information will assist in facilitating the verification process.
  On April 2, 2007, CMS issued a Final Rule on accreditation for DMEPOS suppliers. Because of the Final Rule, Section 2.F was added for suppliers to provide information concerning accreditation.
  
  
• 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.
  

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 form . Failure to provide the updated information is grounds for denial or revocation of the National Provider Identifier (NPI). 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:

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.

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 Web site.

The Medicare DMEPOS supplier standards were finalized and became effective December 11, 2000. These standards are listed below.

Source: Section 424.57 Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges.

(A) Definitions
As used in this section, the following definitions apply:

(B) General Rule
A DMEPOS supplier must meet the following conditions in order to be eligible to receive payment for a Medicare-covered item:

1. The supplier has submitted a completed application to CMS to furnish Medicare-covered items including required enrollment forms. (The supplier must enroll separate physical locations it uses to furnish Medicare-covered DMEPOS, with the exception of locations that it uses solely as warehouses or repair facilities.)

2. The item was furnished on or after the date CMS conveyed billing privileges to the supplier.

3. The CMS has not revoked or excluded the DMEPOS supplier’s privileges during the period which the item was furnished has not been revoked or excluded.

4. A supplier that furnishes a drug used as a Medicare-covered supply with durable medical equipment or prosthetic devices must be licensed by the state to dispense drugs (A supplier of drugs must bill and receive payment for the drug in its own name. A physician, who is enrolled as a DMEPOS supplier, may dispense, and bill for, drugs under this standard if authorized by the state as part of the physician's license.)

5. The supplier has furnished to CMS all information or documentation required to process the claim.

(C) Application Certification Standards
The supplier must meet and must certify in its application for billing privileges that it meets and will continue to meet the following standards:

1. Operates its business and furnishes Medicare-covered items in compliance with all applicable federal and state licensure and regulatory requirements.

2. Has not made, or caused to be made, any false statement or misrepresentation of a material fact on its application for billing privileges. (The supplier must provide complete and accurate information in response to questions on its application for billing privileges. The supplier must report to CMS any changes in information supplied on the application within 30 days of the change.)

3. Must have the application for billing privileges signed by an individual whose signature binds a supplier.

4. Fills orders, fabricates, or fits items from its own inventory or by contracting with other companies for the purchase of items necessary to fill the order. If it does, it must provide, upon request, copies of contracts or other documentation showing compliance with this standard. 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 Government Executive Branch procurement or nonprocurement program or activity.

5. Advises beneficiaries that they may either rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental durable medical equipment, as defined in Section 414.220(a) of this subchapter. (The supplier must provide, upon request, documentation that it has provided beneficiaries with this information, in the form of copies of letters, logs or signed notices.)

6. Honors all warranties expressed and implied under applicable state law. A supplier must not charge the beneficiary or the Medicare program for the repair or replacement of Medicare covered items or for services covered under warranty. This standard applies to all purchased and rented items, including capped rental items, as described in Section 414.229 of this subchapter. The supplier must provide, upon request, documentation that it has provided beneficiaries with information about Medicare-covered items covered under warranty, in the form of copies of letters, logs, or signed notices.

7. Maintains a physical facility on an appropriate site. The physical facility must contain space for storing business records including the supplier’s delivery, maintenance, and beneficiary communication records. For purposes of this standard, a post office box or commercial mailbox is not considered a physical facility. In the case of a multisite supplier, records may be maintained at a centralized location.

8. Permits CMS, or its agents to conduct on-site inspections to ascertain supplier compliance with the requirements of this section. The supplier location must be accessible during reasonable business hours to beneficiaries and to CMS, and must maintain a visible sign and posted hours of operation.

9. Maintains a primary business telephone listed under the name of the business locally or toll-free for beneficiaries. The supplier must furnish information to beneficiaries at the time of delivery of items on how the beneficiary can contact the supplier by telephone. The exclusive use of a beeper number, answering service, pager, facsimile machine, car phone, or an answering machine may not be used as the primary business telephone for purposes of this regulation.

10. Has a comprehensive liability insurance policy 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. In the case of a supplier that manufactures its own items, this insurance must also cover product liability and completed operations. Failure to maintain required insurance at all times will result in revocation of the supplier's billing privileges retroactive to the date the insurance lapsed.

11. Must agree not to contact a beneficiary by telephone when supplying a Medicare-covered item unless one of the following applies:
    
    

    (i)	The individual has given written permission to the supplier to contact them by telephone concerning the furnishing of a Medicare-covered item that is to be rented or purchased.
    (ii)	The supplier has furnished a Medicare-covered item to the individual and the supplier is contacting the individual to coordinate the delivery of the item.
    (iii)	If the contact concerns the furnishing of a Medicare-covered item other than a covered item already furnished to the individual, the supplier has furnished at least one covered item to the individual during the 15-month period proceeding the date on which the supplier makes such contact.

12. Must be responsible for the delivery of Medicare covered items to beneficiaries and maintain proof of delivery. (The supplier must document that it or another qualified party has at an appropriate time, provided beneficiaries with necessary information and instructions on how to use Medicare covered items safely and effectively).

13. Must answer questions and respond to complaints a beneficiary has about the Medicare-covered item that was sold or rented. A supplier must refer beneficiaries with Medicare questions to the appropriate carrier. A supplier must maintain documentation of contacts with beneficiaries regarding complaints or questions.

14. 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. The item must function as required and intended after being repaired or replaced.

15. Must accept returns from beneficiaries of substandard (less than full quality for the particular item) or unsuitable items (i.e., inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.

16. Must disclose these supplier standards to each beneficiary to whom it supplies a Medicare covered item.

17. Must comply with the disclosure provisions in Section 420.206 of this subchapter.

18. Must not convey or reassign a supplier’s billing privileges.

19. Must have a complaint resolution protocol to address beneficiary complaints that relate to supplier standards in paragraph (c) of this section and keep written complaints, related correspondence and any notes of actions taken in response to written and oral complaints. Failure to maintain such information may be considered evidence that supplier standards have not been met. (This information must be kept at its physical facility and made available to CMS, upon request.)

20. Must maintain the following information on all written and oral beneficiary complaints, including telephone complaints, it receives:
    

    (i)	Name, address, telephone number, and health insurance claim number of the beneficiary.
    (ii)	A summary of the complaint; the date it was received; the name of the person receiving the complaint, and a summary of actions taken to resolve the complaint.
    (iii)	If an investigation was not conducted, the name of the person making the decision and the reason for the decision.

21. Provides to CMS, upon request, any information required by the Medicare statute and implementing regulations.

22. All suppliers of DMEPOS and other items and services 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 for those specific products and services.

23. All DMEPOS suppliers must notify their accreditation organization when a DMEPOS location is opened. The accreditation organization may accredit the new supplier location for three month months after it is operational without requiring a new site visit.

24. All DMEPOS supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare. An accredited supplier may be denied enrollment or their enrollment may be revoked, if CMS determines that they are not in compliance with the DMEPOS quality standards.

25. All DMEPOS suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation. If a new product line is added after enrollment, the DMEPOS supplier will be responsible for notifying the accrediting body of the new product so that the DMEPOS supplier can be resurveyed and accredited for these new products.

(D) Failure to Meet Standards
The CMS will revoke a supplier’s billing privileges if it is found not to meet the standards in paragraphs (b) and (c) of this section. (The revocation is effective 15 days after the entity is sent notice of the revocation, as specified in Section 405.874 of this subchapter.)

(E) Renewal of Billing Privileges
A supplier must renew its application for billing privileges every three years after the billing privileges are first granted. Each supplier must complete a new application for billing privileges three years after its last renewal of privileges. The NSC will notify suppliers via mail when a new renewal application is due.

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 thirty (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 . According to 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 inactivated. 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 section of the NSC Web site at www.PalmettoGBA.com/NSC .

Resources Available to Assist Suppliers with the Enrollment Process

The NSC Web Site www.PalmettoGBA.com/NSC

• Helpful hints for completing the CMS-855S
  
• Numerous Frequently Asked Questions (FAQs) regarding the enrollment process
  
• The NSC Top Ten—the top ten reoccurring issues that delay processing
  
• 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
  

The NSC Customer Service Line
866-238-9652

NSC analysts are available Monday through Friday from 9:00 a.m. until 5:00 p.m. eastern time (ET) to answer questions regarding the enrollment process. If the supplier has 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 suppliers who do not speak English.

NSC E-Mail Address
Medicare.NSC@PalmettoGBA.com

If preferred, suppliers can e-mail their questions to this address. Questions received will be answered within a reasonable time frame. The NSC suggests suppliers do not submit protected health care information via e-mail.

NSC Interactive Voice Response Unit
The NSC Interactive Voice Response (IVR) unit allows suppliers to obtain:

• 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, durable medical equipment regional carrier/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.