Understanding the Approval Recommendation Process for Certified Providers

• The certified provider completes and submits a CMS-855 enrollment application and all supporting documentation to its MAC, including any state require documentation and certifications according to the supplier type.
• The MAC reviews the application with the supporting documentation and makes a “recommendation for approval or denial” to the State Survey Agency and the CMS Survey and Operations Group (CMS SOG).
• The MAC will send the certified provider a copy of the “recommendation for approval or denial” letter by mail, email or fax. All inquiries about the application from this point forward must be directed to the State Survey Agency or CMS Survey and Operations Group using the contact information in the recommendation letter. 
  • If the certified provider is not familiar with the state requirements for their supplier type, contact the state survey agency to determine if additional documentation or certification is needed to process the application.
• The State Survey Agency may conduct a survey. Based on the survey results, they will make a recommendation for approval or denial (a certification of compliance or noncompliance) to the CMS Survey and Certifcation Group, who makes the final decision regarding program eligibility. The certified provider can check with CMS Location regarding your enrollment status. Contact Your CMS Location
  • Certain provider types may elect voluntary accreditation by a CMS-recognized accrediting organization in lieu of a state survey.
• Once the MAC and the provider receives the approval survey results (tie in notice), a second review will be conducted by the MAC to verify that a provider continues to meet the enrollment requirements prior to granting Medicare billing privileges and may request a site visit, if needed.
  • If the MAC receives a denied survey result notice or if the certified provider no longer meets the enrollment requirements, the letter sent to the provider will indicate why the application was denied.
• If the provider is granted Medicare billing privileges the provider will be approved in PECOS with a PTAN number and a welcome letter will be sent to the contact person identified on application. 
• • The certified provider can begin the EDI Enrollment process to electronically submit claims or update their EDI enrollment information to include this approval.

Related Content

• Medicare Provider-Supplier Enrollment
• MLN^® Educational Tool: Medicare Provider Enrollment, for more information and a list of the State Survey Agencies, select Enrollment, scroll under Step 2B and click on “Certified Providers & State Survey Agency.”
• Work with Your MAC and the State Agency: for more information scroll under Medicare Enrollment Guide > Step 4

Posted 6/30/2021