Revalidation
Revalidation is re-proving an enrollment that already exists. Missing it can deactivate a provider who has changed nothing and done nothing wrong.
Updated
Revalidation is the periodic re-verification of an enrollment record that is already in place. Medicare requires enrolled providers to revalidate on a cycle CMS publishes; commercial payers run their own re-credentialing cycles on their own schedules.
The provider has not necessarily changed anything. Revalidation is not triggered by an event — it is triggered by time, which is what makes it easy to miss.
In practice
The consequence of missing it is out of proportion to the task, and it sits in regulation rather than at a contractor's discretion: CMS may deactivate a provider's Medicare billing privileges where the provider “does not furnish complete and accurate information and all supporting documentation” within the period the deactivation rule allows after CMS notifies them to submit or re-certify their enrollment information. A deactivated provider's claims stop paying — not because of anything about the care, the coding, or the claim, but because the record behind them lapsed. Note what the trigger is: incompleteness, not lateness, so a revalidation filed on time and short a document is exposed to the same outcome.
It is also the credentialing failure that hits an established practice rather than a new one. Onboarding a new provider has an owner and a deadline everyone is watching; revalidating a physician who has been there for years has neither, until the claims stop.
Commonly confused with
- Initial enrollment: Initial enrollment creates the record. Revalidation keeps it alive. The second is easier to forget precisely because nothing is changing.
- Re-credentialing: The term commercial payers generally use for their own periodic re-verification. The same idea, a different payer's word for it and its own cycle.
Sources
- 42 CFR § 424.515 — reporting changes and updates to, and periodic revalidation of, Medicare enrollment information (opens in a new tab)
- 42 CFR § 424.540 — deactivation of Medicare billing privileges, and reactivation (opens in a new tab)
- NCQA — Credentialing Accreditation and Certification (opens in a new tab)