Medicare/Medicaid Enrollment Compliance Assessment

Are all providers and suppliers enrolled in Medicare via PECOS (Provider Enrollment, Chain and Ownership System)?*

CMS-855 application required for reimbursement

Have you submitted complete and accurate CMS-855 enrollment applications?*

Forms: 855A (institutional), 855B (physician), 855I (DME), 855O (ordering/referring), 855S (ambulance)

Do all billing NPIs match enrolled provider information in PECOS?*

National Provider Identifier must be validated

Are Practice Locations accurately listed and match where services are provided?*

Do you track Medicare enrollment revalidation deadlines (every 5 years)?*

CMS sends revalidation notices; failure to respond results in deactivation

Are changes to enrollment information reported to CMS within 30 days?*

Address changes, ownership changes, practice location additions

Do you monitor PECOS for enrollment status and correspondence from CMS?*

Check for requests for additional information or pending actions

Have all owners, managing employees, and authorized officials completed background checks?*

Fingerprinting required for high categorical risk (DME, HHA)

Do you screen providers against OIG Exclusion List and SAM.gov monthly?*

LEIE (List of Excluded Individuals/Entities) mandatory screening

Are site visits conducted for moderate and high categorical risk providers?*

CMS may conduct unannounced site visits pre- or post-enrollment

Have you paid applicable application fees for enrollment/revalidation?*

Fees range from $585-$670 depending on provider type

Do you maintain compliance with all Medicare Conditions of Participation (CoPs)?*

Varies by facility type (hospitals, SNFs, HHAs, etc.)

Are you free from unresolved Medicare/Medicaid debt or overpayments?*

Outstanding debts can result in enrollment denial

Do you report adverse legal actions (revocations, felonies) to CMS within 30 days?*

State license revocations, DEA sanctions, felony convictions

Have you attested to compliance with all Medicare laws and regulations?*

False attestations subject to civil and criminal penalties

If dispensing Part D drugs, are you enrolled as a Medicare Part D pharmacy?

Separate enrollment required for prescription drug coverage

Do you comply with e-prescribing requirements for controlled substances?

Are you separately enrolled in state Medicaid programs where you operate?*

State-specific Medicaid enrollment separate from Medicare

Do you comply with state-specific Medicaid revalidation timelines?*

State requirements may differ from federal Medicare

Are you registered with state Medicaid Management Information Systems (MMIS)?*