Upload
dinhkien
View
220
Download
0
Embed Size (px)
Citation preview
Page 1 of 14
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
MLN BookletMedicare Enrollment for Physicians, NPPs, and Other Part B Suppliers
ICN 903768 December 2017Page 3 of 14
.................................................................................................................
....................................................................................
.....................................................
............................................
................................................................
.........................................
..........................................................................................................................................
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
MLN BookletMedicare Enrollment for Physicians, NPPs, and Other Part B Suppliers
ICN 903768 December 2017Page 4 of 14
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.
MLN BookletMedicare Enrollment for Physicians, NPPs, and Other Part B Suppliers
ICN 903768 December 2017Page 5 of 14
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 [email protected].
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
MLN BookletMedicare Enrollment for Physicians, NPPs, and Other Part B Suppliers
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.
MLN BookletMedicare Enrollment for Physicians, NPPs, and Other Part B Suppliers
ICN 903768 December 2017Page 7 of 14
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
MLN BookletMedicare Enrollment for Physicians, NPPs, and Other Part B Suppliers
ICN 903768 December 2017Page 8 of 14
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.
MLN BookletMedicare Enrollment for Physicians, NPPs, and Other Part B Suppliers
ICN 903768 December 2017Page 9 of 14
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
MLN BookletMedicare Enrollment for Physicians, NPPs, and Other Part B Suppliers
ICN 903768 December 2017Page 11 of 14
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
MLN BookletMedicare Enrollment for Physicians, NPPs, and Other Part B Suppliers
ICN 903768 December 2017Page 12 of 14
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
MLN BookletMedicare Enrollment for Physicians, NPPs, and Other Part B Suppliers
ICN 903768 December 2017Page 13 of 14
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
MLN BookletMedicare Enrollment for Physicians, NPPs, and Other Part B Suppliers
ICN 903768 December 2017Page 14 of 14
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).