Guide to Medicare Enrollment
If you plan to see Medicare patients, you need to enroll as a Medicare provider. The following is a step-by-step guide:
Step 1: Obtain a National Provider Identifier (NPI)
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates the use of a standard unique 10-digit identifier for healthcare providers. There are two types of NPI:
1) Type 1 or individual NPI assigned to individual healthcare providers. The type 1 NPI of the rendering provider is the number that should be used in box 24J of the CMS-1500 claim form.
2) Type 2 or organizational NPI assigned to healthcare organizations, including sole proprietors who have formed a corporation to conduct business. The type 2 NPI is considered the billing NPI that should be used in box 33 of the CMS-1500 claim form
To obtain your NPI, either complete an on-line application at https://NPPES.cms.hhs.gov/NPPES/Welcome.do or download an application at www.cms.hhs.gov/NationalProvidentStand/ and mail it to the address on the form.
If completed correctly, you should receive your NPI number within 10 days. Please remember to retain the notification document that NPPES sends you.
Step 2: Submit the Medicare enrollment application (CMS-855)
There is an internet-based, scenario-driven application process called PECOS (Provider Enrollment, Chain and Ownership System) that can ensure an accurate and efficient submission: This can be found at: https://pecos.cms.hhs.gov/pecos/login.do
You may also find a copy of the Medicare enrollment application at: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855o.pdf, then complete and submit it to the appropriate Medicare contractor. A list of the Medicare fee-for-service contractors by state may be found in the download section of www.cms.hhs.gov/MedicareProviderSupEnroll
The application must be signed (preferably in blue ink) by the authorized individual and mailed to the appropriate Medicare contractor.
It is in your best interest to respond fully and promptly to any request for additional or clarifying information you may receive from the contractor.
Enrollment Status: Participating or Non-Participating Provider
To “participate”, a provider must sign a participation agreement (CMS-460) to accept assignment for all covered services provided to Medicare patients, found at: Medicare CMS 460 Form.
- Your Medicare fee schedule amount is 5 percent higher than that of a non-participating provider.
- Collections from patients are much easier because Medicare pays 80 percent to the provider and you only need to collect 20 percent (co-payment) of the bill from the beneficiary.
- Medicare will automatically forward Medigap claims to the proper insurer for payment when you send in your completed claim form. This “one stop” billing eliminates the need for you to submit a separate bill to the supplementary insurer or beneficiary after receiving Medicare’s payment.
- Participation also improves your relationship with the beneficiary because it helps reduce the beneficiary’s out-of-pocket expenses.
- If you choose not to become a participating provider in the Medicare program, you may choose either to accept or not accept assignment on Medicare claims on a claim-by-claim basis. If you choose not to accept assignment, you may not charge the beneficiary more than the Medicare limiting charge for unassigned claims for Medicare services.
- The limiting charge applies to non-participating providers in the Medicare Part B program when they do not accept assignment. The limiting charge is 115 percent of the physician fee schedule amount. The beneficiary is not responsible for billed amounts in excess of the limiting charge for a covered service. Effective Jan. 1, 1994, the limiting charge applies to all services and supplies billed under the Physician Fee Schedule (including drugs and biologicals) regardless of the provider rendering the services.
Changing Your Status
Typically providers are given the last six weeks of the calendar year (Nov. 15-Dec. 31) to change their participation status. Once made, the decision is binding throughout the following calendar year (unless the decision period is re-opened). Another exception could be in situations where a physician’s practice changes significantly, such as relocation to a different geographic area or transformation into a group practice.
- If you are currently non-participating and wish to become participating, you must sign a participation agreement: Medicare CMS 460 Form
- If you are currently a participating provider and wish to become non-participating, you will need to submit a letter (on office letterhead) to your local carrier or administrative contractor stating your intent to become non-participating. This letter must include an original signature of the authorized representative or individual provider. If you wish your status to remain unchanged, you need not do anything.