Physicians must include their National Provider Identifier number (NPI) on all applications, as well as on all claims for payment, to enroll in Medicare and Medicaid programs beginning July 6, 2010.
Effective July 6, 2010, enrolled physicians, providers and suppliers must include not only their own NPIs, but also the NPIs of any other referring physician, provider, and/or supplier on their electronic and paper Medicare claims.
Physicians and eligible professional who order and refer covered items and services for Medicare beneficiaries must also be enrolled in Medicare, and providers, physicians, and other suppliers participating in the Medicare program must provide documentation on referrals to programs that are at high risk of waste and abuse, including durable medical equipment, prosthetics, orthotics and supplies (DMEPOS); home health services; and other items or services specified by Secretary of Health and Human Services.
Since May 23, 2008, Medicaid providers have also been required to report their NPIs on their Medicaid claims. As of July 6, NPIs must also be submitted for Medicaid provider agreements.
CMS has established the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) for physicians, non-physician practitioners, providers and supplier organizations. PECOS allows physicians, non-physician practitioners, providers and supplier organizations to enroll, make a change in their Medicare enrollment, view their Medicare enrollment information on file with Medicare, or check on the status of a Medicare enrollment application via the Internet.
Maintaining enrollment, reporting changes
After enrolling in the Medicare program, all physicians are responsible for maintaining and reporting changes in their Medicare enrollment information to their designated Medicare contractor. By reporting changes as soon as possible, physicians will help to ensure that their claims are processed correctly. The reportable events listed below may affect claims processing, a payment amount, or a physician's eligibility to participate in the Medicare program.
Physicians are required to report the following reportable events as soon as possible, but no later than 90 days after the reportable event:
- Change in practice location occurs when a physician establishes a new practice location, moves an existing practice location, closes an existing practice location or changes any portion of an existing practice location address where Medicare information is sent.
- Change in final adverse action occurs when a physician is debarred or excluded by any federal or state health care program, has his or her medical license suspended or revoked by a state licensing authority, was convicted of a felony within the last 10 years, has his or her Medicare billing privileges revoked by a Medicare contractor, or has a revocation or suspension by an accreditation organization.
- Change of business structure occurs when a physician changes his or her business structure (e.g., sole proprietorship to sole incorporated owner or vice versa).
- Change in organization legal business name/tax identification number occurs when a business owner changes the organization's legal business name and/or taxpayer identification number with the Internal Revenue Service.
- Change in practice status occurs when a physician decides to retire or voluntarily withdraw from the Medicare program. This type of change is referred to as a voluntary withdrawal.
- Change in reassignment of benefits occurs when a physician adds or voluntarily withdraws his or her reassignment of Medicare benefits. Physicians must report this type of change on the CMS-855R.
- Change in banking arrangements or any payment information occurs when a physician changes his or her bank or bank account or makes other payment information changes. This type of change should be reported immediately to the Medicare contractor. A physician can update his or her electronic funds transfer information by submitting the Electronic Funds Transfer Authorization Agreement (CMS-588) to his or her Medicare contractor.
Enrolling and making changes
Physicians can apply for enrollment in the Medicare Program or make a change in their enrollment information using either:
- The Internet-based Provider Enrollment, Chain and Ownership System (PECOS) or
- The paper enrollment application process (e.g., CMS-855I).
There are three steps to completing an enrollment action using Internet-based PECOS. Physicians and non-physician practitioners must:
- Have a National Plan and Provider Enumeration System (NPPES) user ID and password to use Internet-based PECOS.
For security reasons, passwords should be changed periodically; at least once a year. For information about how to change a password, go to the NPPES application help page and select the reset password page.
- Go to PECOS to complete, review, and submit the electronic enrollment application.
- Print, sign and date the two-page certification statement and mail it with all supporting paper documentation to the Medicare contractor within seven days of the electronic submission.
Note: A Medicare contractor will not process an Internet enrollment application without the signed and dated two-page certification statement and the required supporting documentation. The effective date of filing an enrollment application is the date the Medicare contractor receives the signed two-page certification statement associated with the Internet submission.
Physicians who are enrolled in the Medicare program but have not submitted the CMS-855I since 2003 are required to submit a Medicare enrollment application (i.e., Internet-based PECOS or the CMS-855I) as an initial application when reporting a change for the first time.
If a physician has any questions about reporting a change, he or she should contact his or her designated Medicare contractor in advance of submitting the CMS-855I. You can find additional information regarding the Medicare enrollment process, including Internet-based PECOS, on the CMS website.
Verify Medicare PECOS enrollment to ensure eligibility
The Centers for Medicare and Medicaid Services (CMS) requires that all individuals enrolled in Medicare who are eligible to order items or services, or refer Medicare beneficiaries to other Medicare providers or suppliers for services, must also be enrolled in PECOS. If you are not enrolled in this system and submit a claim as the provider who ordered or referred a service, the claim will be rejected. The deadline to complete this action was recently extended from April 5 to July 6, 2010. You must enroll by the deadline to be eligible as a PECOS provider.
Visit this link to determine if your information needs to be updated. This chart lists the name and National Provider Identifier (NPI) of providers who have updated their information and are legally eligible to order and refer in the Medicare program. If your name is on this list, you do not need to complete any further action. If your name is omitted from this list, visit this link for more information about submitting an updated application to CMS.
Tips to facilitate the Medicare enrollment process
To ensure that your Medicare enrollment application is processed timely, you should:
- Consider using PECOS to enroll or make a change in your Medicare enrollment if it is available for your provider or supplier type. Internet-based PECOS is a scenario-driven application process with front-end editing capabilities and built-in help screens. The scenario-driven application process will ensure that physicians and non-physician practitioners complete and submit only the information necessary to enroll or make changes in their Medicare enrollment records.
- Submit the current version of the Medicare enrollment application (CMS-855). CMS revised the Medicare enrollment application (i.e., CMS-855A, CMS-855I, CMS-855B, and CMS-855R) in February 2008. CMS revised the DMEPOS supplier enrollment application (i.e., CMS-855S) in March 2009. Medicare contractors will continue to accept the February 2008 version of the Medicare enrollment application (CMS-855I and CMS-855B) through November 2009, but physicians, non-physician practitioners, and other suppliers should begin to use the new Medicare enrollment applications (i.e., (02/2008) (EF 07/2009)) immediately. View the Medicare enrollment application.
- Submit the correct application for your provider or supplier type to the Medicare fee-for-service contractor servicing your state or location. The Medicare contractor that serves your state or practice location is responsible for processing your enrollment application. Applicants must submit their application(s) to the appropriate Medicare fee-for-service contractor. View a list of the Medicare fee-for-service contractors by state.
- Submit a complete application. If you are enrolled in Medicare but have not submitted the CMS-855 since November 2003, you are required to submit a complete application. Providers and suppliers should follow the instructions for completing an initial enrollment application. When completing a CMS-855 for the first time for any reason, each section of an application must be completed. When reporting a change to your enrollment information, complete each section listed in Section 1B of the CMS-855.
- Request and obtain your National Provider Identifier (NPI) number before enrolling or making a change in your Medicare enrollment information. CMS requires that providers and suppliers obtain their National Provider Identifier (NPI) prior to enrolling or updating their enrollment record with Medicare. If you do not have an NPI, contact the NPI Enumerator online or call (800) 465-3203 or TTY (800) 692-2326.
- Submit the Electronic Funds Transfer Authorization Agreement (CMS-588) with your enrollment application, if applicable. CMS requires that providers and suppliers who are enrolling in the Medicare program or making achange in their enrollment data receive payments via electronic funds transfer. Reminder: When filling out CMS-588, complete each section. The CMS-588 must be signed by the authorized official who signed the Medicare enrollment application. If a provider or supplier already receives payments electronically and is not making a change to his or her banking information, the CMS-588 is not required. If you are a supplier who is reassigning all of your benefits to a group, neither you nor the group is required to receive payments via electronic funds transfer.
- Submit all supporting documentation. In addition to a complete application, each provider or supplier is required to submit all
applicable supporting documentation at the time of filing. Supporting documentation includes, if applicable, an Electronic Funds Transfer Authorization Agreement (CMS-588). Note: Only durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers are required to submit the National Provider Identifier notification received from the National Plan and Provider Enumeration System. See Section 17 of the CMS-855 for additional information regarding the applicable documentation requirements.
- Sign and date the application. Applications must be signed and dated by the appropriate individuals. Signatures must be original and in ink (blue preferable). Copied or stamped signatures will not be accepted.
- Respond to fee-for-service contractor requests promptly and fully. To facilitate your enrollment into the Medicare program, respond promptly and fully to any request for additional or clarifying information from the fee-for-service contractor.
If you have further questions about this process, email Senior Manager of Coding and Reimbursement Norma Border at firstname.lastname@example.org,