Supplier Enrollment Update and Continued Medical Need Reminder

Published in Member Communities on February 06, 2025

Ronda Buhrmester, Sr. Director of Payer Relations and Reimbursement, shares updates on supplier enrollment and a reminder of continued medical need.

Supplier Enrollment Update

For suppliers that have billing privileges with CMS using a supplier transaction number (PTAN), maintaining enrollment is of high priority. Any disruptions with not maintaining a PTAN cause havoc, including disruptions with cash flow from Medicare with the possibility of a domino effect to Medicaid and other payers.

One of the key factors in maintaining a PTAN is updating the national provider enrollment (NPE) contractor of any changes. Common updates being submitted on the 855s/PECOS are related to a change to the business. Common changes include:

Change in ownership
Change of address
Change in store hours
Change in surety bond
Change in services/products being offered
Change in states of services being offered

Recently, the NPE council met with the NPE contractor that provided an update on an issue. If a state is being added to the business’ territory where services are going to be offered or adding a new product, the update to the 855s cannot be submitted until the state license or certification requirements are met first. If the application is submitted without having the license or any certifications attached, this delays the update causing the application to not process until the license or any certifications are processed by the state.

Basically, it will kick back to your company causing a resubmission all over again.

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Continued Medical Need Reminder

Once initial qualifications have been met for a DME item, ongoing medical need must be met. Depending on the type of item, such as supplies or equipment, the continued medical need can vary.

Generally, for items such as CPAP supplies and home oxygen therapy, ongoing medical need can be justified with a valid standard written order (SWO) within the preceding 12 months.

Oxygen therapy is unique because it’s considered a drug which is governed by the state’s Board of Pharmacy. For that reason, an annual order is required.

For DME items such a hospital bed or standard wheelchair, the need is met with documentation in the medical record. This does not mean a visit is required with the treating practitioner. The treating practitioner can make a note in the patient’s chart documenting the medical need and benefits of use.

For repairs to the equipment, the continued medical need can be completed with a valid SWO.

Bottom line, it is important to know the policy requirements in addition to setting up the billing software to notify staff to maintain continued medical need requirements.

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