CMS Pub. 100-08, ch. 10, § 10.4.1.4.1

(This section 10.4.1.4.1 does not apply in situations where another CMS instruction contains

alternative direction.)

A. Non-Certified Suppliers and Individual Practitioners

(This section 10.4.1.4.1(A) does not apply to ambulatory surgical centers, portable x-ray

suppliers, DMEPOS suppliers, MDPP suppliers, or providers and suppliers that complete the

Form CMS-855A.)

If the contractor approves a supplier’s enrollment, it shall notify the supplier via letter of the

approval. The letter shall follow the content and format of the applicable model letter in section

10.7 et seq. of this chapter.

The contractor shall send the approval letter via e-mail, mail, or fax for paper applications (and

the PCV for PECOS applications) within 5 business days of approving the enrollment

application in PECOS. (This timeframe should allow for the updating the enrollment

information in the shared systems (MCS, FISS or VMS)). For all applications other than the

Form CMS-855S, the contractor shall send the letter to the supplier’s contact person if one is

listed; otherwise, the contractor may send the letter to the supplier at the supplier’s

correspondence address or special payment address.

B. Certified Providers and Certified Suppliers

(This section 10.4.1.4.1(B) only applies to: (1) initial Form CMS-855A applications or CHOW,

acquisition/merger, or consolidation applications submitted by the new owner; and (2) initial

ambulatory surgical center and portable x-ray supplier applications. Note also that this

subsection (B) contains only general instructions regarding certified provider/supplier approvals.

Instructions in other chapter 10 sections (e.g., sections 10.2.1 et seq., 10.2.2 et seq., section 10.3,

10.6.1 et seq.) may contain more specific direction, such as with the processing of FQHC

applications. Except as stated otherwise, these more specific instructions take precedence over

those in this section 10.4.1.4.1(B)). To illustrate, processes for “transitioned” provider initial

enrollment (e.g., hospitals, HHAs) are described in provider-specific sections of section 10.2.1,

et seq.) and take precedence over those in this section 10.4.1.4.1(B).

If the contractor decides to recommend approval of the provider or supplier’s application, the

contractor shall send a recommendation letter to the applicable state agency, with a copy to the

SOG Location. The recommendation letter shall follow the guidance and format of the

applicable template letter in section 10.7 et seq. of this chapter. The contractor may also include

an explanation of any special circumstances, findings, or other information that the state should

know about. The letter can be sent to the state/SOG Location via mail, fax, or e-mail.

Also, the contractor:

(i) Shall send either a photocopy (not the original), faxed version, or e-mail version of the final

completed Form CMS-855 to the state agency, along with all updated Form CMS-855 pages,

explanatory data, documentation, correspondence, final sales agreements, etc. (which can also be

sent via mail, fax, or e-mail). If the Form CMS-855, associated documentation, and

recommendation letter are mailed, they should be included in the same package.

(ii) Shall not send a copy of the Form CMS-855 to the SOG Location unless the latter

specifically requests it or if the transaction in question is one for which state involvement is

unnecessary.

(iii) Notify the applicant that the contractor has completed its initial review of the application.

The notification can be furnished via e-mail, the PCV, or via the letter identified in Section

10.7.5 of this chapter (which may be sent to the applicant’s contact person). The contractor may,

but is not required to, send a copy of its recommendation letter to the provider as a means of

satisfying this requirement. However, the contractor should not send a copy to the provider if the

recommendation letter contains sensitive information.

C. DMEPOS Suppliers

As stated in 42 CFR § 424.57(b), a DMEPOS supplier must, among other things, meet the

following conditions to be eligible to receive payment for a Medicare-covered item: (i) the

supplier has submitted a complete Form CMS-855S (including all supporting documentation) to

the applicable contractor); and (ii) the item was furnished on or after the date the contractor

issued to the supplier a DMEPOS supplier number conveying Medicare billing privileges.

D. Medicare Diabetes Prevention Program (MDPP) Suppliers

As stated in 42 CFR § 424.205(d), an MDPP supplier must, among other things, not have an

ineligible coach on its roster. Though the MDPP supplier’s effective date for billing privileges is

the date a successful Form CMS-20134 application was submitted, the contractor must notify

MDPP suppliers of their application approval because some MDPP suppliers may not begin

furnishing services until receiving such information.

If the contractor approves an MDPP supplier’s enrollment, it shall notify the supplier via letter of

the approval. The letter shall follow the content and format of the applicable model letter in

section 10.7 et seq. of this chapter.

Absent a CMS instruction or directive to the contrary, the contractor shall send the approval

letter within 5 business days of approving the enrollment application in PECOS. The letter shall

be sent to the supplier’s contact person if one is listed; otherwise, the contractor may send the

letter to the supplier’s correspondence address or special payment address.

For claims submitted by MDPP suppliers prior to the date of enrollment, the contractor shall

follow the instructions in Pub. 100-04, chapter 1, section 70, with respect to the claim filing

limit. Payments cannot be made for services furnished prior to the date the applicant submitted

an application or CAP that resulted in successful enrollment.

E. Additional Copies of Approval Letters

With the exception of Form CMS-855S applications, if any contact person listed on a

provider/supplier’s enrollment record requests a copy of the provider/supplier’s Medicare

approval letter, the contractor shall send it to the contact person via e-mail, the PCV, fax, or mail.

(This excludes certification letters from the state or SOG Location, for the contractor does not

generate these approvals. Also, see section 10.3 of this chapter for information regarding those

contact persons for PECOS applications/enrollments who can and cannot receive documents or

information pertaining to a specific application.)

For Form CMS-855S application approval letters, suppliers may contact their applicable NPE

East or NPE West contractor for a copy thereof.