Centers for Medicare & Medicaid Services (CMS) released several pieces of Medicare provider enrollment guidance this spring, both emphasizing current policy and requirements as well as providing guidance and clarification relating to provider enrollment practices and forms. In particular, CMS reminded Medicare providers of the sanctions associated with failure to disclose their “managing employees” and updated its sub-regulatory guidance to clarify that Medicare providers’ legal business name as reported to CMS must very closely match what is listed on its IRS and NPI documentation.
In its Medicare Learning Network newsletter released on April 3, 2025, CMS reiterated Medicare enrollment requirements for providers and suppliers to report managing employees or face enrollment deactivation. CMS specified that managing employees are “general managers, business managers, administrators, directors, or other individuals who exercise operational or managerial control or directly or indirectly conduct day-to-day operations.” Roles that typically qualify as “managing employees,” per CMS, are Chief Executive Officer, Chief Operating Officer, Chief Financial Officer, Compliance Officer, Regional Manager, Clinical Manager, Operations Manager, Care Coordination Manager, Location Manager, Administration Manager, Compliance Director and Clinical Director. This guidance is a reminder to providers and suppliers to ensure the appropriate individuals are listed on its enrollment records as well as to continue to update enrollment records as individuals holding managerial positions change within an organization.
CMS also recently updated the Medicare Program Integrity Manual, Chapter 10, through Transmittal 13062. The updates became effective April 11, 2025.
Of note, CMS made several clarifications related to legal business name matches between provider enrollment systems (i.e., NPPES and PECOS) and a provider or supplier’s IRS CP-575. CMS’s general rule is that the legal business name must match between the IRS CP-575 as well as NPPES/PECOS. Deviations in legal business names across these sources can cause issues for providers and suppliers, particularly when punctuation, special characters or common words are involved. CMS addresses these situations by providing flexibility specifying cases where a Medicare Administrative Contractor (MAC) may accept certain mismatches.
- CMS permits the MAC to accept a legal business name mismatch between the CP575 and NPPES/PECOS if there is no more than one punctuation/character discrepancy between the legal business name as listed on the CP575 and NPPES/PECOS and if the MAC believes based on the data and documentation furnished on and with the application that the legal business name listed on the CP575 and NPPES/PECOS belong to the same provider.
- CMS also clarifies its stance in instances where certain common words may be present on the CP-575 but not in PECOS/NPPES or vice versa (for example, “the”, “a”, “to”, “of”, “and”, “in”, “for”, “as”, “you” and “at”). CMS permits the MAC to accept a legal business name mismatch between the CP575 and NPPES/PECOS if there is no more than one discrepancy between the two LBNs involving any of these 10 words, and if the MAC believes based on the data and documentation furnished on and with the application that the legal business name listed on the CP575 and NPPES/PECOS belong to the same provider.
- A provider may have one discrepancy involving punctuation/special characters and one involving a common word, but no more than one of either. A discrepancy involving a common word only applies to the 10 words above, however, the discrepancy can be between one of the common words and a non-common word (for example, “of” and “with”).
Additional updates included in the transmittal mainly involve clarifying requirements involving provider enrollment forms and approval letter templates. A summary of those updates can be found below.
- CMS has included instructions clarifying that the account holder’s street address on the CMS 588 EFT Form can be the provider or supplier’s practice location address, correspondence address, special payment address or chain home office address for those providers reporting a chain home office on the CMS 855A.
- CMS also provides guidance indicating an already-enrolled supplier is not required to submit a new CMS-460 if they are enrolling in another state or MAC jurisdiction. A copy of the already-enrolled supplier’s CMS-460 must be provided to the new contractor.
- CMS has included additional language in its Part A/B Certified Provider and Supplier Approval Letter Templates clarifying that if the provider/supplier has elected to use a CMS approved accreditation organization (AO), the AO will conduct the survey and recommend approval to the State Agency to finalize certification.