Provider Enrollment and Revalidation Frequently Asked Questions
Questions are organized by the following topics:
1. What is provider revalidation?
Section 6401 of the Affordable Care Act (ACA) established a requirement for all enrolled providers and suppliers for Medicare and Medicaid to revalidate their enrollment information under new enrollment screening criteria. Currently enrolled providers are required to submit a revalidation application that applies new screening criteria to remain a MaineCare provider.
2. When will I need to revalidate my information with MaineCare?
The schedule is posted in the Revalidate as a Current Provider section of the MaineCare Provider Enrollment webpage.
Providers who have enrolled after January 17, 2017 must revalidate every five years - three years for DME providers - or at MaineCare Service's request. Newly enrolling providers are subject to these requirements as part of their initial enrollment.
3. Does revalidation apply to all providers, even out-of-state providers?
Yes. The provider revalidation process is a federal requirement that applies to all MaineCare providers, including those who offer service outside of Maine.
4. Why are there new screening and enrollment guidelines?
The Affordable Care Act (ACA) mandates new provider screening and enrollment requirements that state Medicaid agencies must implement to comply with the federal law. The requirements can be found in 42 CFR 455 Subpart E-Provider Screening and Enrollment.
These requirements apply to all providers who:
- Submit new applications
- Submit a maintenance case
The requirements also apply to rendering providers, service locations, and to Non-billing, Ordering, Prescribing, and Referring (NOPR) providers who are updating their current enrollment. For more detail about these requirements, see the Screening Requirements document.
5. Who is affected by the screening requirements?
The screening requirements apply to all new providers and existing providers who are adding a new service location or a new rendering provider. Non-billing, Ordering, Prescribing, or Referring (NOPR) providers are also be able to enroll with MaineCare to continue to prescribe, order, and refer services for MaineCare members.
6. Are non-medical service providers subject to screening?
All new providers who are enrolled with and bill MaineCare for services under the State Plan or a waiver must be screened by MaineCare.
7. How long are the cycles, and what is the cycle schedule?
Each cycle is open for a total of 60 days. There are a total of 13 cycles. Please visit the MaineCare Provider Enrollment webpage to view the revalidation cycle schedule.
8. How will I know which cycle I am in and when it is time to revalidate?
Cycle assignments ware posted to the MaineCareProvider Enrollment webpage. E-messages inform providers of the confirmed cycle scheduled dates. Sixty days prior to each cycle, letters are sent to the Pay To provider name and address, and again 30 days prior. Providers should not take any steps to revalidate until the revalidation date indicated in the letter. If you are enrolling as a new provider, you can begin that process at any time.
9. How do I revalidate with MaineCare?
You will receive a letter that will advise you on your exact cycle and time frame for revalidation. Revalidation will be done through your Trading Partner Account (TPA) account on the MIHMS Health PAS Online Portal. If you need further assistance about your revalidation, please see the Enrollment Checklists on the Health PAS Online Portal. If you need additional help, you can contact the Provider Services Call Center at: 1-866-690-5585, Option 7, TTY Users, dial 711 (Maine Relay).
10. Will paper applications be accepted?
No. You will be unable to submit paper enrollment applications for MaineCare to process. All enrollments and revalidations must be completed through your Trading Partner Account.
11. Can I submit paper copies of supporting documents to MaineCare?
Although paper applications will not be accepted, you will have the ability to submit supporting paper documents to MaineCare, such as licenses and certifications. This can be done in the following ways:
Upload: Upload documentation and attach to your enrollment application
Mail: MaineCare Provider Enrollment
PO Box 1024
Augusta, ME 04332-1024
12. Is a Trading Partner Account (TPA) optional?
No. All providers are required to create a TPA if they do not currently have one. If you have an existing TPA, you are not be required to create a new one.
13. I have never used the Health PAS Online Portal and do not have a TPA. Who can help?
For assistance with setting up your TPA, please see the Trading Partner Account Presentation. This will give you step-by-step instructions on how to register for your TPA. If you still need help, you can contact the Provider Services Call Center at: 1-866-690-5585, Option 7, TTY Users, dial 711 (Maine Relay).
14. Are Social Security Numbers (SSN) and Dates of Birth (DOB) required?
Yes. This applies to:
- New providers
- Revalidating providers
- New rendering providers
- Non-billing, Ordering, Prescribing, and Referring Providers (NOPRs) who will be required to enroll with MaineCare to continue to prescribe, order, and refer services for MaineCare members.
Providers are required to supply social security numbers and dates of birth for board members, managing employees, rendering providers, and any person with ownership or controlling interest of 5% or more in the disclosing entity. Providers ware also required to disclose managing employees. A managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operation of the provider or supplier, either under contract or through another arrangement, whether or not the individual is a W-2 employee of the provider or supplier.
The only exception is for Public School (PT87) Board Members: they are exempt from providing social security numbers or dates of birth on the applications, but is still required for managing employees.
15. What information is required for board members, managing employees, rendering providers, and persons with ownership or controlling interest of 5% or more in the disclosing entity?
Providers will be required to supply social security numbers and dates of birth for board members, managing employees, rendering providers, and persons with ownership or controlling interest of 5% or more in the disclosing entity.
16. What is a managing employee?
A managing employee is a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or directly or indirectly conducts the day-to-day operations of the provider or supplier.
17. Who is facilitating the screening process?
All screening will be conducted by MaineCare and MaineCare's contractors.
18. How often am I required to revalidate?
Depending on your provider type and specialty, you are required to revalidation every 3-5 years, or at MaineCare's request. Only DME providers are required to revalidate every 3 years.
19. What happens if I do not revalidate with MaineCare by my cycle deadline?
MaineCare may terminate the enrollment and/or suspend payment of claims for any provider who fails to revalidate by the end of their scheduled provider revalidation cycle; however, you will still have the ability to bill for services up to the date of termination.
20. What if I no longer wish to be a MaineCare provider?
If you do not plan on revalidating with MaineCare, please disenroll by logging into your Trading Partner Account (TPA) on the MIHMS Health PAS Online Portal and updating your current enrollment by selecting the Disenrollment option. You may also choose to disenroll specific service locations or rendering providers during the revalidation process regardless if you are currently enrolled with MaineCare.
21. What information and documentation is needed for the revalidation process?
There are several requirements for MaineCare's revalidation process. For more detail about these requirements, please see the updated Enrollment Checklists. If you need additional help, you can contact the Provider Services Call Center at: 1-866-690-5585, Option 7, TTY Users, dial 711.
22. How will I be notified that my application has been processed and what the decision is?
You will receive notification through email that your application is complete. Once a decision is made regarding your application, we will send a letter to the Pay-To provider through U.S. mail.
23. How will I know if my revalidation was successful, and will I receive revalidation results?
Providers who are successfully revalidated will receive a letter via U.S. mail.
24. What is a risk level and why is that important?
The federal government requires MaineCare to screen all re-enrolling providers based on a categorical risk level of "limited," "moderate," or "high." Providers will be assigned a risk level based on their provider type and specialty. By adding risk levels, MaineCare can tighten program integrity oversight on the "front end" through the enrollment process. A full listing of the categorical risk level criteria can be found in the Risk Category Assignments document.
25. What are the screening requirements for each risk level?
- Limited risk providers must meet federal and state rules and regulations, have their provider license verified (where applicable), and not be excluded from Medicaid or Medicare participation by federal and state databases. These databases include, but are not limited to: National Plan and Provider Enumeration System (NPPES), SSA Death Master File, and List of Excluded Individuals and Entities (LEIE).
- Moderate risk providers are subject to pre and post enrollment site visits in addition to the requirements for limited risk providers.
- High risk providers are subject to future criminal background checks of their owners in addition to the requirements for limited and moderate risk providers.
26. What risk levels require a site visit?
Site visits are conducted for those provider locations that are assigned a "moderate" or "high" risk level.
27. Is a site visit still required as part of the application process if I have recently had a site visit from another State of Maine Department?
Yes. The rule requires MaineCare to conduct site visits before and after enrollment to:
- Verify information contained within the MaineCare application
- Ensure that prospective providers meet enrollment requirements
- Verify that current providers remain operational while continuing to meet required provider standards.
Because these site visits will have a different purpose than existing site surveys performed by other agencies, MaineCare may collect different information during these visits for the purposes of complying with federal requirements.
28. What is a surety bond?
A surety bond is issued by an entity (the surety) guaranteeing that the Durable Medical Equipment (DME) provider or Home Health Agency (HHA) will fulfill an obligation or series of obligations to a third party (i.e. the MaineCare program). Surety bond firms review the organizational and financial integrity of a DME or HHA and agree to cover the MaineCare obligations, up to a set amount, for those agencies, according to certain guidelines. A surety bond will cover liabilities that occur when an agency does not repay funds it owes and allows the third party to recover its losses via the bond. For example, when an agency is found to have improperly billed for services that result in overpayment, the bond will allow MaineCare to recover that loss.
29. How do I know if I need to secure a surety bond?
Only Durable Medical Equipement (DME) providers and Home Health Agencies (HHA) are required to obtain surety bonds. A letter is sent to these provider types informing them of the need to secure a surety bond. DME are required to have a $50,000 surety bond per each service location. Home Health Agencies (HHA) are required to have a $50,000 surety bond or 15% of the annual amount paid to the HHA by MaineCare for the previous fiscal year, whichever is greater.
30. Why is an application fee required?
Section 455.460 of the Affordable Care Act (ACA) establishes a requirement for Medicare and Medicaid to collect an application fee for each "institutional provider of medical or other items or services and suppliers." The application fee is imposed on institutional providers that are newly enrolling or adding new practice locations. This fee varies from year to year, based on adjustments made pursuant to the Consumer Price Index for Urban Areas (CPI-U), and as determined by the Centers for Medicare and Medicaid Services (CMS).
31. How much is the application fee?
Each year CMS will publish the application fee via the Federal Register 60 days prior to the new CY. The fee for CY 2019 is $586.00.
32. What provider types and specialties are required to pay the application fee?
See the Application Fee Spreadsheet for more detail about provider types that will be required to pay an application fee for each service location.
33. When am I subject to paying the application fee?
Provider types who are required to pay the application fee and are submitting applications for the following reasons are required to pay the fee:
- Initial Enrollment
- Adding a practice or service location
34. If I have already paid an application fee to Medicare or another state's Medicaid or Children's Health Insurance Program (CHIP) within the last twelve months, do I need to pay another fee to MaineCare?
No. Service locations that have enrolled or revalidated with Medicare, MaineCare, or another state's Medicaid or CHIP program, and have been approved, are not required to pay the fee to MaineCare. Newly affiliated service locations that are not enrolled or revalidated with Medicare, or another state's Medicaid or CHIP program, will be required to pay the application fee.
35. What if I think I am due a refund of my application fee?
Please contact Provider Services at 1-866-690-5585, Option 7.
36. What are the refund policies regarding the application fee?
Providers who receive a hardship exemption from the Centers for Medicare and Medicaid Services (CMS) must provide the CMS letter as proof of the exemption within 30 days of receipt of the letter to obtain a refund.
37. Do non-profit facilities have to pay the application fee?
Yes. MaineCare is required to collect an enrollment application fee for providers regardless of non-profit status.
38. Is this fee tax deductible?
Please refer to your accountant or tax professional.
39. Who is exempt from paying the application fee?
- Individual physician and non-physician practitioners (including those who are part of a group or clinic)
- Service locations that were enrolled with Medicare in the last 12 months, using the new federal regulations outlined in Title 42 Code of Federal Regulations, (CFR) 455.460
- Providers who have enrolled in another state's Medicaid or Children's Health Insurance Program if the Department has determined that the screening procedures in the state in which the provider is enrolled are at least as comprehensive as the screening procedures required for enrollment in MaineCare.
40. Do I have to enroll and pay an application fee for each service location?
Application fees are assessed per application, not per service location.
41. How do I pay the application fee?
The application fee is accepted via debit or credit card during the enrollment or revalidation process in your Trading Partner Account.
Training and Other Resources
42. Will MaineCare offer training on provider revalidation?
Yes. MaineCare has provider training available through webinars. There is training available prior to the implementation of each cycle. An e-message ise sent prior to each cycle to inform you when the training calendar has been updated.
43. What is the best way to stay informed?
In order to remain informed about provider enrollment and revalidation, please subscribe to our provider revalidation e-message service. The e-message service is an automated email messaging tool that we will use as the main communication method for provider enrollment, revalidation, and associated changes. To ensure you receive important updates, please sign up for the MaineCare e-message service and follow these steps:
- Enter your email address in the text box and select "Submit."
- Confirm your email address by entering it in the text box.
- Add a password if you wish (optional).
- Select "Submit."
- Click on the blue link at the bottom that says "Add Subscriptions."
- Scroll down to the section for the "Office of MaineCare Services" and check the box for "Provider Revalidation."
- Scroll to the bottom of the page and click on "Submit."
44. Where can I find more information about the ACA and provider revalidation?
The following resources are available:
- MaineCare's Provider Enrollment webpage
- Centers For Medicare and Medicaid Services Revalidations Resource webpage
- Providers may contact MaineCare by emailing the MaineCare Revalidation email box at: MaineCareACARevalidation@MolinaHealthcare.com
- Contact the Provider Services Call Center at: 1-866-690-5585, Option 7, TTY Users, dial 711 (Maine Relay).