Provider Enrollment and Revalidation

The following topics may help with the enrollment process:

*See our Provider Enrollment and Revalidation Frequently Asked Questions webpage for additional information.

Background

Section 6401 of the Affordable Care Act (ACA) established additional screening requirements for all Medicare and Medicaid providers. All provider applications, including initial enrollments and changes such as the addition of new service or practice locations, new rendering providers, and/or Non-billing, Ordering, Prescribing, or Referring (NOPR) providers will have new requirements as of January 17, 2017. See the New Enrollment Requirements document for detailed information.

All enrolled providers, regardless of provider type, must revalidation enrollment information under new screening criteria at least every five years - three years for Durable Medical Equipment (DME) providers - or upon MaineCare Services' request.

New Screening Requirements

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 a new application
  • Reactivate an application
  • Submit a revalidation application
  • Perform maintenance

The requirements also apply to service locations, rendering providers, and Non-billing, Ordering, Prescribing, and Referring (NOPR) providers who are updating their current enrollment.

For more detail about these requirements, see the New Screening Requirements document.

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Non-billing, Ordering, Prescribing, and Referring (NOPR) Providers

Providers who bill MaineCare will be required to provide the NPI of an enrolled MaineCare practitioner who is ordering, prescribing, or referring on their claims to avoid their claims being denied in the future. These practitioners are also known as NOPRs and they may enroll independently or as part of an organization that is enrolled in MaineCare. If you belong to a group or are employed by a group, please discuss your enrollment with your group or organization.

NOPR providers who are not enrolled with MaineCare will need to enroll to continue to prescribe, order, and refer services for MaineCare members. This new requirement also means that providers such as Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs), Indian Health Services (IHS), and hospitals will need to enroll their NOPRs or the associated claims will not be paid. Organizations currently enrolled with MaineCare will have the opportunity to enroll NOPR providers during their assigned revalidation cycle.

To view a list of organization provider types that may have NOPR providers, please see the NOPR Organizations (PDF) document.

Provider Risk Category Assignments

The Affordable Care Act (ACA) mandates that state Medicaid agencies establish categorical risk levels of limited, moderate, or high for initial applications or new practice locations. States must, at a minimum, use the same categorical risk levels that apply to Medicare. For provider types that are not recognized by Medicare, states must assess the appropriate categorical risk level by provider type and subsequently follow the applicable screening requirements for that categorical risk level.

MaineCare has implemented risk category assignments of limited, moderate, and high for all provider types. A full listing of the categorical risk level criteria can be found in the Risk Category Assignments document.

For additional information regarding the Centers for Medicare and Medicaid Services' (CMS) risk category assignments, please see CMS's Frequently Asked Questions.

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Application Fees

Section 455.460 of the Affordable Care Act (ACA) establishes a requirement for Medicare to collect an application fee for each "institutional provider of medical or other items or services and suppliers." The application fee is to be imposed on institutional providers that are newly enrolling, revalidating, or adding new practice locations. This fee will vary from year to year, based on adjustments made pursuant to the Consumer Price Index for Urban Areas (CPI-U), and as determined by CMS.

An application fee of $569.00 is required for specified provider types beginning in January 2018. Providers are required to pay their application fee by credit or debit card at the time of application submission. Providers are not required to pay the application fee to MaineCare if they have already paid the fee to MaineCare, Medicare, or another state Medicaid or Children's Health Insurance Program (CHIP).

See the Application Fee Spreadsheet for more detail about provider types that will be required to pay an application fee for each new enrollment, maintenance, or revalidation application. This spreadsheet was updated on April 18, 2018.

Home Health Agencies (HHA) and Durable Medical Equipment (DME): Surety Bonds

HHA and DME providers are required to provide surety bonds when enrolling as a new provider, revalidating, or adding a new service location. The surety bond must name the DME or HHA provider as Principal, MaineCare as the Obligee, and the surety company as Surety. The surety's name, street address or post office box number, city, state, and zip code must also be included.

The bond must contain appropriate guarantees for payment to MaineCare to cover uncollected overpayments and liability for unpaid claims that are identified during the term of the bond, regardless of when the overpayments took place. The bond must be in the amount of:

  • HHA providers: The greater of $50,000 or 15% of Annual Medicaid Payment based on previous fiscal year. 
  • DME providers: An amount of no less than $50,000 per National Provider Identifier (NPI). An additional $50,000 bond is required for each adverse legal action you've had within the past 10 years.

More detailed information will be sent to all HHAs and DME providers at a future date.

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Updates to MIHMS Health PAS Online Portal

The Health PAS Online Portal upgrades were completed on January 17, 2017 to support the new screening requirements related to Section 6401 of the Affordable Care Act (ACA). The upgrades included enhancements and improvements to the portal's layout and navigation, but the overall functionality has not changed. The portal upgrades were necessary to prepare the system for the new screening requirements and provider revalidation.
The following enhancements were implemented:

  • The requirement for all providers to obtain a Trading Partner Account (TPA)
  • The ability to send secure emails to the MaineCare call center from your TPA
  • A redesigned homepage using a tab layout
  • Improved navigational changes for accessing information and resources
  • The ability to view letters online
  • Access to a new Enrollment Summary Report

See the Trading Partner Account Presentation for more detail about the portal enhancements.

Revalidate as a Current Provider

MaineCare will require providers enrolled prior to January 17, 2017 to submit a MaineCare enrollment revalidation application using the Health PAS Online Portal during one of thirteen sixty-day cycles. Please view the Provider Revalidation Cycle Assignment Report to identify the cycle to which you have been assigned. This report was updated on November 1, 2018.

The revalidation application will be available during your assigned sixty-day cycle. Paper applications are no longer accepted by MaineCare. Providers who do not submit a revalidation application within their assigned cycle will be terminated from the MaineCare program. Failure to meet this deadline will impact claims being processed for payment.

The revalidation cycle dates are as follows:

  • Cycle 1:  Summer 2017
  • Cycle 2:  Fall 2017
  • Cycle 3:  Spring 2018
  • Cycle 4:  Summer 2018
  • Cycle 5:  Summer/Fall 2018
  • Cycle 6:  Fall/Winter 2018
  • Cycle 7:  Winter 2018
  • Cycle 8:   Spring 2019
  • Cycle 9:   Spring/Summer 2019
  • Cycle 10:  Summer 2019
  • Cycle 11:  Fall 2019
  • Cycle 12:  Winter 2019
  • Cycle 13:  Spring 2020

These cycle dates are subject to change.

You will receive a letter 60 days prior to your cycle start date. You will also receive a second reminder letter 30 days prior to this date. You should not take any steps to revalidate until the beginning of your cycle date, as indicated in your letter.

Please see the sample letters below for more information:

You may download your current Enrollment report from the Provider Enrollment Application to assist you. MaineCare also recommends that you review the updated Enrollment Checklist prior to submitting your revalidation application. We also suggest you check out the Revalidation Tips document to prevent application processing delays.

E-Message Sign Up

In order to remain informed about provider enrollment, please subscribe to our 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 updates and associated changes. To ensure you receive important updates, please sign up for MaineCare's e-message service.

Please follow these steps to sign up:

  1. Enter your email address in the text box and select “Submit.”
  2. Confirm your email address by entering it in the text box.
  3. Add a password if you wish (optional).
  4. Select “Submit.”
  5. Click on the blue link at the bottom that says “Add Subscriptions.”
  6. Scroll down to the section for the “Office of MaineCare Services” and check the box for “Provider Enrollment.”
  7. Scroll to the bottom of the page and click on “Submit.”

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Training Opportunities

For the schedule of trainings about revalidating with MaineCare, see the Event Calendar on the Health PAS Online Portal. MaineCare will be conducting training webinars to assist providers prior to each cycle. These webinars will offer an opportunity for you to ask questions and for MaineCare to conduct an overview of the revalidation process and provide key information and resources. MaineCare will send an e-message with the training schedule prior to the beginning of each cycle.

We will offer multiple free trainings through the Learning Management System (LMS) on a variety of topics related to enrollment. The online webinar trainings will be scheduled through each of the thirteen revalidation cycles to offer a number of training opportunities. 

If you have not registered with the LMS, see the First Time User Guide for assistance. To access the guide, go to the Health PAS Online Portal and log into your Trading Partner Account (TPA). Click on the section called "Trading Partner User Training" and you will see the link to the LMS First Time User Guide.

For assistance with registering or any other training related topic, please email the Medicaid Training Center.

Other Resources

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