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MEDICARE ENROLLMENT FOR PHYSICIANS, NPPs, AND OTHER PART B SUPPLIERS

ICN 903768 December 2017

PRINT-FRIENDLY VERSION

Target Audience: Medicare Fee-For-Service Program (also known as Original Medicare)

The Hyperlink Table, at the end of this document, provides the complete URL for each hyperlink.

MLN BookletMedicare Enrollment for Physicians, NPPs, and Other Part B Suppliers

ICN 903768 December 2017Page 2 of 14

QUICK START

GUIDESTEP1 Get an NPI

• Check to see if you have one• If not, apply online, via paper

application, or through an EFI

STEP2Enroll • Online in PECOS (Instructions for

physicians & NPPs or supplier organizations)

• Via paper application (CMS-855I or CMS-855B)

STEP3 Respond to requests from your MAC for more information

STEP4 Keep enrollment information up to date (use PECOS or paper enrollment form)

STEP5 Decide if you want to be a Participating Provider and accept Medicare-allowed amounts as payment in full

Accept

Updated

NPI

Provide more information

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ICN 903768 December 2017Page 3 of 14

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TABLE OF CONTENTSWho Are Part B Suppliers? 4

Step 1: Obtain a National Provider Identifier 5

Step 2: Complete the Proper Medicare Enrollment Application 6

Step 3: Respond to Requests From Your MAC for More Information 8

Step 4: Use PECOS to Keep Enrollment Information Up to Date 8

Determine If You Want to Be a Medicare Part B Participating Provider 8

Resources 10

Physicians, non-physician practitioners (NPPs), and other Part B suppliers must enroll in the Medicare Program to be paid for covered services they furnish to Medicare beneficiaries. This booklet provides education for physicians and certain Part B suppliers to determine if they are eligible to enroll in the Medicare Program and how to enroll.

Explore these booklets for information on Medicare enrollment for other provider types:

● PECOS for DMEPOS Suppliers ● Medicare Enrollment for Institutional Providers ● Medicare Enrollment for Providers Who Solely Order, Certify, or Prescribe

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WHO ARE PART B SUPPLIERS?For Medicare Part B provider enrollment purposes, Table 1 lists physicians, NPPs, clinics/group practices, and specified other suppliers who can enroll as a Medicare Part B provider as defined in enrollment Forms CMS-855I and CMS-855B.

Table 1. Physician, NPP, Clinical/Group Practice, and Specified Other Suppliers

Physicians/NPPs/Suppliers (Form CMS-855I) Clinics/Group Practices and Certain Other Suppliers (Form CMS-855B)

● Anesthesiology Assistants ● Audiologists ● Certified Nurse-Midwives ● Certified Registered Nurse Anesthetists ● Clinical Nurse Specialists ● Clinical Social Workers ● Mass Immunization Roster Billers, individuals ● Nurse Practitioners ● Occupational/Physical Therapists in

private practice ● Physicians (Doctors of Medicine or Osteopathy,

Doctors of Dental Medicine; Dental Surgery; Podiatric Medicine; or Optometry)

● Physician Assistants ● Psychologist, Clinical ● Psychologists billing independently ● Registered Dietitians or Nutrition Professionals ● Speech-Language Pathologists

● Ambulance Service Suppliers ● Ambulatory Surgical Centers (ASCs) ● Clinics/Group Practices ● Hospital Department(s) ● Independent Clinical Laboratories ● Independent Diagnostic Testing Facilities

(IDTFs) ● Intensive Cardiac Rehabilitation Suppliers ● Mammography Centers ● Mass Immunization Roster Billers, entities ● Part B Drug Vendor ● Pharmacy ● Physical/Occupational Therapy Group in

Private Practice ● Portable X-ray Suppliers ● Radiation Therapy Centers

If your provider or supplier type is not listed in Table 1, contact your Medicare Administrative Contractor (MAC) before submitting a Medicare enrollment application. Refer to the Medicare Fee-For-Service Provider Enrollment Contact List for MAC contact information for each State.

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STEP 1: OBTAIN A NATIONAL PROVIDER IDENTIFIERThe Centers for Medicare & Medicaid Services (CMS) encourages using the following systems for provider enrollment: the Identity & Access Management (I&A) System, the National Plan and Provider Enumeration System (NPPES), and the Provider Enrollment, Chain, and Ownership System (PECOS).

You may authorize users in the I&A System to work in CMS systems on your behalf. For more information on designating CMS system users in the I&A System, refer to PECOS for Physicians and NPPs if you are in the first column of Table 1 and PECOS for Provider and Supplier Organizations if you are in the second column.

Physicians, NPPs, and other Part B suppliers must obtain a National Provider Identifier (NPI) before enrolling in the Medicare Program. You can apply for an NPI in one of three ways:

1. Online Application: You must have an I&A System user account as described above. Then you must apply for an NPI through NPPES.

2. Paper Application: Complete, sign, and mail the NPI Application/Update Form (Form CMS-10114) paper application to the NPI Enumerator address on the form. To request a hard copy application, call 1-800-465-3203 or TTY 1-800-692-2326, or email customerservice@npienumerator.com.

3. Bulk Enumeration: Apply for Electronic File Interchange (EFI) access and upload your own comma-separated values (CSV) files.

NOT SURE IF YOU HAVE AN NPI?

Search for your NPI on the NPPES NPI Registry.

PROTECT YOURSELF AND CMS PROGRAMS FROM FRAUD

Your NPI and Tax ID are publicly available information. Use extra caution to monitor and protect your professional and personal information to help prevent fraud and abuse. You must also ensure your patients’ personal health information is secure. CMS provides the following resources to help:

● Medicare Fraud & Abuse: Prevention, Detection, and Reporting ● Office of Inspector General ● Help Fight Medicare Fraud for patients

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ICN 903768 December 2017Page 6 of 14

STEP 2: COMPLETE THE PROPER MEDICARE ENROLLMENT APPLICATIONAfter you have an NPI, you can apply to enroll in the Medicare Program, revalidate your enrollment, or change your enrollment information. Make sure you have the information you need to enroll before starting. Complete these actions via PECOS or the paper enrollment form.

A. Online PECOS ApplicationThis is CMS’ preferred method for Medicare enrollment. You must log in to PECOS with your I&A System credentials to initiate and complete the application process.

PECOS is a scenario-driven application—it presents a series of questions to retrieve only the information needed to process your specific enrollment scenario. You can submit all supporting documentation through PECOS. Review the Medicare Provider-Supplier Enrollment National Educational Products listing for your practitioner/supplier type for more information.

PECOS IS EASY!

We encourage you to use PECOS instead of the paper Medicare enrollment application. Advantages of using PECOS include:

● Completely paperless process, including electronic signature and digital document feature ● Faster than paper-based enrollment ● Tailored application process means you only supply information relevant to your application

and specialty ● More control over your enrollment information, including reassignments ● Easy to update and check your information for accuracy ● Less staff time and administrative costs to complete and submit enrollment to Medicare

B. Paper Medicare Enrollment Applications (Forms CMS-855)Alternatively, submit the appropriate paper enrollment application. Carefully review the paper application instructions to determine which form is right for your type of practice. The paper Medicare enrollment application collects your information, including the documentation necessary to ensure you are eligible to enroll in the Medicare Program. Even if you submit your application on a paper form, a record is still created in PECOS.

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The enrollment applications for physicians, NPPs, and the specified other Part B suppliers listed in Table 1 are:

● Medicare Enrollment Application: Physicians and Non-Physician Practitioners (Form CMS-855I): Used by individual physicians or NPPs to initiate the Medicare enrollment/revalidation process or to change Medicare enrollment information.

● Medicare Enrollment Application: Reassignment of Medicare Benefits (Form CMS-855R): Used to initiate a reassignment of a right to bill the Medicare Program and get Medicare payments.NOTE: To initiate the enrollment process, most physicians and NPPs complete Form CMS-855I.

If you also reassign your benefits to another entity, such as a medical group or group practice that receives payment for your services, you must also complete Form CMS-855R or the associated PECOS enrollment applications.

● Medicare Enrollment Application: 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 enrollment process, initiate the revalidation process, or change Medicare enrollment information.

● Medicare Enrollment Application: Eligible Ordering, Certifying, and Prescribing Physicians and Other Eligible Professionals (Form CMS-855O): Used by physicians and other eligible NPPs to enroll in the Medicare Program solely to order or certify items or services, or prescribe Part D drugs for Medicare beneficiaries. This includes those physicians and other eligible NPPs who do not and will not send claims to a MAC for the services they furnish. Refer to the Medicare Enrollment for Providers Who Solely Order, Certify, or Prescribe booklet for more information.

Application FeePhysicians, NPPs, physician organizations, and non-physician organizations do not have an application fee. For more information about the provider types subject to an application fee, refer to the Application Fee Requirements Matrix.

ELECTRONIC FUNDS TRANSFER (EFT)

CMS requires all providers use EFT if enrolling in Medicare or making certain changes to their enrollment. The most efficient way to enroll in EFT is to complete the EFT information section in PECOS. When submitting a PECOS web application, you must:

● Complete the EFT information for your organization (if applicable) ● Include a copy of a voided check or bank letter that includes a legal business name ● Include the account number and routing number that match the numbers entered in PECOS

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STEP 3: RESPOND TO REQUESTS FROM YOUR MAC FOR MORE INFORMATIONYour MAC pre-screens and verifies all information on the enrollment application. During processing, you may be required to submit additional information. Respond to any requests from your MAC as soon as possible, but within 30 days of the request. Failure to do so may delay enrollment or result in the rejection of the submitted application (deactivation). Once your MAC approves the application, it will switch the PECOS record to an “approved” status and send you an approval letter.

STEP 4: USE PECOS TO KEEP ENROLLMENT INFORMATION UP TO DATE

How to Report ChangesYou can report a change in your Medicare enrollment information using PECOS. You must report a change of ownership or control, a change in practice location, and any final adverse legal actions (such as revocation or suspension of a Federal or State license) within 30 days of the reportable event (see the PECOS FAQs section on reportable events for a definition). Submit all other changes within 90 days of the reportable event.

DETERMINE IF YOU WANT TO BE A MEDICARE PART B PARTICIPATING PROVIDERIn Medicare, “participation” means you agree to always accept claims assignment for all covered services furnished to Medicare beneficiaries. By agreeing to always accept assignment, you agree to always accept Medicare-allowed amounts as payment in full and not to collect more than the Medicare deductible and coinsurance or copayment from the beneficiary. The Social Security Act requires you to submit claims for Medicare beneficiaries whether you participate or not.

To participate in the Medicare Program as a participating provider or supplier, submit the Medicare Participating Physician or Supplier Agreement (Form CMS-460). You have 90 days from when you enroll to decide if you want to be a participating provider or supplier. The only other time you may change your participation status is during the open enrollment period, generally from mid-November through December 31 of each year.

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Table 2. Medicare Participation vs. Nonparticipation

Participation Nonparticipation

● Medicare reimbursement is 5 percent higher than nonparticipating physicians and other suppliers

● Medicare issues payments directly to you because the claims are always assigned

● Claim information is forwarded to Medigap (Medicare supplemental coverage) insurers

● Medicare reimbursement is 5 percent lower than participating physicians and other suppliers

● You cannot charge the beneficiary more than the limiting charge, 115 percent of the Medicare Physician Fee Schedule amount

● You may accept assignment on a case-by-case basis

● You have limited appeal rightsFor more information on Medicare participation, refer to the Medicare Claims Processing Manual, Chapter 12.

RevalidationRevalidation—resubmitting and recertifying the accuracy of your enrollment information—is an important tool in the fight against fraud. All providers and suppliers enrolled in Medicare must revalidate their enrollment information periodically. Generally, physicians, including physician organizations, revalidate enrollment every 5 years, or when CMS requests it. PECOS is the most efficient way to submit your revalidation information.

If you are currently and actively enrolled, check the Medicare Revalidation Lookup Tool to find your revalidation due date. If you see a due date, submit your revalidation prior to that date. Your MAC will also send you a notice to revalidate. If you submit your application after the due date, the MAC may place a hold on your Medicare payments, deactivate your billing privileges, or revoke your existing billing privileges.

For more information, refer to:

● Medicare Provider-Supplier Enrollment: Revalidations webpage ● Provider Enrollment Revalidation – Cycle 2 MLN Matters® article

LARGE GROUP COORDINATION

Groups with more than 200 members can access the Medicare Revalidation Lookup Tool and search by their organization’s name to download their group information. They will also receive a letter and spreadsheet from their MAC listing the providers linked to their group required to revalidate within 6 months. Large groups should work together to ensure only one application from each provider/supplier is submitted.

MLN BookletMedicare Enrollment for Physicians, NPPs, and Other Part B Suppliers

ICN 903768 December 2017Page 10 of 14

QUESTIONS?

Refer to the PECOS FAQs, or review the Provider Enrollment Revalidation Cycle 2 FAQs.

RESOURCESFor more information about the Medicare enrollment process, visit the Medicare Provider-Supplier Enrollment webpage, which provides information about:

● PECOS, including how to update your records using PECOS ● Paper Medicare enrollment application forms ● Frequently asked questions (FAQs) ● Contact information for all MACs ● CMS updates on provider enrollment

Table 3. Resources

For More Information About… Resource

CMS External User Services (EUS) Help Desk To report PECOS navigation, access, or printing problems, contact the CMS EUS Help Desk. Find contact information at EUS.custhelp.com.

I&A FAQs NPPES.CMS.HHS.gov/IAWebContent/FAQs.pdf

I&A System Account Registration NPPES.CMS.HHS.gov/IAWeb/register/startRegistration.do

MACs Provider Enrollment ContactsCMS.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/contact_list.pdf

Review Contractor Directory – Interactive MapCMS.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map

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Table 3. Resources (cont.)

For More Information About… Resource

Medicare Application Fee Hardship Exception CMS.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7350.pdf

MLN Connects® National Provider Call, Creating and Verifying Your National Provider Identifier

CMS.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/ 2017-07-12-NPI.html

MLN Matters Article, Implementation of Fingerprint-Based Background Checks

CMS.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1417.pdf

MLN Matters Article, Modernized National Plan and Provider Enumeration System

CMS.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17016.pdf

NPI CMS.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdent Stand

PECOS PECOS SystemPECOS.CMS.HHS.gov

About PECOSCMS.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Internet basedPECOS.html

PECOS Technical Assistance Contact Information CMS.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243418.html

Revalidations CMS.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidations.html

Video Resources Medicare Provider Enrollment, Chain, and Ownership System (PECOS)YouTube.com/playlist?list=PLaV7m2-zFKpia1Mc B1WKKkw2esAdiZRem

What’s New in NPPES 3.0YouTube.com/embed/BOJCAj1P2u8

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Table 4. Hyperlink Table

Embedded Hyperlink Complete URL

Application Fee Requirements Matrix https://www.cms.gov/Medicare/Provider- Enrollment-and-Certification/MedicareProvider SupEnroll/Downloads/ApplicationFeeRequirement Matrix.pdf

Change of Ownership or Control https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-05-18-eNews.html#_Toc482773810

Check https://npiregistry.cms.hhs.gov

Electronic File Interchange (EFI)EFI

https://nppes.cms.hhs.gov/webhelp/nppeshelp/EFI%20HELP%20PAGE.html

Help Fight Medicare Fraud https://www.medicare.gov/forms-help-and-resources/report-fraud-and-abuse/fraud-and-abuse.html

Identity & Access Management (I&A) SystemI&A System

https://nppes.cms.hhs.gov/IAWeb

Information You Need to Enroll https://pecos.cms.hhs.gov/pecos/help-main/checklists.jsp

Medicare Claims Processing Manual, Chapter 12 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

Medicare Enrollment Application: Clinics/Group Practices and Certain Other Suppliers (Form CMS-855B)CMS-855B

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855b.pdf

Medicare Enrollment Application: Eligible Ordering, Certifying, and Prescribing Physicians and Other Eligible Professionals (Form CMS-855O)

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855o.pdf

Medicare Enrollment Application: Physicians and Non-Physician Practitioners (Form CMS-855I)CMS-855I

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855i.pdf

Medicare Enrollment Application: Reassignment of Medicare Benefits (Form CMS-855R)CMS-855R

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855r.pdf

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Table 4. Hyperlink Table (cont.)

Embedded Hyperlink Complete URL

Medicare Enrollment for Institutional Providers https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243482.html

Medicare Enrollment for Providers Who Solely Order, Certify, or Prescribe

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1247538.html

Medicare Fee-For-Service Provider Enrollment Contact List

https://www.cms.gov/Medicare/Provider- Enrollment-and-Certification/MedicareProvider SupEnroll/Downloads/contact_list.pdf

Medicare Fraud & Abuse: Prevention, Detection, and Reporting

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243333.html

Medicare Participating Physician or Supplier Agreement (Form CMS-460)

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS460.pdf

Medicare Provider-Supplier Enrollment https://www.cms.gov/Medicare/Provider- Enrollment-and-Certification/MedicareProvider SupEnroll

Medicare Provider-Supplier Enrollment National Educational Products Listing

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSup Enroll/Downloads/Medicare_Provider-Supplier_Enrollment_National_Education_Products.pdf

Medicare Provider-Supplier Enrollment: Revalidations

https://www.cms.gov/Medicare/Provider- Enrollment-and-Certification/MedicareProvider SupEnroll/Revalidations.html

Medicare Revalidation Lookup Tool https://data.cms.gov/revalidation

National Plan and Provider Enumeration System (NPPES)NPPES

https://nppes.cms.hhs.gov

NPI Application/Update Form (Form CMS-10114) https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS10114.pdf

NPPES NPI Registry https://npiregistry.cms.hhs.gov

Office of Inspector General https://oig.hhs.gov

Online https://nppes.cms.hhs.gov/IAWeb

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Table 4. Hyperlink Table (cont.)

Embedded Hyperlink Complete URL

Paper Application https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS10114.pdf

PECOS FAQs https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/ICN909015.html

PECOS for DMEPOS Suppliers https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243483.html

PECOS for Physicians and NPPs https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243414.html

PECOS for Provider and Supplier Organizations https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243426.html

Physicians & NPPs https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243414.html

Provider Enrollment, Chain, and Ownership System (PECOS)PECOS

https://pecos.cms.hhs.gov

Provider Enrollment Revalidation – Cycle 2 https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNMatters Articles/Downloads/SE1605.pdf

Provider Enrollment Revalidation Cycle 2 FAQs https://www.cms.gov/Medicare/Provider- Enrollment-and-Certification/MedicareProvider SupEnroll/Downloads/Reval_Cycle2_FAQs.pdf

Revalidate Their Enrollment Information https://www.cms.gov/Medicare/Provider- Enrollment-and-Certification/MedicareProvider SupEnroll/Downloads/RevalidationChecklist.pdf

Supplier Organizations https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243426.html

Medicare Learning Network® Product DisclaimerThe Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).