Medicare Enrollment Guide for Individual Physicians

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1 Medicare enrollment processes have changed considerably over the years, and even more so with the introduction of national provider identifiers (NPIs). The enrollment application process for individuals can be complex and burdensome. The California Medical Association (CMA) has developed this document to guide new physicians through the enrollment process, and to assist enrolled physicians who are making changes or revalidating their enrollment. The revalidation process implemented by the Centers for Medicare & Medicaid Services (CMS) in 2011 requires all physicians who have not enrolled, changed, or revalidated their enrollment since March 25, 2011, to complete a revalidation request by March 23, Physicians who wish to enroll, update or revalidate their enrollment information can complete the enrollment process with the CMS 855I enrollment form or utilize the Internet-based PECOS (Provider Enrollment, Chain and Ownership System). Physicians who wish to participate in the incentives that CMS provides for the Electronic Prescribing Program, the Physicians Quality Reporting System (PQRS), and the Electronic Health Records Program must be in PECOS. Enrollment Requirements You must notify your Medicare contractor for enrollment purposes when you encounter the following situations: Initial enrollment: Change of information: Revalidation: Revalidations are normally conducted five years after your last enrollment activity. You will be notified by your contractor that you are required to revalidate your information within 60 days of the date of the notice. Due to changes in the law, virtually every Medicare physician and provider will be asked to revalidate prior to March 23, You are required by Medicare to resubmit and recertify the accuracy of your enrollment information in order to maintain Medicare billing privileges. Requests for revalidation will come from the contractor. At the present time, they do not encourage voluntary revalidation so as to maintain a manageable workflow and provide timely completion of applications. Rev page 1 of 12

2 Contractors will send revalidation letters to physicians who must revalidate. Check the PTAN used on the letter and make sure it is the current PTAN you are using for the individual NPI and your current practice address(es). If it is an old PTAN or address at which you are no longer providing services, request that it be deactivated. This may occur if, at some point, the physician was working for another corporation, and deactivation of the reassignment to that organization was never completed. Complete your revalidation enrollment within 60 days of the date of the revalidation request letter. Failure to complete a revalidation request could result in deactivation of your PTAN and Medicare billing privileges. Physicians may determine if they have been sent a revalidation request by checking the lists provided on the CMS Medicare Provider-Supplier Enrollment website under Revalidations at MedicareProviderSupEnroll/Revalidations.html. Deactivation: CMS may deactivate your billing privileges in the following situations: of the first month without a claim submission through the last day of the 12th month without a submitted claim. You may not reactivate your billing privileges until you are prepared to submit a new claim. change occurred. There may be serious consequences if do not enroll in a timely fashion, fail to notify Medicare of changes to your practice, or do not enrollment based on the later of: prior to the first date you begin seeing patients at that location. There may be a period of time when you may not bill Medicare until your enrollment, revalidation or reactivation has been completed and your effective date established. Your effective date is defined as the date your Medicare contractor receives your approvable Medicare enrollment application. In the case of an application submitted using Internet-based PECOS, the filing date is the date the contractor receives all of the following: digitally signed electronic application. Rev page 2 of 12

3 Background for Ordering/Referring Physicians Section 1833(q) of the Social Security Act requires that all ordering and referring physicians and non-physician practitioners meet the definitions in Section 1861(r) and 1842(b)(18)(C) and be uniquely identified in all claims for items and services that are the results of orders or referrals. Ordering/referring providers must be in PECOS, the national database that contains information on all providers enrolled in Medicare. PECOS was implemented in 2003, and existing records from contractors were grandfathered in. However, because much of the information from contractors was based on enrollments over many years, and from different versions of the enrollment applications, the records were not complete. Physicians who are not in PECOS were among the first to receive a revalidation request. CMS determines the physicians to be revalidated and provides the list to contractors for them to mail the revalidation requests. In order to be in PECOS, a physician must submit a provider enrollment application with the Medicare contractor either through the paper application process or through the Internet-based PECOS system. How to Determine If You Are in PECOS There are several ways to determine if you are in PECOS: record in PECOS. The Internet-based PECOS page is located at gov/medicare/provider-enrollment-and-certification/medicareprovidersupenroll/medicareorderingandreferring.html. Click on the OrderingReferringReport navigation link on the left-hand side. Note: This list is updated periodically as enrollments are completed. NPI number. This is a national listing and there are many providers listed with the same name. Enrolling in PECOS Physicians may choose to use either the paper enrollment form CMS 855I to enroll, update or revalidate their current enrollment with Medicare, or the CMS developed Internet-based PECOS enrollment system. They do not need to do both, as the PECOS application is an enrollment tool. PECOS is a scenario-driven application process. You will only see the enrollment screens necessary to complete your initial enrollment or your change of information action. The information collected using the PECOS enrollment process is the same as the information collected through the paper application submission process. There are three basic steps to completing the enrollment process using PECOS: 1. Have an individual NPPES user ID and password. Rev page 3 of 12

4 2. Submit your online application. 3. Complete the digitized signature process, or print, sign, date and mail the two-page Certification Statement along with any required supporting documentation. The details on the following pages will help you complete the necessary steps to successfully enroll using the Internet-based Medicare PECOS system. NOTE: If you are a solo incorporated physician who has been submitting claims using only your individual NPI, and you are now revalidating or making changes, you must obtain a corporate NPI as an organization, tied to your tax number. To make this change to 1. Have your NPPES user ID and password handy. NPPES is the contractor that assigns NPIs. If a physician applied for an individual NPI using the online process, he or she received a user ID and password. If you have not used your NPPES password in the last year, it has probably expired. You can change your password by going to, selecting If you are a Health Care Provider, you must click on National Provider Identifier (NPI) to login or apply for an NPI, then click on Login. You can log-in or reset your forgotten password. A link to reset your password or establish a user account is also available on the PECOS log-in page. If you applied for your NPI number by mail and do not have an individual NPPES user ID and password, you can establish a user ID and password by contacting NPPES via telephone, or mail. Telephone contact is the fastest and easiest way to obtain your user ID and password. Rev page 4 of 12

5 Phone: By Mail: 2. Submit your Internet-based application. Prior to using Internet-based PECOS, you should have the following physician information available: state or local business licenses, and certifications or registrations specifically required to operate as a health care facility. To get started with PECOS, go to the CMS website at Provider-Enrollment-and-Certification/ MedicareProviderSupEnroll/index and click on the Internet-based PECOS link found in left navigation section. This will take you to the PECOS home page. Rev page 5 of 12

6 On the PECOS home page there are various download documents that may offer additional guidance on completing the online enrollment process. PECOS has limitations on what may be changed via the online process. Please review the Medicare Provider-Supplier Enrollment National Education Products, which includes a link Enrollment, Chain and Ownership System (PECOS) for Physicians and Non-Physician Practitioners. To reach the login page of PECOS, go to the Related Links section at the bottom of the page, and click on Access to Enter your user ID vand password in the spaces indicated. You may also use the links provided to reset your password or update your NPI account. practitioner is not currently enrolled in PECOS, the Existing Associates section will display, There are no Associates currently present for the details provided. Physicians must then complete the application to enroll in Medicare so they are added to PECOS. For PECOS enrollment, select the [NEW APPLICATION] button. Rev page 6 of 12

7 If the individual practitioner record is name and NPI will be displayed under Existing Associates. This applies to those practitioners with private practice locations and those who reassign some or all of their benefits to another individual or supplier. Select the drop down under Filter Enrollments to proceed. From this point you may begin the process to view, complete and electronically sign the application. Follow the prompts given you throughout the enrollment process. Remember, only the screens that are needed will display, based on your responses.

8 3. Print, sign, and date the two-page Certification Statement. The last few steps in the process involve checking the application for errors and submitting the application. Follow the steps outlined on the screens, which are self-explanatory. Follow the prompts to use the electronic signature process for either the 855I, 855R or If submitting a paper certification, it must be printed out and signed by the physician. Signatures must be original and in ink (blue ink recommended). Copied or stamped signatures will not be accepted. [SUBMIT] button. Your submission receipt will appear. You should print a receipt for your files. Statement that is associated with the online submission. CMA encourages physicians to print and retain a copy of the enrollment application for their records, but they should only mail the Paper Enrollment Form Physicians are encouraged to use the Internet-based PECOS system when possible. The paper enrollment form for individual physicians to enroll, update or revalidate their enrollment is the CMS 855I. The current version of the form can be found on the CMS forms page. Enrollment requests submitted on outdated versions will be denied. Information can be typed into the online form, but that information cannot be saved. You must print for mailing. Read all instructions and definitions carefully before completing the application. Make sure you indicate why you are submitting an application in section 1A on page 3 of the 855I enrollment form and follow the tips from Required Sections to complete. If a section does not apply, leave it blank. Do not use NA or not applicable. This will cause the contractor to request additional information, delaying the process until the information is received or a corrected page is submitted. If you are reassigning your benefits to another entity (group, partnership, corporation, etc.) you must also complete the 855R. You must sign the application as the individual, as must an authorized official of the organization to which you are assigning your benefits. Mail both the 855I and the 855R applications together along with any other required documentation. Rev page 8 of 12

9 Solo Incorporated Physicians Many solo incorporated physicians have used their tax numbers for Medicare billing for many years. Most times their business checking accounts and letterheads will reflect their status as a corporation. However, for billing purposes they have utilized their entities: an individual and an organization. and provide that information in the enrollment application. The change from an individual to a corporation cannot be achieved using the Internet-based PECOS enrollment application. Physicians who are sole owners of a business that is incorporated (Inc., LLC, PC, etc.) only need to complete a CMS 855I paper application. Tips: corporation paperwork. The enrollment application, the NPI and the IRS documentation of the corporation must match exactly, down to the periods and commas. the same name. an application is submitted. NPI in the spaces identified for physicians reassigning their benefits (in this case to their own corporations). Following is the section indicated: Number (if issued) and your individual (Type 1) NPI here: Medicare Identification Number(s) NPI: Note: The Medicare Identification Number may be the PTAN or PIN used for Medicare billing prior to NPI. Identification Number should be left blank. Your corporation does not yet have one. require a date, mark the box ADD and indicate the date you first began practice at your current location under that tax number.

10 business name and tax number. General Enrollment Tips: Section 15 (Certification Statement) to be completed again. You must authorize any changes with a new signature and date. Electronic Funds Transfer Mandatory for all Provider/Supplier Types If you do not already receive payments electronically, you must complete the Form CMS-588 Electronic Funds Transfer Authorization Agreement (EFT). This is a CMS requirement for new enrollees or anyone submitting an 855 application for changes or revalidation. If you are enrolling for the first time as a corporation, provide the organization (corporation) NPI in Part II. If you already receive EFT, but are changing to a corporation or changing your physical location, you must submit an update to your enrollment to reflect the corporate NPI. If the name on your checking account does not match the legal business name of the corporation exactly, obtain a confirmation of account information on bank letterhead. The letter should contain the name on the account, electronic routing transit number, account Frequently Asked Questions I was a solo physician and have now become incorporated. I was a participating physician as a solo physician. Will my participation status continue? you want to continue to be a participating physician, you must submit a completed CMS 460 Medicare Participation Enrollment form for the corporation. I submitted my CMS 855I enrollment form as a solo incorporated physician. Must I also complete the CMS 855B for clinics and groups and the CMS 855R for reassignment? to complete if you are unsure. Rev page 10 of 12

11 I am a non-participating physician, so all money goes to my patient. Must I sign up for Electronic Funds Transfer when I revalidate my enrollment? Yes. As required in 42 Code of Federal Regulations (CFR) (d)(2)(iv) and (e), any provider not currently on Electronic Funds Transfer (EFT) that submits any change to its existing enrollment data or submits a revalidation application, must also submit a CMS 588 form and thereafter receive payments via EFT. Any payment made to the patient will continue to be issued in the How will I know how much is being paid for each patient? I have been practicing for 20 years in the same location. Why must I complete an enrollment application? Per 42 CFR , Medicare providers and suppliers (other than DMEPOS suppliers) must resubmit and recertify the accuracy of their enrollment information every five years in order to maintain Medicare billing privileges. Contractors may initiate revalidation activities at any time during the fiscal year. I submitted my enrollment by the Internet-based enrollment process, but have never heard anything from the contractor. I have my tracking form but they say they don t have my application. Why? There could be several reasons why your Internet application apparently was not received or processed: You did not mail the required certification pages (signature page) or waited too long to mail it. You must mail the original signed Certification Statement from Internet-based PECOS and supporting documents to the Medicare contractor within seven days of your electronic submission. The effective date of filing an enrollment application is the date the Medicare contractor receives the signed and dated (blue ink recommended) Certification Statement. Note: A Medicare contractor will not process an Internet enrollment application without the signed and dated Certification Statement. You did not hit the submit button. Verify that your status on the Internet-based application reflects submitted. The contractor asked me for additional information and had me sign a new Certification Statement. Why? Certification Statement, you agree to adhere to all of the requirements and you attest that the information is true, accurate and accuracy of the change. I am planning on retiring in six months. Whom do I have to notify and can I do it by letter? A physician closing a practice, whether it is because of retirement or moving out of the contractor area must complete an 855I enrollment form. It is best to do this within 30 days of the effective date. The sections to be completed are Sections 1A, 13 and 15. Rev page 11 of 12

12 A physician who will no longer be submitting claims to any payor, should also notify the NPPES Enumerator ( I received my enrollment approval as a corporation, and have changed my system to bill with my corporation NPI in item 33, and my individual NPI in item 24J, or the electronic equivalent. However, my clearinghouse says Medicare is rejecting my transmissions. Why? paperwork as a new entity. All signatures and enrollment information should reflect the corporate NPI number. Resources The following resources are on the CMS website. The links may change periodically as information is added and updated. If a link does not work, go to for downloads and related links. The Basics of Medicare Enrollment for Physicians and Other Part B Suppliers The Basics of Internet-based Provider Enrollment, Chain and Ownership System (PECOS) for Physicians and Non-Physician Practitioners Internet-Based PECOS Enrollment Example Medicare Ordering and Referring Information Medicare Internet Only Manual , Medicare Program Integrity Manual CMS has PECOS Enrollment Example webinars on its website. These provide additional information on using the Internet-based enrollment depending on the type of enrollment you need. The following information is available from the CMS Medicare Provider-Supplier Enrollment website at Rev page 12 of 12