CMS Pub. 100-08, ch. 10, § 10.7.15

A. Revalidation Letter – Non-DMEPOS Supplier

REVALIDATION

[month] [day], [year]

[Provider/Supplier Name]

[Address]

[City], [State] [Zip Code]

Dear [Provider/Supplier Name],

Every five years, CMS requires you to revalidate your Medicare enrollment record. You need to

update or confirm all the information in your record, including your practice locations and

reassignments.

We need this from you by [Due date, as Month dd yyyy]. If we don’t receive your response by

then, we may stop your Medicare billing privileges.

If you are a non-certified provider or supplier, and your enrollment is deactivated, you will

maintain your original PTAN, however will not be paid for services rendered during the period

of deactivation. This will cause a gap in your reimbursement.

What record needs revalidating by [Due date, as Month dd yyyy]

[Name] | NPI [NPI] | PTAN [PTAN]

Reassignments: <Only include this title if the record has any reassignments>

[Legal Business Name] | [dba Name] | Tax ID [Tax ID, mask all but last 4 digits]<Repeat for

other reassignments>

CMS lists the records that need revalidating at go.cms.gov/MedicareRevalidation.

What you need to do

Revalidate your Medicare enrollment record, through

https://pecos.cms.hhs.gov/pecos/login.do or [form CMS-855 or Form CMS-20134].

• Online: PECOS is the fastest option. If you don’t know your username or password,

PECOS offers ways to retrieve them. Our customer service can also help you by phone at 866-

484-8049.

• Paper: Download the right version of form [CMS-855 or Form CMS-20134] for your

situation at cms.gov. We recommend getting proof of receipt for your mailing. Mail to

[contractor address].

If you have a fee due, use PECOS to pay. If you feel you qualify for a hardship waiver, mail us a

request on practice letterhead with financial statements, application form, and certification. For

more on fees and exceptions, search cms.gov for “CR 7350” or “Fee Matrix”.

A new Electronic Funds Transfer (EFT) Authorization Form (CMS-588) is only required to be

submitted as part of your revalidation package if: (1) you have no Form CMS-588 on file with

Medicare at all; or (2) you are changing any of your existing Form CMS-588 data.

The current version of the form can be found at http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS588.pdf.

If you need help

Visit go.cms.gov/MedicareRevalidation

Call [contractor phone #] or visit [contractorsite.com] for more options.

Sincerely,

[Name]

[Title]

[Company]

B. Revalidation Letter – DMEPOS Supplier

REVALIDATION

[month] [day], [year]

[Provider/Supplier Name]

[Address]

[City], [State] [Zip Code]

Dear [Provider/Supplier Name],

Every three years, CMS requires you to revalidate your Medicare enrollment record. You need

to update or confirm all the information in your record, including your practice location.

We need this from you by [Due date, as Month dd yyyy]. If we do not receive your

response by then, we may stop your Medicare billing privileges.

If you are a non-certified provider or supplier and your enrollment is deactivated, you will

maintain your original PTAN. However, you will not be paid for services rendered during the

period of deactivation. This will cause a gap in your reimbursement.

What record needs revalidating by [Due date, as Month dd yyyy]

[Name] | NPI [NPI] | PTAN [PTAN]

[Legal Business Name] | [dba Name] | Tax ID [Tax ID, mask all but last 4 digits]

The CMS lists the records that need revalidating at go.cms.gov/MedicareRevalidation.

What you need to do

Revalidate your Medicare enrollment record, through

https://pecos.cms.hhs.gov/pecos/login.do or [Form CMS-855S or Form CMS-20134].

• Online: PECOS is the fastest option. If you do not know your username or password,

PECOS offers ways to retrieve them. Our customer service can also help you by

phone at 866-484-8049.

• Paper: Download the right version of form [CMS-855S] for

your situation at cms.gov. We recommend getting proof of receipt for your mailing.

Mail to [contractor address].

If you have a fee due, use PECOS to pay. If you feel you qualify for a hardship waiver,

mail us a request on practice letterhead with financial statements, application form, and

certification. For more on fees and exceptions, search cms.gov for “CR 7350” or “Fee

Matrix”.

A new Electronic Funds Transfer (EFT) Authorization Form (CMS-588) is only

required to be submitted as part of your revalidation package if: (1) you have no Form

CMS-588 on file with Medicare at all; or (2) you are changing any of your existing

Form CMS-588 data.

The current version of the form can be found at

http://www.cms.gov/Medicare/CMSForms/CMS-Forms/Downloads/CMS588.pdf.

If you need help

Visit go.cms.gov/MedicareRevalidation

Call [contractor phone #] or visit [contractorsite.com] for more options.

Sincerely,

[Name]

[Title]

[Company]

C. Revalidation Letter – CHOW Scenario Only

[month] [day], [year]

PROVIDER/SUPPLIER NAME NPI:

ADDRESS 1, ADDRESS 2PTAN:

CITY STATE ZIP CODE

Dear Provider/Supplier Name:

THIS IS A PROSPECTIVE PROVIDER ENROLLMENT REVALIDATION REQUEST

IMMEDIATELY SUBMIT AN UPDATED

PROVIDER ENROLLMENT PAPER APPLICATION 855 FORM TO VALIDATE YOUR

ENROLLMENT INFORMATION

In accordance with Section 6401 (a) of the Patient Protection and Affordable Care Act, all new

and existing providers must be reevaluated under the new screening guidelines. Medicare

requires all enrolled providers and suppliers to revalidate their enrollment information every five

years (reference 42 CFR §424.515). To ensure compliance with these requirements, existing

regulations at 42 CFR §424.515(d) provide that the Centers for Medicare & Medicaid Services

(CMS) is permitted to conduct off-cycle revalidations for certain program integrity purposes.

Upon the CMS request to revalidate its enrollment, the provider/supplier has 60 days from the

post mark date of this letter to submit complete enrollment information.

You previously submitted a change of ownership (CHOW) application that is currently being

reviewed by the State Agency. Since your application has not been finalized, please validate that

we have the most current information on file. Any updated information received since your

initial submission will be forwarded to the State Agency for a final determination.

Providers and suppliers can validate their provider enrollment information using the paper

application form. To validate by paper, download the appropriate and current CMS-855

Medicare Enrollment application from the CMS Web site at

https://www.cms.gov/MedicareProviderSupEnroll/. Mail your completed application and all

required supporting documentation to the [insert contractor name], at the address below.

[Insert application return address]

A new Electronic Funds Transfer (EFT) Authorization Form (CMS-588) is only required to be

submitted as part of your revalidation package if (1) you have no Form CMS-588 on file with

Medicare at all; or (2) you are changing any of your existing Form CMS-588 data.

The current version of the form can be found at http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS588.pdf.

If additional time is required to complete the validation applications, you may request one 60-day extension, which will be added onto the initial 60 days given to respond to the request. The

request may be submitted in writing from the individual provider, the Authorized or Delegated

Official of the organization or the contact person and addressed to the MAC(s). The request

should include justification of why a 60-day extension is needed. The request may also be made

by contacting your MAC(s), via phone.

Physicians, non-physician practitioners and physician and non-physician practitioner

organizations must report a change of ownership, any adverse legal action, or a change of

practice location to the MAC within 30 days. All other changes must be reported within 90 days.

For most but not all other providers and suppliers, additions/changes in adverse legal actions

and of ownership or control, including changes in authorized official(s), must be reported within

30 days; all other changes to enrollment information must be made within 90 days. For all

provider and supplier types, any change of practice location (including practice location

additions, deletions, and relocations) must be reported within 30 days.

Failure to submit complete enrollment application(s) and all supporting documentation within 60

calendar days of the postmark date of this letter may result in your Medicare billing privileges

being deactivated and your CHOW not being processed. We strongly recommend you mail your

documents using a method that allows for proof of receipt.

If you have any questions regarding this letter, please call [contractor telephone number will be

inserted here] between the hours of [contractor telephone hours will be inserted here] or visit our

Web site at [insert Web site] for additional information regarding the enrollment process or the

[insert application type].

Sincerely,

[Your Name]

[Title]

D. Large Group Revalidation Notification Letter

[month] [day], [year]

PROVIDER/SUPPLIER GROUP NAME NPI:

ADDRESS 1, ADDRESS 2 PTAN:

CITY STATE ZIP CODE

Dear Provider/Supplier Group Name:

THIS IS NOT A PROVIDER ENROLLMENT REVALIDATION REQUEST

This is to inform you that a number of physicians and/or non-physician practitioners reassigning

all or some of their benefits to your group have been selected for revalidation. For your

convenience, a list of those individuals is attached. A revalidation notice will be sent to the

physician or non-physician practitioner within the next seven months. The physician or non-physician practitioner will need to respond by the revalidation due date provided for each

provider. It is the responsibility of the physician /or non-physician practitioner to revalidate all

the physician’s or practitioner’s Medicare enrollment information and not just that associated

with the reassignment to your group practice.

In accordance with Section 6401 (a) of the Patient Protection and Affordable Care Act, all new

and existing providers must be reevaluated under the new screening guidelines. Medicare

requires all enrolled providers and suppliers to revalidate their enrollment information every five

years (reference 42 CFR §424.515). To ensure compliance with these requirements, existing

regulations at 42 CFR §424.515(d) provide that the Centers for Medicare & Medicaid Services

(CMS) is permitted to conduct off-cycle revalidations for certain program integrity purposes.

Physicians and non-physician practitioners can revalidate by using either Internet-based PECOS

or submitting a paper CMS-855 enrollment application. Failure to submit a complete

revalidation application and all supporting documentation within 60 calendar days may result in

the physician or non-physician practitioner’s Medicare billing privileges being deactivated. As

such, your group will no longer be reimbursed for services rendered by the physician or non-physician practitioner.

If you have any questions regarding this letter, please call [contractor telephone number will be

inserted here] between the hours of [contractor telephone hours will be inserted here] or visit our

Web site at [insert Web site] for additional information regarding the revalidation process.

Sincerely,

[Your Name]

[Title]

E. Revalidation Pend Letter

PAYMENT HOLD

[month] [day], [year]

[Provider/Supplier Name]

[Address]

[City], [State] [Zip Code]

Dear [Provider/Supplier Name],

We are holding all payments on your Medicare claims, because you haven’t revalidated your

enrollment record with us. This does not affect your Medicare participation agreement, or any of

its conditions.

Every [three or five years], CMS requires you to revalidate your Medicare enrollment record

information. You need to update or confirm all the information in your record, including your

practice locations and reassignments.

Failure to respond to this notice will result in a possible deactivation of your Medicare

enrollment. If you are a non-certified provider or supplier, and your enrollment is deactivated,

you will maintain your original PTAN, however will not be paid for services rendered during the

period of deactivation. This will cause a gap in your reimbursement.

What record needs revalidating

[Name] | NPI [NPI] | PTAN [PTAN]

Reassignments:

[Legal Business Name] | [dba Name] | Tax ID [Tax ID, mask all but last 4 digits] <Repeat for

other reassignments>

CMS lists the records that need revalidating at go.cms.gov/MedicareRevalidation.

How to resume your payments

Revalidate your Medicare enrollment record, through

https://pecos.cms.hhs.gov/pecos/login.do or [form CMS-855 or Form CMS-20134].

• Online: PECOS is the fastest option. If you don’t know your username or password,

PECOS offers ways to retrieve them. Our customer service can also help you by phone at 866-

484-8049.

• Paper: Download the right version of [form CMS-855 or Form CMS-20134] for your

situation at cms.gov. We recommend getting proof of receipt for your mailing. Mail to

[contractor address].

If you have a fee due, use PECOS to pay. If you feel you qualify for a hardship waiver, mail us a

request on practice letterhead with financial statements, application form, and certification.

If you need help

Visit go.cms.gov/MedicareRevalidation

Call [contractor phone #] or visit [contractorsite.com] for more options.

Sincerely,

[Name]

[Title]

[Company]

F. Revalidation Deactivation Letter

STOPPING BILLING PRIVILEGES

[month] [day], [year]

[Provider/Supplier Name]

[Address]

[City], [State] [Zip Code]

Dear [Provider/Supplier Name],

Your Medicare billing privileges are being deactivated effective [Month] [DD], [YYYY],

pursuant to 42 C.F.R. § 424.540(a)(3) because you have not timely revalidated your enrollment

record with us, or your revalidation application has been rejected because you did not timely

respond to our requests for more information. We will not pay any claims after this date.

Every five years [three for DMEPOS suppliers], CMS requires you to revalidate your Medicare

enrollment record.

What record needs revalidating

[Name] | NPI [NPI] | PTAN [PTAN]

Reassignments:

[Legal Business Name] | [dba Name] | Tax ID [Tax ID, mask all but last 4 digits] <Repeat for

other reassignments>

CMS lists the records that need revalidating at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidations.html.

Rebuttal Rights:

If you believe that this determination is not correct, you may rebut the deactivation as indicated

in 42 C.F.R. § 424.546. The rebuttal must be received in writing within 15 calendar days of the

date of this letter. The rebuttal must state the issues or findings of fact with which you disagree

and the reasons for disagreement. You may submit additional information with the rebuttal that

you believe may have a bearing on the decision. You must submit all information that you would

like to be considered in conjunction with the rebuttal. This includes any application(s) to update

your enrollment, if necessary. You may only submit one rebuttal in response to this deactivation

of your Medicare enrollment.

The rebuttal must be signed and dated by the individual provider/supplier, the authorized or

delegated official, or a legal representative. (Delete next sentence if letter is related to a

DMEPOS supplier’s enrollment.) Authorized or delegated officials for groups cannot sign and

submit a rebuttal on behalf of a reassigned provider/supplier without the provider/supplier

submitting a signed statement authorizing that individual from the group to act on the reassigned

provider’s/supplier’s behalf.

If the provider/supplier wishes to appoint a legal representative that is not an attorney to sign the

rebuttal, the provider/supplier must include with the rebuttal a written notice authorizing the

legal representative to act on the provider’s or supplier’s behalf. The notice should be signed by

the provider/supplier.

If the provider/supplier has an attorney sign the rebuttal, the rebuttal must include a statement

from the attorney that the attorney has the authority to represent the provider/supplier.

If you wish to receive communication regarding your rebuttal via email, please include a valid

email address in your rebuttal request.

The rebuttal should be sent to the following:

[Contractor Rebuttal Receipt Address]

[Contractor Rebuttal Receipt Email Address]

[Contractor Rebuttal Receipt Fax Number]

If you have any questions, please contact our office at [phone number] between the hours of

[x:00 a.m./p.m ET/MT/CT/PT] and [x:00 a.m./p.m ET/MT/CT/PT].

How to recover your billing privileges

Revalidate your Medicare enrollment record, through PECOS.cms.hhs.gov, or [Form CMS-855

or Form CMS-20134].

• Online: PECOS is the fastest option. If you don’t know your username or password,

PECOS offers ways to retrieve them. Our customer service can also help you by phone at 866-

484-8049.

• Paper: Download the right version of [form CMS-855 or Form CMS-20134] for your

situation at cms.gov. We recommend getting proof of receipt for your mailing. Mail to

[contractor address].

If you have a fee due, use PECOS to pay. If you feel you deserve a hardship waiver, mail us a

request on practice letterhead with financial statements, application form, and certification.

If you are a non-certified provider or supplier, and your enrollment is deactivated, you will

maintain your original PTAN, however will not be paid for services rendered during the period

of deactivation. This will cause a gap in your reimbursement.

If you need help Visit https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidations.html.

Call [contractor telephone number] or visit [contractorsite.com] for more options.

Sincerely,

[Name]

[Title]

[Company]

G. Revalidation Past-Due Group Member Letter

REVALIDATION | Past-Due Group Member

[month] [day], [year]

[Provider/Supplier Name]

[Address]

[City], [State] [Zip Code]

Dear [Provider/Supplier Name],

Every five years, CMS requires providers to revalidate their Medicare enrollment records. You

have not revalidated by the requested due date of [revalidation due date].

You need to update or confirm all the information in your record, including your practice

locations and reassignments. If you are a non-certified provider or supplier, and your enrollment

is deactivated, you will maintain your original PTAN, however will not be paid for services

rendered during the period of deactivation. This will cause a gap in your reimbursement.

If multiple records below need to be revalidated, please coordinate with the appropriate parties to

provide only one response.

What record needs revalidating

[Name] | NPI [NPI] | PTAN [PTAN]

Reassignments: <Only include this title if the record has any reassignments>

[Legal Business Name] | [dba Name] | Tax ID [Tax ID, mask all but last 4 digits] <Repeat for

other reassignments>

The CMS lists the records that need revalidating at go.cms.gov/MedicareRevalidation.

What your group member needs to do

Revalidate the member’s Medicare enrollment record, through

https://pecos.cms.hhs.gov/pecos/login.do. or [form CMS-855 or Form CMS-20134].

• Online: PECOS is the fastest option. If the member doesn’t know the member’s

username or password, PECOS offers ways to retrieve them. Our customer service can also help

by phone at 866-484-8049.

• Paper: Download the right version of [Form CMS-855 or Form CMS-20134] for the

enrollment situation at cms.gov. We recommend getting proof of receipt for this mailing. Mail to

[contractor address].

If your group member needs help

Visit go.cms.gov/MedicareRevalidation

Call [contractor phone #] or visit [contractorsite.com] for more options.

Sincerely,

[Name]

[Title]

[Company]

H. Model Return Revalidation Letter

RETURN REVALIDATION

[month] [day], [year]

[Provider/Supplier Name]

[Address]

[City], [State] [Zip Code]

NPI: [xxxxxxxxxx]

Dear [Provider/Supplier Name],

Your Medicare enrollment application(s) was received on [date]. We are closing this request and

returning your application(s) for the following reason(s):

• The [Form CMS-855 or Form CMS-20134] application received by

[PROVIDER/SUPPLIER NAME] was unsolicited.

An unsolicited revalidation is one that is received more than seven months prior to the

provider/supplier’s due date. Due dates are established around 5 years from the

provider/supplier’s last successful revalidation or initial enrollment.

To find the provider/suppliers revalidation due date, please go to

http://go.cms.gov/MedicareRevalidation.

If you are not due for revalidation in the current seven-month period, you will find that your due

date is listed as “TBD” (or To Be Determined). This means that you do not yet have a due date

for revalidation within the current seven-month period. This list with be updated monthly.

• If your intention is to change information on your Medicare enrollment file, you must

complete a new Medicare enrollment application(s) and mark ‘change’ in section 1 of the [form

CMS-855 or Form CMS-20134].

• Please address the above issues as well as sign and date the new certification statement

page on your resubmitted application(s).

Providers and suppliers can apply to enroll in the Medicare program using one of the following

two methods:

1. Internet-based Provider Enrollment, Chain and Organization System (PECOS). Go to:

https://pecos.cms.hhs.gov/pecos/login.do.

2. Paper application process: Download and complete the Medicare enrollment application(s) at

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/EnrollmentApplications.html.

If you need help

Visit http://go.cms.gov/MedicareRevalidation, or

Call2 [contractor phone #] or visit [contractorsite.com] for more options.

Sincerely,

[Name]

[Title]

[Company]