Medicare Enrollment For Physicians And Other Part B
DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Medicare & Medicaid ServicesOpen aText-OnlyVersionMedicare Enrollment for Physiciansand Other Part B SuppliersPROVIDER–SUPPLIER ENROLLMENT SERIESICN 903768 June 2016
Medicare Enrollment for Physicians andOther Part B SuppliersTable of ContentsWho Are Part B Suppliers? . 1Step 1: Obtain a National Provider Identifier (NPI) . 3Step 2: Complete the Proper Medicare Enrollment Application . 4Online PECOS Application . 4The Paper Medicare Enrollment Application (Forms CMS-855) . 5Application Fee . 6Step 3: Await Application Processing . 6Step 4: Keep Your Enrollment Information Up to Date . 7How to Report Changes . 7Revalidation . 7Determine If You Want to Be a Participating Provider . 8Resources . 9The information in this publication applies only to the Medicare Fee-For-ServiceProgram (also known as Original Medicare) and Part D prescribers.Table 4. Hyperlink Table, at the end of the document, provides the complete URLfor each hyperlink.
Medicare Enrollment for Physicians andOther Part B SuppliersPhysicians, non-physician practitioners (NPPs), and other Part B suppliers must enroll in theMedicare Program to be paid for covered services they furnish to Medicare beneficiaries.This publication provides education for physicians and certain Part B suppliers todetermine if they are eligible to enroll in the Medicare Program and how to enroll.Explore these publications for information on Medicare enrollment for other provider types: PECOS for DMEPOS Suppliers Medicare Enrollment for Institutional Providers Medicare Enrollment Guidelines for Ordering/Referring Providers forordering/referring physicians and NPPs enrolling in the Medicare Program for thesole purpose of ordering/referring specific services for Medicare beneficiariesWho Are Part B Suppliers?For Medicare Part B provider enrollment purposes, Table 1 lists physicians, NPPs, andspecified other suppliers who can enroll as a Medicare Part B provider.Table 1. Physician, Part B NPP, Clinical/Group Practice, and Specified Other SuppliersClinics/Group Practices andCertain Other SuppliersPhysicians/NPPs/Suppliers Anesthesiology Assistants Ambulance Service Suppliers Audiologists Certified Nurse-MidwivesAmbulatory SurgicalCenters (ASCs) Certified Registered Nurse Anesthetists Clinics/Group Practices Clinical Nurse Specialists Clinical PsychologistsIndependent ClinicalLaboratories Clinical Social Workers Mass Immunization Roster Billers, individualsIndependent DiagnosticTesting Facilities (IDTFs) Nurse Practitioners Intensive CardiacRehabilitation Suppliers Physical/Occupational Therapists in private practice Mammography Centers Physicians (Doctors of Medicine or Osteopathy,Doctors of Dental Medicine; Dental Surgery;Podiatric Medicine; or Optometry) Mass Immunization RosterBillers, entities Physical/OccupationalTherapy Group in PrivatePractice Portable X-ray Suppliers Radiation Therapy Centers Physician Assistants Psychologists practicing independently Registered Dietitians or Nutrition Professionals Speech-Language PathologistsIf your provider or supplier type is not listed in Table 1, contact your Medicare AdministrativeContractor (MAC) before submitting a Medicare enrollment application. Refer to the MedicareFee-For-Service Provider Enrollment Contact List for MAC contact information for each State.1
Medicare Enrollment for Physicians andOther Part B SuppliersTake These Steps to Enroll in the Medicare ProgramStep 1: Obtain a NationalProvider Identifier (NPI)Step 2: Complete the Proper MedicareEnrollment ApplicationStep 3: Await ApplicationProcessingStep 4: Keep Your EnrollmentInformation Up to Date2
Medicare Enrollment for Physicians andOther Part B Suppliers Step 1: Obtain a National Provider Identifier (NPI)Physicians, NPPs, and other Part B suppliers must obtain an NPI before enrollingin the Medicare Program. You can apply for an NPI in one of three ways:1. Online Application: Apply through the online application process by visiting theNational Plan and Provider Enumeration System (NPPES) website.2. Paper Application: Complete, sign, and mail the NPI Application/Update Form(Form CMS-10114) paper application to the NPI Enumerator address listed onthe form. To request a hard copy application from the NPI Enumerator,call 1-800-465-3203 or TTY 1-800-692-2326, or send an email tocustomerservice@npienumerator.com.3. Bulk Enumeration: Give permission to have an Electronic File InterchangeOrganization (EFIO) submit your application data through a bulk enumerationprocess. For more information on this option, visit the EFI webpage.Not Sure If You Have an NPI?Search for your NPI on the NPPES NPI Registry.3
Medicare Enrollment for Physicians andOther Part B Suppliers Step 2: Complete the Proper Medicare Enrollment ApplicationOnce you have an NPI, you can apply for enrollment in the Medicare Program,revalidate your enrollment, or make a change to your enrollment information. Completethese actions using either of the following options: Online Application: Register for an Identity and Access Management (I&A)System user account, and then visit the Medicare Provider Enrollment, Chain andOwnership System (PECOS) website Paper Application: Submit the appropriate paper enrollment application (moreinformation below)Carefully review the paper application instructions to determine which form is rightfor your type of practice. To initiate the enrollment process, most physicians andNPPs complete Form CMS-855I. If you also reassign your benefits to anotherentity, such as a medical group or group practice who receives payment for yourservices, you must also complete Form CMS-855R or the associated PECOSenrollment applications.Submit All Enrollment Materials ElectronicallyYou do not need to mail paper copies of your supporting documentation. For moreinformation, refer to the Digital Document Repository (DDR) How To Guide.Online PECOS ApplicationThe PECOS application process is scenario driven. It presents a series of questions toretrieve only the information needed to process your specific enrollment scenario. ThePECOS for Physicians and Non-Physician Practitioners publication has more information.PECOS Is Easy!We encourage you to use PECOS instead of the paper Medicare enrollmentapplication. Advantages of using PECOS include: Completely paperless process, including electronic signature and digitaldocument feature Faster than paper-based enrollment Tailored application process means you only supply information relevant toyour application and specialty More control over your enrollment information, including reassignments Easy to check and update your information for accuracy Less staff time and administrative costs to complete and submit enrollmentto Medicare4
Medicare Enrollment for Physicians andOther Part B SuppliersThe Paper Medicare Enrollment Application (Forms CMS-855)The paper Medicare enrollment application collects your information and secures thedocumentation necessary to ensure you are eligible to enroll in the Medicare Program.The enrollment applications for physicians, Part B NPPs, and the specified othersuppliers listed in Table 1 are: Medicare Enrollment Application for Physicians and Non-Physician Practitioners(Form CMS-855I): Used by individual physicians or NPPs to initiate the Medicareenrollment/revalidation process or to change Medicare enrollment information. Medicare Enrollment Application for Reassignment of Medicare Benefits(Form CMS-855R): Used to initiate a reassignment of a right to bill the MedicareProgram and get Medicare payments.NOTE Only individual physicians and NPPs can reassign the right to bill theMedicare Program. Medicare Enrollment Application for Clinics/Group Practices and Certain OtherSuppliers (Form CMS-855B): Used by group practices and other organizationalsuppliers, except Durable Medical Equipment, Prosthetics, Orthotics, andSupplies (DMEPOS) suppliers, to initiate the Medicare enrollment process, initiatethe revalidation process, or change Medicare enrollment information. Medicare Enrollment Application for Ordering/Referring Physicians and NPPS(Form CMS-855O): Used by physicians and other eligible NPPs to enroll in theMedicare Program and to order/refer items or services for Medicare beneficiaries.This includes those physicians and other eligible NPPs who do not andwill not send claims to a MAC for the services they furnish. Refer to theMedicare Enrollment Guidelines for Ordering/Referring Providers publicationfor more information.New Provider Enrollment Requirement for Part D PrescribersIf you write prescriptions for covered Medicare Part D drugs, you must now beenrolled in Medicare or have a valid opt-out affidavit on file for Part D to cover theprescriptions you write. Submit your Medicare enrollment application by completingthe paper CMS-855I or CMS-855O. If you choose to opt out of Medicare, you mustsubmit your opt-out affidavit to the Part B MAC in your jurisdiction. Review thefollowing for more information: Part D prescriber requirements (MLN Matters SE1434) Opting out of Medicare (MLN Matters SE1311)5
Medicare Enrollment for Physicians andOther Part B SuppliersApplication FeePhysicians, NPPs, physician organizations, and non-physician organizations donot have an application fee. For more information about the provider types subject toan application fee, refer to the Application Fee Requirements Matrix.Electronic Funds Transfer (EFT)CMS requires all providers use EFT if enrolling in Medicare, revalidating, ormaking any changes to their enrollment. The most efficient way to enroll in EFT is tocomplete the EFT information section in PECOS. When submitting a PECOS webapplication, you must: Complete the EFT information for your organization (if applicable) Include a copy of a voided check/bank letter that includes a legalbusiness name Include the account number and routing number that match the numbersentered in PECOS Step 3: Await Application ProcessingYour MAC pre-screens and verifies all information on the enrollment application. Duringprocessing, you may be required to submit additional information. Respond to anyrequests from your MAC as soon as possible. Failure to do so may delay enrollmentor result in the rejection of the submitted application (deactivation). Once your MACapproves the application, it will switch the PECOS record to an “approved” status andsend you an approval letter.6
Medicare Enrollment for Physicians andOther Part B Suppliers Step 4: Keep Your Enrollment Information Up to DateHow to Report ChangesYou can submit a change of information, including a change of address, using PECOSor the appropriate paper enrollment application. You must report a change of ownershipor control, a change in practice location, and any final adverse legal actions, such asrevocation or suspension of a Federal or State license, within 30 days of the reportableevent. Submit all other changes within 90 days of the reportable event.RevalidationAll providers and suppliers enrolled with Medicare must revalidate their enrollmentinformation on a periodic basis. Generally, physicians and NPPs revalidate enrollmentevery 5 years or when CMS requests it.If you are currently and actively enrolled, check the Medicare Revalidation Lookup Toolto find your revalidation due date. If you see a due date listed, submit your revalidationwithin 6 months of that date. The MAC will also send you a notice to revalidate. Ifyou submit your application after the due date, the MAC may place a hold on yourMedicare payments, deactivate your Medicare billing privileges, or revoke your existingbilling privileges.The most efficient way to submit your revalidation information is by using PECOS. Formore information on revalidating, refer to the following: Medicare Provider-Supplier Enrollment: Revalidations webpage Provider Enrollment Revalidation – Cycle 2 (MLN Matters SE1605)Questions?Find answers in the PECOS FAQs publication, or review the Provider EnrollmentRevalidation Cycle 2 FAQs.Large Group CoordinationGroups with more than 200 members can access the Medicare RevalidationLookup Tool and search by their organization’s name to download their groupinformation. They will also receive a letter and spreadsheet from their MAClisting the providers linked to their group required to revalidate within 6 months.Large groups should work together to ensure only one application from eachprovider/supplier is submitted.7
Medicare Enrollment for Physicians andOther Part B SuppliersDetermine If You Want to Be a Participating ProviderIn Medicare, “participation” means you agree to always accept claims assignment forall covered services furnished to Medicare beneficiaries. By agreeing to always acceptassignment, you agree to always accept Medicare-allowed amounts as payment in fulland not to collect more than the Medicare deductible and coinsurance or copaymentfrom the beneficiary. The Social Security Act requires you to submit claims for Medicarebeneficiaries whether you participate or not.To participate in the Medicare Program as a participating provider or supplier, submitthe Medicare Participating Physician or Supplier Agreement (Form CMS-460). You have90 days from when you enrolled to decide if you want to be a participating provider orsupplier. The only other time you may change your participation status is during theopen enrollment period, generally from mid-November through December 31.Table 2. Medicare Participation vs. NonparticipationParticipationNonparticipation Medicare reimbursement is 5percent higher than nonparticipatingphysicians and other suppliers Medicare reimbursement is 5 percentlower than participating physiciansand other suppliers Medicare issues payments directly toyou because the claims are alwaysassigned Claim information is forwarded toMedigap (Medicare supplementalcoverage) insurersYou cannot charge the beneficiarymore than the limiting charge, 115percent of the Medicare PhysicianFee Schedule amount You may accept assignment on acase-by-case basis You have limited appeal rightsFor more information on participating, refer to Pub 100-04, Medicare Claims ProcessingManual, Chapter 12.8
Medicare Enrollment for Physicians andOther Part B SuppliersResourcesFor more information about the Medicare enrollment process, visit the MedicareProvider-Supplier Enrollment webpage, which provides information about: PECOS, including how to update your records using PECOS Paper Medicare enrollment application forms Frequently asked questions Contact information for all MACs CMS updates on provider enrollmentTable 3. Resources TableFor More InformationAbout ResourceCMS External User Services To report PECOS navigation, access, or printing(EUS) Help Deskproblems, contact the CMS EUS Help Desk. Findcontact information, including email address, telephonenumbers, and live chat, at EUS.custhelp.comMACContact your MAC with any additional questions aboutthe Medicare enrollment tact list.pdfMedicare LearningNetwork (MLN) GuidedPathways (GPs)Provider Specific Medicare athways Provider Specific Booklet.pdfMLN Connects NationalProvider Call “StreamlinedAccess to PECOS, EHR,and -15NPC.htmlMLN Matters ArticleMM7350, “Implementationof Provider EnrollmentProvisions in CMS-6028-FC”Information on screening requirement for enrollmentand /MM7350.pdfMLN Matters SE1417,“Implementation ofFingerprint-BasedBackground strativeSimplification/NationalProvIdentStand9
Medicare Enrollment for Physicians andOther Part B SuppliersTable 3. Resources Table (cont.)For More InformationAbout ResourcePECOSPECOS.cms.hhs.gov/pecos/login.doPECOS TechnicalAssistance ations-Items/CMS1243418.htmlVideo ResourcesYouTube.com/playlist?list PLaV7m2zFKpia1McB1WKKkw2esAdiZRemTable 4. Hyperlink TableEmbedded HyperlinkApplication FeeRequirements MatrixComplete oads/ApplicationFeeRequirementMatrix.pdfDigital Document Repository DR) How To efi.htmlIdentity and AccessManagement (I&A) SystemMedicare EnrollmentApplication for Clinics/GroupPractices and Certain OtherSuppliers (Form CMS-855B)Medicare EnrollmentApplication for Ordering/Referring Physicians andNPPS (Form CMS-855O)Medicare EnrollmentApplication for Physiciansand Non-PhysicianPractitioners cms855i.pdf10
Medicare Enrollment for Physicians andOther Part B SuppliersTable 4. Hyperlink Table (cont.)Embedded HyperlinkComplete URLMedicare EnrollmentApplication forReassignment of MedicareBenefits (Form CMS-855R)Medicare Enrollment forInstitutional SForms/Downloads/cms855r.pdfMedicare EnrollmentGuidelines for Ordering/Referring tmlMedicare er-EnrollmentProvider Enrollment Contact wnloads/contact list.pdfMedicare ParticipatingPhysician or SupplierAgreement (Form CMS-460)Medicare are Provider-SupplierEnrollment: roll/Revalidations.htmlMedicare RevalidationLookup ToolNational Plan and ProviderEnumeration SystemNPI Application/UpdateForm (Form CMS-10114)https://data.cms.gov/revalidationNPPES NPI Registryhttps://npiregistry.cms.hhs.govOpting Out of Downloads/SE1311.pdfPart D ttersArticles/Downloads/SE1434.pdfPECOS Forms/Downloads/CMS10114.pdf11
Medicare Enrollment for Physicians andOther Part B SuppliersTable 4. Hyperlink Table (cont.)Embedded HyperlinkComplete URLPECOS for MLNPublications-Items/CMS1243483.htmlPECOS for Physicians andNon-Physician NPublications-Items/CMS1243414.htmlProvider Enrollment, Chainand Ownership System(PECOS)Provider EnrollmentRevalidation – Cycle 2https://pecos.cms.hhs.gov/pecos/login.doProvider EnrollmentRevalidation Cycle 2 loads/Reval Cycle2 FAQs.pdfPub 100-04, MedicareClaims Processing Manual,Chapter he Medicare Learning Network Disclaimers are available at http://go.cms.gov/Disclaimer-MLN-Product.The Medicare Learning Network , MLN Connects , and MLN Matters are registered trademarks ofthe U.S. Department of Health & Human Services (HHS).Check out CMS on:TwitterLinkedIn YouTube12
Medicare Enrollment Application for Clinics/Group Practices and Certain Other Suppliers (Form CMS-855B): Used by group practices and other organizational suppliers, except Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers, to initiate the Medicare
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