Medicare Program Integrity Manual Chapter 10 Guide

Name: Medicare Program Integrity Manual (Pub. 100-08)
Creator: Centers for Medicare & Medicaid Services
License: https://www.usa.gov/government-works

TL;DR

Chapter 10 of the Medicare Program Integrity Manual is CMS's provider and supplier enrollment manual. It explains which form each provider type uses, how MACs process applications in PECOS, how enrollment effective dates and retrospective billing work, reporting changes, revalidation every five years (three for DMEPOS suppliers), reassignment of benefits, risk-based screening and application fees, and the grounds and procedures for denials, deactivations and revocations.

Chapter 10 at a glance

Current revision: Rev. 13717; Issued July 8, 2026
Effective: January 1, 2026; Implemented August 7, 2026
Sections: 235; 7 top-level sections
Official PDF: 985 pages; pim83c10.pdf
Transmittals in history: 126; Listed at the end of the chapter
Monthly searches: 50; Google Ads, US, October 2026

What chapter 10 governs for billing

Sections 10.1 to 10.3 cover who enrolls and how. Certified providers and certified suppliers such as hospitals, home health agencies and FQHCs use the Form CMS-855A, clinics, group practices and other suppliers the CMS-855B, individual physicians and nonphysician practitioners the CMS-855I, and DMEPOS suppliers the CMS-855S, with the CMS-20134 for Medicare Diabetes Prevention Program suppliers (10.2 and 10.3). Section 10.3.1.4 notes that reassignment of benefits to a group or other entity is now made on the CMS-855I, because the Form CMS-855R has been discontinued. Applications are processed in PECOS, and section 10.4.1 lists the contractor's general processing functions.

Section 10.6.2 sets effective dates. For physicians, practitioners and many other suppliers, billing privileges start on the later of the date the supplier filed an enrollment application that was subsequently approved (the date the contractor received it) or the date it first began furnishing services at a new practice location, and retrospective billing reaches back 30 days before that date, or 90 days after a presidentially declared disaster. Changes must be reported on time: practice location changes and adverse legal actions within 30 days, other changes within the timeframes in 10.4.4. Every enrolled provider and supplier revalidates every five years, DMEPOS suppliers every three (10.4.5), when the contractor sends a revalidation notice.

The rest of the chapter covers screening and enforcement: risk-based screening at limited, moderate or high levels with site visits and fingerprinting for higher-risk categories (10.6.15 and 10.6.20), application fees for institutional providers (10.6.14), opt-out (10.6.12), ordering and certifying suppliers (10.6.13), denials (10.4.2), revocations and the re-enrollment bar (10.4.7), deactivations, which stop billing privileges without a sanction, for example after a period with no claims or a missed revalidation (10.4.8), the newer stay of enrollment (10.4.9), the appeals process (10.6.18) and the model letters contractors send (10.7).

Sections billing teams use most

Section numbers and headings are CMS's; the notes are ours. Each section number opens the official chapter 10 PDF at the page where that section starts.

Key sections of Medicare Program Integrity Manual Chapter 10: Medicare Enrollment
Section	CMS heading	Why it matters
10.1.4	General Overview of Medicare Enrollment Application Forms	Overview of the Medicare enrollment application forms.
10.3.1.3	Form CMS-855I – Medicare Enrollment Application for Physicians and Non-Physician Practitioners	Form CMS-855I for physicians and nonphysician practitioners.
10.3.1.4	Reassignment of Medicare Benefits Via the Form CMS-855I	Reassignment of benefits on the CMS-855I after the CMS-855R was discontinued.
10.4.5	Revalidations	Revalidation every five years, three for DMEPOS suppliers.
10.4.7	Revocations	Revocations of billing privileges and the re-enrollment bar.
10.4.8	Deactivations	Deactivations and how billing privileges are reactivated.
10.6.2	Establishing Effective Dates	Establishing effective dates and retrospective billing.

How chapter 10 shows up on claims and denials

Enrollment problems surface on claims as provider-eligibility denials. A claim for a date of service before the enrollment effective date, after a deactivation or revocation, or at a practice location that is not enrolled is denied with reason code B7, the provider was not certified or eligible to be paid on that date. NPI and enrollment mismatches return reason code 208, and a rendering practitioner who is not enrolled or not reassigned to the billing group triggers remark N290.

These denials are fixed in enrollment, not through claim appeals. A deactivated provider must update or revalidate its enrollment to reactivate, and dates of service outside the effective date and the retrospective billing window generally cannot be paid. Because ordering and certifying practitioners must also be enrolled or validly opted out, DMEPOS, laboratory, imaging and home health claims can deny for the ordering practitioner's enrollment status as well.

Codes you are likely to see on the remittance when a claim runs into this chapter's rules. The code pages explain each code's meaning, root causes and the usual fix.

Remittance codes associated with Medicare Program Integrity Manual Chapter 10: Medicare Enrollment
Code	Type	When it appears
B7	Claim adjustment reason code	Provider not certified or eligible to be paid for this service on this date.
208	Claim adjustment reason code	National Provider Identifier not matched to an enrolled provider.
N290	Remark code	Missing or invalid rendering provider identifier.
16	Claim adjustment reason code	Enrollment-related information missing from the claim.

Current revision and recent transmittals

The chapter PDF posted on cms.gov is current through Rev. 13717, issued July 8, 2026, effective January 1, 2026, implemented August 7, 2026 (change request 14220). That revision changed sections 10.1.1 (Definitions), 10.2.5.1 (DMEPOS Supplier Accreditation), 10.4.1.4.3 (Rejections), 10.4.2.2 (Denial Reasons), 10.4.4 (Changes of Information), 10.4.7.2 (Revocation Effective Dates), 10.4.7.3 (Revocation Reasons), 10.4.8 (Deactivations). Its subject line reads: “Incorporation of Recent Provider Enrollment Regulatory Changes into Chapter 10 of CMS Publication (Pub.) 100-08 - Calendar Year (CY) 2026 Home Health Prospective Payment System (HH PPS) Final Rule”.

The newest rows of the transmittal history printed at the end of the chapter (126 revisions in all). Rows whose subject could not be read reliably from the PDF table are left out; the PDF has the complete list.

Newest transmittals for Medicare Program Integrity Manual Chapter 10: Medicare Enrollment
Revision	Issued	Subject	CR
R13717CP	July 8, 2026	Incorporation of Recent Provider Enrollment Regulatory Changes into Chapter 10 of CMS Publication (Pub.) 100-08 - Calendar Year (CY) 2026 Home Health Prospective Payment System (HH PPS) Final Rule	14220
R13355PI	August 13, 2025	Removal of Gender References from CMS Publication (Pub.) 100-08, Chapter 10	13981
R13062PI	March 13, 2025	Sixteenth General Update to Provider Enrollment Instructions in Chapter 10 of CMS Publication 100-08	13848
R12796PI	August 15, 2024	Fourteenth General Update to Provider Enrollment Instructions in Chapter 10 of CMS Publication (Pub.) 100-08	13725
R12717PI	July 18, 2024	Thirteenth General Update to Provider Enrollment Instructions in Chapter 10 of CMS Publication (Pub.) 100-08	13683
R12639PI	May 16, 2024	Twelfth General Update to Provider Enrollment Instructions in Chapter 10 of CMS Publication (Pub.) 100-08	13551

Sections ordered by the date in the revision note printed under each heading.

Most recently revised sections of Medicare Program Integrity Manual Chapter 10: Medicare Enrollment
Section	Heading	Revision
10.1.1	Definitions	Rev. 13717, July 8, 2026; effective January 1, 2026
10.2.5.1	DMEPOS Supplier Accreditation	Rev. 13717, July 8, 2026; effective January 1, 2026
10.4.1.4.3	Rejections	Rev. 13717, July 8, 2026; effective January 1, 2026
10.4.2.2	Denial Reasons	Rev. 13717, July 8, 2026; effective January 1, 2026
10.4.4	Changes of Information	Rev. 13717, July 8, 2026; effective January 1, 2026
10.4.7.2	Revocation Effective Dates	Rev. 13717, July 8, 2026; effective January 1, 2026
10.4.7.3	Revocation Reasons	Rev. 13717, July 8, 2026; effective January 1, 2026
10.4.8	Deactivations	Rev. 13717, July 8, 2026; effective January 1, 2026

Section index

Every section in the chapter's table of contents, grouped under its top-level heading, with the PDF page where it starts. Open a heading to see its subsections.

10.1 Introduction to Medicare Provider Enrollment · p. 8 · 4 subsections

Open section 10.1 in the PDF
10.1.1 Definitions · p. 8
10.1.2 Enrolling to Receive Medicare Payment · p. 14
10.1.3 General Summary of Process to Enroll in Medicare · p. 15
10.1.4 General Overview of Medicare Enrollment Application Forms · p. 16

10.2 Provider and Supplier Types/Services · p. 18 · 61 subsections

Open section 10.2 in the PDF
10.2.1 Certified Providers and Certified Suppliers That Enroll Via the Form CMS-855A · p. 18
10.2.1.1 Community Mental Health Centers (CMHCs) · p. 18
10.2.1.2 Comprehensive Outpatient Rehabilitation Facilities (CORFs) · p. 25
10.2.1.3 End-Stage Renal Disease Facilities (ESRDs) · p. 29
10.2.1.4 Federally Qualified Health Centers (FQHCs) · p. 36
10.2.1.5 Histocompatibility Laboratories · p. 48
10.2.1.6 Home Health Agencies (HHAs) · p. 48
10.2.1.6.1 Reserved for Future Use · p. 53
10.2.1.6.2 HHA Capitalization · p. 53
10.2.1.7 Hospices · p. 56
10.2.1.8 Hospitals and Hospital Units · p. 60
10.2.1.8.1 Rural Emergency Hospitals (REHs) · p. 66
10.2.1.8.1.1 Indian Health Service (IHS) Rural Emergency Hospital Hospital (REH) · p. 71
10.2.1.9 Indian Health Services (IHS) Facilities · p. 71
10.2.1.10 Organ Procurement Organizations (OPOs) · p. 73
10.2.1.11 Outpatient Physical Therapy/Outpatient Speech Pathology · p. 74
10.2.1.12 Religious Non-Medical Health Care Institutions (RNHCIs) · p. 78
10.2.1.13 Rural Health Clinics (RHCs) · p. 80
10.2.1.14 Skilled Nursing Facilities (SNFs) · p. 81
10.2.2 Suppliers That Enroll Via the Form CMS-855B · p. 85
10.2.2.1 Ambulatory Surgical Centers (ASCs) · p. 85
10.2.2.2 Home Infusion Therapy Suppliers · p. 89
10.2.2.3 Independent Clinical Laboratory Improvement Act (CLIA) Labs · p. 91
10.2.2.4 Independent Diagnostic Testing Facilities (IDTFs) · p. 94
10.2.2.5 Intensive Cardiac Rehabilitation (ICR) · p. 108
10.2.2.6 Mammography Screening Centers (MSCs) · p. 109
10.2.2.7 Pharmacies · p. 111
10.2.2.8 Portable X-Ray Suppliers (PXRSs) · p. 111
10.2.2.9 Radiation Therapy Centers (RTCs) · p. 115
10.2.2.10 Suppliers of Ambulance Services · p. 116
10.2.3 Individual Practitioners Who Enroll Via the Form CMS-855I · p. 121
10.2.3.1 Anesthesiology Assistants · p. 122
10.2.3.2 Audiologists · p. 122
10.2.3.3 Certified Nurse-Midwives · p. 123
10.2.3.4 Certified Registered Nurse Anesthetists · p. 123
10.2.3.5 Clinical Nurse Specialists · p. 124
10.2.3.6 Clinical Psychologists · p. 125
10.2.3.7 Clinical Social Workers · p. 125
10.2.3.8 Nurse Practitioners · p. 126
10.2.3.9 Occupational Therapists in Private Practice · p. 127
10.2.3.10 Physical Therapists in Private Practice · p. 129
10.2.3.11 Physicians · p. 134
10.2.3.12 Physician Assistants · p. 134
10.2.3.13 Psychologists Practicing Independently · p. 136
10.2.3.14 Registered Dietitians/Nutrition Professionals · p. 137
10.2.3.15 Speech Language Pathologists in Private Practice · p. 138
10.2.3.16 Manufacturers of Replacement Parts/Supplies for Prosthetic Implants or Implantable Durable Medical Equipment (DME) Surgically Inserted at an Ambulatory Surgical Center (ASC) · p. 138
10.2.3.17 Marriage and Family Therapists · p. 139
10.2.3.18 Mental Health Counselors · p. 142
10.2.4 Other Medicare Part B Services · p. 145
10.2.5 Suppliers That Enroll Via the Form CMS-855S · p. 147
10.2.5.1 DMEPOS Supplier Accreditation · p. 147
10.2.5.2 Fraud Level Indicators for DMEPOS Suppliers - Development and Use · p. 148
10.2.5.3 Surety Bonds · p. 151
10.2.5.3.1 Basics of the Surety Bond Requirement · p. 151
10.2.5.3.2 Claims against Surety Bonds · p. 154
10.2.5.4 Indian Health Services (IHS) Facilities' Enrollment as DMEPOS Suppliers · p. 166
10.2.5.5 Pharmacy Enrollment as a DMEPOS Supplier – Accreditation · p. 167
10.2.6 Medicare Diabetes Prevention Program (MDPP) Suppliers · p. 169
10.2.7 Opioid Treatment Programs · p. 171
10.2.8 Providers/Suppliers Not Eligible to Enroll · p. 182

10.3 Medicare Enrollment Forms – Information, Processing, and PECOS 2.0 · p. 183 · 63 subsections

Open section 10.3 in the PDF
10.3.1 CMS-855 Series Enrollment Forms: Information and Processing · p. 200
10.3.1.1 Form CMS-855A – Medicare Enrollment Application for Institutional Providers · p. 200
10.3.1.1.1 Section 1 (Basic Information) - Form CMS-855A · p. 201
10.3.1.1.2 Section 2 (Identifying Information) - Form CMS-855A · p. 201
10.3.1.1.3 Section 3 (Final Adverse Legal Actions/Convictions) - Form CMS-855A · p. 203
10.3.1.1.4 Section 4 (Practice Location Information) - Form CMS-855A · p. 203
10.3.1.1.5 Sections 5 and 6 (Ownership Interest and/or Managing Control Information) - Form CMS-855A · p. 207
10.3.1.1.6 Section 7 (Chain Home Office Information) - Form CMS-855A · p. 207
10.3.1.1.7 Section 8 (Billing Agency Information) - Form CMS-855A · p. 209
10.3.1.1.8 Section 12 (Special Requirements for Home Health Agencies) - Form CMS-855A · p. 209
10.3.1.1.9 Sections 13 and 14 (Contact Person and Penalties for Falsifying Information) - Form CMS-855A · p. 210
10.3.1.1.10 Certification Statement - Form CMS-855A · p. 210
10.3.1.1.11 Section 15 (Authorized Officials) - Form CMS-855A · p. 212
10.3.1.1.12 Section 16 (Delegated Officials) - Form CMS-855A · p. 215
10.3.1.1.13 Additional Form CMS-855A Processing Information · p. 217
10.3.1.1.14 Form CMS-855A Processing Alternatives · p. 219
10.3.1.2 Form CMS-855B –Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers · p. 221
10.3.1.2.1 Section 1 (Basic Information) - Form CMS-855B · p. 221
10.3.1.2.2 Section 2 (Identifying Information) - Form CMS-855B · p. 222
10.3.1.2.3 Section 3 (Final Adverse Legal Actions/Convictions) - Form CMS-855B · p. 225
10.3.1.2.4 Section 4 (Practice Location Information) – Form CMS-855B · p. 225
10.3.1.2.5 Sections 5 and 6 (Ownership Interest and/or Managing Control Information) - Form CMS-855B · p. 228
10.3.1.2.6 Sections 8, 13, and 14 (Billing Agencies, Contact Persons, and Penalties for Falsifying Information) - Form CMS-855B · p. 229
10.3.1.2.7 Certification Statement - Form CMS-855B · p. 229
10.3.1.2.8 Section 15 (Authorized Officials) - Form CMS-855B · p. 232
10.3.1.2.9 Section 16 (Delegated Officials) - Form CMS-855B · p. 234
10.3.1.2.10 Additional Form CMS-855B Processing Information · p. 236
10.3.1.3 Form CMS-855I – Medicare Enrollment Application for Physicians and Non-Physician Practitioners · p. 239
10.3.1.3.1 Section 1 (Basic Information) – Form CMS-855I · p. 239
10.3.1.3.2 Section 2 (Personal Identifying Information) – Form CMS-855I · p. 240
10.3.1.3.3 Section 3 (Final Adverse Legal Actions/Convictions) - Form CMS-855I · p. 244
10.3.1.3.4 Section 4 (Business Information) - Form CMS-855I · p. 244
10.3.1.3.5 Sections 6, 8, 12, 13, and 14 - Form CMS-855I · p. 248
10.3.1.3.6 Section 15 (Certification Statement) - Form CMS-855I 10.3.1.3.7/Additional Processing Information and Alternatives – Form CMS-855I · p. 249
10.3.1.4 Reassignment of Medicare Benefits Via the Form CMS-855I · p. 254
10.3.1.5 Form CMS-855O – Medicare Enrollment Application for Eligible Ordering and Certifying Physicians, and other Eligible Professionals · p. 260
10.3.1.5.1 Sections 1 through 7 of the Form CMS-855O · p. 260
10.3.1.5.2 Section 8 (Certification Statement) - Form CMS-855O · p. 262
10.3.1.5.3 Form CMS-855O Initial Applications and Change Requests · p. 265
10.3.1.5.4 Form CMS-855O Processing Alternatives and Miscellaneous Policies · p. 268
10.3.1.5.5 Form CMS-855O Revocations · p. 271
10.3.1.6 Form CMS-855S – Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers · p. 272
10.3.1.6.1 Sections 1 through 13 – Form CMS-855S · p. 272
10.3.1.6.2 Authorized and Delegated Officials – Form CMS-855S · p. 274
10.3.1.6.3 Additional Processing Information and Alternatives for Form CMS-855S · p. 276
10.3.2 CMS-20134 – Enrollment Form: Information and Processing · p. 277
10.3.2.1 CMS-20134 (Section 1 - Basic Information) · p. 278
10.3.2.2 CMS-20134 (Section 2 - Identifying Information) · p. 279
10.3.2.3 CMS-20134 (Section 3 - Final Adverse Legal Actions/Convictions) · p. 280
10.3.2.4 CMS-20134 (Section 4 - MDPP Location Information) · p. 280
10.3.2.5 CMS-20134 (Sections 5 & 6 - Owning and Managing Organizations and Individuals) · p. 285
10.3.2.6 Reserved for Future Use · p. 285
10.3.2.7 CMS-20134 (Section 7 - Coach Roster) · p. 285
10.3.2.8 CMS-20134 (Section 8 - Billing Agency Information) · p. 288
10.3.2.9 CMS-20134 (Section 13 - Contact Person) · p. 288
10.3.2.10 CMS-20134 (Section 14 - Penalties for Falsifying Information) · p. 289
10.3.2.11 CMS-20134 (Section 15 - Certification Statement and Authorized Officials) · p. 289
10.3.2.12 CMS-20134 (Section 16 - Delegated Officials) · p. 293
10.3.2.13 CMS-20134 (Section 17 - Supporting Documents) · p. 295
10.3.2.14 Additional Form CMS-20134 Processing Information and Alternatives · p. 295
10.3.3 Other Enrollment Forms: Information and Processing · p. 297
10.3.3.1 Form CMS-588 – Electronic Funds Transfer (EFT) Authorization Agreement · p. 297
10.3.3.2 Form CMS-460 – Medicare Participating Physician or Supplier Agreement · p. 301

10.4 Medicare Enrollment: Contractor Processing Duties · p. 302 · 36 subsections

Open section 10.4 in the PDF
10.4.1 General Processing Functions · p. 302
10.4.1.1 Overview of the Process · p. 302
10.4.1.2 Receipt of Application · p. 303
10.4.1.3 Review of Application · p. 304
10.4.1.3.1 Initial Steps of Review of Application · p. 304
10.4.1.3.2 Data Verification · p. 306
10.4.1.3.3 Requesting Missing/Clarifying Data/Documentation (Development) · p. 308
10.4.1.3.4 Receiving Missing/Clarifying Data/Documentation (Response to Development) · p. 311
10.4.1.3.5 Provider/Supplier Fails to Submit Requested Data/Documentation · p. 313
10.4.1.4 Application Disposition · p. 313
10.4.1.4.1 Approvals · p. 314
10.4.1.4.2 Returns · p. 316
10.4.1.4.3 Rejections · p. 319
10.4.2 Denials · p. 323
10.4.2.1 Denials – General Principles · p. 324
10.4.2.2 Denial Reasons · p. 326
10.4.2.3 Additional Denial Policies · p. 335
10.4.2.3.4 Denial Based on Survey Failure · p. 337
10.4.3 Voluntary and Involuntary Terminations · p. 339
10.4.4 Changes of Information · p. 341
10.4.5 Revalidations · p. 347
10.4.5.1 Revalidation Solicitations · p. 347
10.4.5.2 Non-Responses to Revalidation and Extension Requests · p. 349
10.4.5.3 Receipt and Processing of Revalidation Applications · p. 350
10.4.6 Reactivations
10.4.7 Revocations · p. 356
10.4.7.1 Revocations – Background and General Requirements · p. 357
10.4.7.2 Revocation Effective Dates · p. 359
10.4.7.3 Revocation Reasons · p. 361
10.4.7.4 Reenrollment Bar · p. 374
10.4.7.5 Additional Revocation Policies · p. 378
10.4.8 Deactivations · p. 384
10.4.8.1 Deactivation Rebuttals · p. 388
10.4.8.2 Rebuttals for Ordering/Certifying Deactivations · p. 398
10.4.9 Stay of Enrollment · p. 400
10.4.9.1 Stay of Enrollment Rebuttals · p. 412

10.5 Timeliness and Accuracy Standards · p. 419

Open section 10.5 in the PDF

10.6 Additional Topics Pertaining to Medicare Enrollment · p. 427 · 41 subsections

Open section 10.6 in the PDF
10.6.1 Certified Providers/Certified Suppliers · p. 427
10.6.1.1 Changes of Ownership (CHOWs) – Transitioned Certified Providers and Suppliers Nursing Facilities (SNFs) · p. 427
10.6.1.1.1 General Background on CHOWs · p. 428
10.6.1.1.2 Examples of CHOW and Non-CHOW Situations · p. 429
10.6.1.1.3 Ascertaining Whether a CHOW Has Occurred · p. 432
10.6.1.1.3.1 Step 1 - Initial Review of the CHOW Application · p. 433
10.6.1.1.3.1.1 Special Processing Instructions and Considerations for the Initial Review Process · p. 435
10.6.1.1.3.2 Step 2 – Post-Initial Review Actions and Scenarios · p. 440
10.6.1.1.3.3 Step 3 – Post-State Review Actions and Scenarios · p. 442
10.6.1.1.4 Additional CHOW Processing Policies · p. 443
10.6.1.1.5 HHA and Hospice Ownership Changes · p. 445
10.6.1.1.6 DMEPOS Supplier Change in Majority Ownership · p. 450
10.6.1.2 Changes of Information – Transitioned Certified Providers and Suppliers · p. 455
10.6.1.3 Voluntary Terminations · p. 460
10.6.2 Establishing Effective Dates · p. 469
10.6.3 Legal Business Name · p. 473
10.6.4 Provider and Supplier Business Structures · p. 476
10.6.5 National Provider Identifier (NPI) · p. 481
10.6.6 Final Adverse Actions · p. 490
10.6.7 Owning and Managing Information · p. 530
10.6.7.1 Organizational Owning and Managing Information · p. 530
10.6.7.2 Individual Owning and Managing Information · p. 537
10.6.7.3 Owning and Managing Information – Tax Identification Numbers (TINs)
10.6.8 Billing Agencies · p. 541
10.6.9 Contact Persons · p. 541
10.6.10 Medicare Payment · p. 542
10.6.11 Participation (Par) Agreements and the Acceptance of Assignment · p. 544
10.6.12 Opting-Out of Medicare · p. 544
10.6.13 Ordering/Certifying Suppliers · p. 553
10.6.14 Application Fees · p. 557
10.6.15 Risk-Based Screening · p. 574
10.6.16 Temporary Moratoria · p. 584
10.6.17 Deceased Practitioners · p. 584
10.6.18 Appeals Process · p. 588
10.6.19 Other Medicare Contractor Duties · p. 612
10.6.20 Screening: On-Site Inspections and Site Verifications · p. 623
10.6.21 Miscellaneous Enrollment Topics · p. 626
10.6.21.1 Additional Miscellaneous Enrollment Topics · p. 628
10.6.22 Non-Transitioned Certified Provider/Supplier Changes of Ownership · p. 630
10.6.22.1 Non-Transitioned Certified Provider/Supplier Changes of Information · p. 638
10.6.23 Special Instructions for Electronic Funds Transfer (EFT) Accounts and Special Payment Addresses · p. 641

10.7 Model Letters · p. 644 · 23 subsections

Open section 10.7 in the PDF
10.7.1 Acknowledgement Letters · p. 650
10.7.2 Development Letters · p. 651
10.7.3 Approval Letters · p. 652
10.7.4 DME Approval Letter Templates · p. 652
10.7.5 Part A/B Certified Provider Approval Letter Templates · p. 662
10.7.5.1 Part A/B Certified Provider and Supplier Letter Templates – Post-Transition · p. 680
10.7.5.1.1 Additional Certified Provider and Certified Supplier Letters · p. 717
10.7.6 Part B Non-Certified Supplier Approval Letter Templates · p. 718
10.7.7 Application Return and Rejection Model Letters · p. 753
10.7.8 Denial Model Letters · p. 756
10.7.9 Revocation Letters · p. 781
10.7.10 Corrective Action Plan (CAP) Model Letters · p. 798
10.7.11 Reconsideration Request Model Letters · p. 819
10.7.12 Deactivation Model Letters · p. 877
10.7.13 Rebuttal Model Letters · p. 880
10.7.14 Model Opt-Out Letters · p. 897
10.7.15 Revalidation Notification Letters · p. 925
10.7.16 Model Letters for Claims Against Surety Bonds · p. 936
10.7.17 Model Identity Theft Prevention Letter · p. 943
10.7.18 Model Documentation Request Letter · p. 944
10.7.19 ESRD Approval Letters · p. 946
10.7.20 Stay of Enrollment Letters · p. 953
10.7.21 DMEPOS Supplier Change in Majority Ownership Letter · p. 974

Using this chapter in a denial or appeal

Start with the remittance. The claim adjustment reason code says what happened to the line, the remark code narrows it, and the group code says who is liable. Match that to the section of the chapter that sets the rule, then read the section in the official PDF rather than a summary: the wording that matters, such as a time limit, a modifier requirement or a documentation element, is usually a single sentence. Check the revision note under the section heading, because a rule that changed after the date of service may not apply to the claim, and an effective date earlier than the issue date can make a new rule reach back.

When the chapter supports the claim, cite it precisely in the redetermination request: the publication number, chapter, section and revision. When it does not, the fix is usually a corrected claim or better documentation rather than an appeal, and a coding or format rejection is corrected and resubmitted because it carries no appeal rights. Manual instructions bind the Medicare Administrative Contractor, so they settle most first-level disputes; at the hearing level, administrative law judges give them substantial deference without being bound by them. If the issue turns on whether a service is covered at all, read the matching Benefit Policy Manual chapter and any national coverage determination or local coverage determination as well, because coverage and billing rules are written in different places.

How QuickIntell works with Program Integrity Manual chapter 10

QuickCode supports qualified coder review and documentation clarification before claims are submitted, which is what record reviews test, and QuickRCM keeps record requests, denials and appeals in one workflow with human review.

See QuickCode for documentation review See QuickRCM for denial follow-up Book a meeting

Frequently asked questions: chapter 10

How often must Medicare providers revalidate enrollment?

Chapter 10 of the Program Integrity Manual says every five years for providers and suppliers generally and every three years for DMEPOS suppliers. The contractor notifies the provider when revalidation is due.

Is the CMS-855R still used for reassignment?

No. Section 10.3.1.4 explains that reassignment of benefits is now made through the Form CMS-855I and that the Form CMS-855R has been discontinued.

How far back can a new physician bill Medicare?

Under section 10.6.2 and 42 CFR 424.521, eligible suppliers can bill retrospectively for up to 30 days before their enrollment effective date, or 90 days when a presidentially declared disaster prevented enrollment.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.

Medicare Program Integrity Manual, Chapter 10: Medicare Enrollment
Version Rev. 13717, issued 2026-07-08 · effective 2026-01-01 · file pim83c10.pdfSHA-256 e76e5bcc5714c20a…
Medicare Program Integrity Manual (Pub. 100-08)
Version 15 chapter PDFs; newest revision Rev. 13890 (chapter 12), issued 2026-07-30 · effective 2026-09-27 · file 100-08-program-integrity-manual/*.pdf (15 chapters; SHA-256 of their sha256sum listing)SHA-256 efb2c5dd5abb3fe4…

Disclaimer

This guide summarizes a CMS manual chapter in our own words for billing teams; section headings and transmittal subjects are quoted from the chapter PDF. The chapter itself is the authority, and it changes by transmittal. Not legal, clinical or billing advice.

Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.

Medicare Program Integrity Manual Chapter 10: Medicare Enrollment