Medicare_Program_Integrity_Manual / Change Request 6097

Why This Topic Matters

These instructions affect how Medicare contractors process enrollment and revalidation actions, verify identity and location changes, respond to adverse findings, and manage sensitive provider data. Understanding the update helps enrollment and integrity staff apply the manual consistently across contractor workflows.

Article Sections

1. Provider enrollment integrity procedures

   General contractor instructions for reviewing enrollment applications, change requests, and related supporting information across Medicare enrollment workflows.

2. Supporting information

   Administrative notes and reference fields for recommendations and related documentation tied to the listed requirements.

3. Contacts

   Implementation contact information for questions related to the change request.

4. Funding

   Funding and implementation responsibility notes for contractors and shared-system environments.

5. Medicare Program Integrity Manual chapter 10 updates

   Revisions and referenced sections within the Medicare Provider/Supplier Enrollment chapter that frame the operational changes in the article.

6. Returning the application

   Conditions and handling steps for applications that are returned rather than processed, including related submission and documentation handling.

7. Licenses and certifications

   Guidance on verifying licensure, certifications, and accreditation-related information for different provider types and settings.

8. Adverse legal actions/convictions

   Instructions for contractor review and escalation of adverse legal history reported or discovered during enrollment processing.

9. Section 4 of the CMS-855A

   Enrollment instructions related to provider address information, practice locations, and HHA site verification.

10. Chain organizations

    Guidance for CMS-855A chain organization reporting and contractor review of chain home office information.

11. Supervising physicians

    Enrollment review requirements for supervising physicians, including licensure, enrollment status, and attestation handling.

12. Jurisdictional issues

    Intermediary roles, change-of-information routing, and coordination issues affecting enrollment processing.

13. EFT payments and CHOWs

    Processing rules for electronic funds transfer matters in change-of-ownership situations.

14. Pre-approval informational changes

    Handling of seller and buyer requests to change enrollment information before tie-in notice issuance.

15. Processing tie-in notices

    Timing and completion expectations for contractor processing after receipt of tie-in or approval notices.

16. Special program integrity procedures

    Additional verification activities for practice location, correspondence, EFT, reactivation, and reassignment-related transactions.

17. Special procedures for physicians and non-physician practitioners

    Ongoing review and verification actions for practitioners, including licensure monitoring, relocation, practice breaks, and EFT-related review.

18. Supplementary revalidation activities

    Priority approach for conducting revalidation work when contractor workload and available funding permit additional review activity.

19. Release of information

    Restrictions and exceptions governing disclosure of provider-specific enrollment information and related records.