US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P)
The Medicare enrollment rules at 42 CFR Part 424 Subpart P: how providers and suppliers establish and keep billing privileges, covering applications, signatures and fees, risk-based screening and fingerprinting, affiliation disclosure, effective dates and retrospective billing, revalidation, change reporting, documentation and exclusion screening, skilled nursing facility ownership disclosure, the denial, revocation, deactivation and stay grounds, ordering and certifying conditions, changes of ownership and the 36-month rule, payment liability and moratoria.
US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P) is a compliance framework from United States (federal) with 6 domains and 22 controls. The largest domains are Enrolling: application content, signatures, fees, screening, affiliations and onsite review (424.507 to 424.519) – US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P) (7 controls), Denial, revocation, deactivation, stay, rebuttals and appeals (424.530 to 424.547) – US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P) (5 controls), Maintaining enrollment: reporting changes, revalidation, documentation, skilled nursing facility disclosures (424.515 to 424.516) – US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P) (4 controls). Every control below carries what it requires and what an assessor expects to see.
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Framework Domains (6)
Denial, revocation, deactivation, stay, rebuttals and appeals (424.530 to 424.547) – US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P)
| Code | Title |
|---|---|
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.530 | Avoid the grounds on which CMS denies enrollment: noncompliance, excluded or debarred persons, felonies within 10 years, false or misleading information, not operational, Medicare debt, payment suspension, missing HHA reserves, unpaid fee, moratoria, prescribing authority loss, revocation under another identity, risky affiliations and other program terminations |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.535(a) | Avoid the grounds on which CMS revokes enrollment: the denial grounds plus misuse of the billing number, abuse of billing privileges, failure to report changes, failure to document or give access, False Claims Act judgments, Treasury-referred debt, improper prescribing, billing from non-compliant locations and the other listed conduct |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.540 | Avoid deactivation: submit a Medicare claim at least every 6 months, report changes on time, answer revalidation requests within 90 days, keep every enrollment requirement and a valid practice location; reactivate by recertifying or submitting a new application, and expect no payment while deactivated |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.541 | During a stay of enrollment (up to 60 days) remedy the noncompliance by the required change of information or revalidation submission; claims in the stay period are rejected unless compliance resumes before the stay ends, and a rebuttal may be filed within 15 days |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.542,424.547 | Physicians and practitioners with a detrimental felony within 10 years may not order, certify, refer or prescribe Medicare items, and those enrolled on Form CMS-855O must appear on a claim at least once in 12 months or be deactivated |
Effective dates, retrospective billing, rejection and return of applications, enhanced oversight (424.520 to 424.527) – US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P)
| Code | Title |
|---|---|
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.520-522 | Know your effective date of billing privileges: survey or accreditation date for certified providers, the later of filing and first service for physicians, practitioners, ambulance, OTP, Part B hospital departments, labs, therapists and the other listed types, and the receipt date for CMS-855O |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.521 | Retrospective billing by the listed supplier types is limited to 30 days before the effective date (90 days in a Presidentially declared disaster) and only where all program requirements were met and services were furnished at the enrolled location |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.525-526 | Respond to contractor development requests within 30 days with the missing information and supporting documentation, submit properly signed, dated, current and complete forms to the right contractor at the right time, and resubmit a new application after a rejection or return (no appeal rights) |
Enrolling: application content, signatures, fees, screening, affiliations and onsite review (424.507 to 424.519) – US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P)
| Code | Title |
|---|---|
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.507 | Bill imaging, laboratory, DMEPOS, home health and hospice services only when ordered or certified by a physician or eligible professional who is identified by legal name and NPI and is enrolled in approved status or validly opted out |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.510(a),(d)(1)-(2) | Submit a complete, accurate and truthful enrollment application with all required supporting documentation, including licenses, certifications, identifiers and ownership and management information |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.510(d)(3),(d)(10) | Have the enrollment application signed by the applying individual or an authorized official who can bind the organisation, delegate update authority only to owners or W-2 managing employees in the prescribed way, and accept legal responsibility for everything submitted |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.510(d)(4)-(9),(e) | Be operational and verifiable at the practice location, complete any required State survey, certification and provider agreement, submit to onsite review, meet the HHA initial reserve operating funds requirement, and receive payment by electronic funds transfer |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.514 | Institutional providers must pay the annual application fee (or request a hardship exception) with each initial, new-location and revalidation application, and pay within 30 days if a hardship exception is refused |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.518 | Cooperate with risk-based screening: limited (licensure and database checks), moderate (plus site visit) or high (plus fingerprint-based criminal background checks of all 5 percent or greater owners within 30 days of request) |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.519 | On CMS request, disclose every current and prior 5-year affiliation of the organisation or its owners and managing employees with a provider or supplier that has a disclosable event, with the required identifying and relationship details |
Maintaining enrollment: reporting changes, revalidation, documentation, skilled nursing facility disclosures (424.515 to 424.516) – US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P)
| Code | Title |
|---|---|
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.515 | Revalidate enrollment every 5 years (every 3 years for DMEPOS suppliers) by submitting the complete application and documentation within 60 days of the CMS notice, and respond to off-cycle revalidation and site visits when CMS requires them |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.516(a),(f) | Certify and maintain compliance with Medicare law, Federal and State licensure and certification, employ or contract with no excluded or debarred persons, and keep orders, certifications, referrals and prescriptions with the ordering NPI for 7 years available to CMS |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.516(d)-(e) | Report changes of ownership or control, adverse legal actions and practice location changes within 30 days, all other enrollment changes within 90 days, and FAA licence actions within 30 days for air ambulance suppliers |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.516(g) | Skilled nursing facilities must disclose on initial enrollment, change of ownership and revalidation every governing body member, officer, director, member, partner, trustee and managing employee, each additional disclosable party and its organisational structure, and report changes on the standard timelines |
Sale or transfer of billing privileges, payment liability, overpayments, moratoria and rural emergency hospitals (424.550 to 424.575) – US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P)
| Code | Title |
|---|---|
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.550-551 | Never sell or let another use your billing number; on a change of ownership both owners must file enrollment applications before completion and the new owner within 30 days; an HHA, hospice or DMEPOS supplier sold within 36 months of enrollment or of its last majority change must enroll anew and be re-surveyed or re-accredited unless an exception applies |
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.555,424.565 | Do not bill or collect for services furnished while deactivated, denied, revoked or under a stay; refund beneficiaries promptly; bear the expense yourself; and expect an overpayment assessment for unreported practice location changes or adverse actions |
Scope, definitions and the basic enrollment requirement (424.500 to 424.506) – US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P)
| Code | Title |
|---|---|
| us-medicare-provider-and-supplier-enrollment-42-cfr-part-424-subpart-p::424.505-506 | Be enrolled in Medicare before billing Medicare or a beneficiary for covered items or services, report your NPI on the enrollment application and include the NPIs of all identified providers on every claim |
What is US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P) and who does it apply to?
US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P) is a compliance framework from United States (federal) with 6 domains and 22 controls. The Medicare enrollment rules at 42 CFR Part 424 Subpart P: how providers and suppliers establish and keep billing privileges, covering applications, signatures and fees, risk-based screening and fingerprinting, affiliation disclosure, effective dates and retrospective billing, revalidation, change reporting, documentation and exclusion screening, skilled nursing facility ownership disclosure, the denial, revocation, deactivation and stay grounds, ordering and certifying conditions, changes of ownership and the 36-month rule, payment liability and moratoria. It is used by organisations to establish and maintain compliance with industry standards and regulatory requirements.
What does US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P) actually require?
US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P) has 22 controls organised across 6 domains. The largest domains are Enrolling: application content, signatures, fees, screening, affiliations and onsite review (424.507 to 424.519) – US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P) (7 controls), Denial, revocation, deactivation, stay, rebuttals and appeals (424.530 to 424.547) – US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P) (5 controls), Maintaining enrollment: reporting changes, revalidation, documentation, skilled nursing facility disclosures (424.515 to 424.516) – US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P) (4 controls). Each control defines specific requirements that organisations must implement to achieve compliance.
If I already comply with another framework, how much of US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P) do I already cover?
US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P) does not currently have cross-framework mappings in our system. Check back as we continuously expand our mapping database.
How do I implement US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P)?
Start your US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P) compliance journey by running a self-assessment on our platform to identify your current compliance posture. Our AI advisory can answer specific questions about US Medicare Provider and Supplier Enrollment (42 CFR Part 424 Subpart P) requirements, and cross-framework mapping helps you leverage existing controls from other frameworks you may already comply with. Create a free account to access all 22 controls and track your progress.
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