How Can I Become A Medicare Provider

Reassignment Of Benefits Details

Note: Regarding Reassigning Benefits – if you were an independent contractor you WOULD NOT reassign benefits. This is because independent contractors receive reimbursements directly and not under the practice or a billing group/person. This is ONLY if you are a true independent contractor and not providing payments to the group Tax ID .

A message from the author – this is my personal experience with the Medicare application process. I am in no way, giving you instructions for how YOU should apply. I am simply showing you the exact way that I went about it.

You need to understand that if you mess up the application process, it can really hurt your practice because you will not be able to see Medicare patients. Not having access to those patients can financially hurt your practice in more ways than one…. I am not responsible if that happens to you.

If you are not prepared to claim responsibility for yourself then DO NOT use this article to help you. In all honesty, I know that this article will be helpful for you. It will speed up the process and help you nail it first try. It took me over 1 year to get on Medicare because of the mistakes I made, so I highly recommend using this article to avoid those same mistakes.

Applying As A National Medicare Provider

How Providers Enroll With The Ihcp

The page offers information about the current provider enrollment process, including links to a number of web pages with detailed information helpful to providers interested in serving IHCP members.

The IHCP enrollment webinar, Ways to avoid common mistakes during the enrollment process, is another resource and covers important details for enrolling as an IHCP provider.

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Determining Your Eligibility As A Medicare Provider

Determine Eligibility As Medicare Provider

Determining your eligibility as a Medicare provider is the next step. To be eligible, you may need to be certified with the Conditions of Participation. The Centers for Medicare and Medicaid Services relies on state agencies to determine the eligibility of most providers. Check with your State Survey Agency to get more information about eligibility requirements.

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Become A Medicare Provider Or Supplier

Ready to become a Medicare provider or supplier? This guide will help you enroll in three steps.

Do not use this guide if

• Youre a DMEPOS supplier. DMEPOS suppliers should follow the instructions on the Enroll as a DMEPOS Supplier page.
• Youre an institutional provider. If youre enrolling a hospital, critical care facility, skilled nursing facility, home health agency, hospice, or other similar institution, you should use the Medicare Enrollment Guide for Institutional Providers.

Use this guide if any of the following apply:

• Youre a health care provider who wants to bill Medicare for your services and also have the ability to order and certify.
• You dont want to bill Medicare for your services, but you do want enroll in Medicare solely to order and certify.
• You wish to provide services to beneficiaries but do not want to bill Medicare for your services.
• You want to enroll as a supplier who does not dispense or furnish durable medical equipment, prosthetics, orthotics and supplies .

Keep Your Information Current

Its important to keep your enrollment information up to date. To avoid having your Medicare billing privileges revoked, be sure to report the following changes within 30 days:

• a change in ownership

Is My Provider Approved By Medicare

Summary:

Medicare spending was $705.9 billion in 2017, according to the Centers for Medicare and Medicaid Services . Medicare providers are motivated to receive and maintain their Medicare certification in order to be eligible to receive some of this sizable sum as payment for their services. To be approved or certified by Medicare means that the provider has met the requirements to receive Medicare payments. Medicare certification is one way to protect you as the Medicare beneficiary and assure the quality of your care.

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Denial Of Ordering Or Certifying Claims

If claims lack a valid individual NPI, MACs deny them if theyre from:

• Clinical labs for ordered tests
• Imaging centers for ordered imaging procedures
• DMEPOS suppliers for ordered DMEPOS
• Part A HHAs that arent ordered or certified by a Doctor of Medicine , Doctor of Osteopathy , or Doctor of Podiatric Medicine

If you bill a service that needs an eligible provider and they arent on the claim, the MAC denies the claim. The claim must have a valid NPI, and the eligible providers name as it appears in PECOS.

If a provider on the Preclusion List prescribes a drug, Part D plans deny Part D covered drugs.

Completing The Medicare Provider Enrollment Process

This article will outline some of the key steps in the Medicare enrollment process for a single physician, John James MD, starting a new practice. This enrollment example assumes the physician has formed a legal business entity under which he will practice, XYZ, LLC. This example illustrates using the paper application process, and highlights sections that would cause an application to be denied if not fully completed.

Overview of forms needed:

Supporting Documents Required:

Dr. James will need to obtain a Medicare number, referred to as a Provider Transaction Identification Number or PTAN, for both himself and his legal business entity. This will allow all payments from Medicare to be made to his business under the business tax id#. Since Dr. James is the sole owner of XYZ, LLC, he can obtain both the Group PTAN and his Individual PTAN using the individual enrollment application CMS855I. The CMS855I contains 17 sections and 27 pages.

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The Medicare Certification Process

A completed Medicare provider application goes to the appropriate state agency, which checks the application and supporting documents for completeness and accuracy. For a health-care facility, the agency will provide a time frame in which you can expect an unannounced inspection to verify that your facility meets Medicare standards. Although an inspection is standard during enrollment, state agencies have the authority to conduct random unannounced inspections at any time. Once verifications and inspections are complete, the agency makes a recommendation and forwards the applications and results to the CMS for final approval or rejection.

Provider Enrollment And Certification: Become A Medicare Provider Or Supplier

Guidance for enrolling as a Medicare provider or supplier

Final

Issued by: Centers for Medicare & Medicaid Services

Issue Date: August 21, 2020

Ready to become a Medicare provider or supplier? This guide will help you enroll in three steps.

Do not use this guide if

• Youre a DMEPOS supplier. DMEPOS suppliers should follow the instructions on the Enroll as a DMEPOS Supplier page.
• Youre an institutional provider. If youre enrolling a hospital, critical care facility, skilled nursing facility, home health agency, hospice, or other similar institution, you should use the Medicare Enrollment Guide for Institutional Providers.

Use this guide if any of the following apply:

• Youre a health care provider who wants to bill Medicare for your services and also have the ability to order and certify.
• You dont want to bill Medicare for your services, but you do want enroll in Medicare solely to order and certify.
• You wish to provide services to beneficiaries but do not want to bill Medicare for your services.
• You want to enroll as a supplier who does not dispense or furnish durable medical equipment, prosthetics, orthotics and supplies .

Keep Your Information Current

• a change in ownership

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Section : Individuals Having Managing Control:

This section must list the name and identifying information of Dr. James. Dr. James would also need to make an additional copy of this page for an office manager or any other person who is responsible for managing the business of the practice.

The Remaining sections of the 855I form include providing information on your billing company if applicable, contact information for the person completing the enrollment form, and signatures for the application. In addition to the 855I, Dr. James will submit a form 460 to elect participation in the program. The 460 is a simple one page form. The final form to be submitted is form 588 to establish Electronic Funds Transfer for payment. The CMS588 is a simple one page form of information and signature on page 2.

Not Sure If You Have An Npi

42 CFR 424.535 has more information on revocation of enrollment in the Medicare Program.

An application is the paper or electronic form you submit for Medicare Program enrollment approval. After the MAC processes the application, PECOS keeps the enrollment record that includes all your enrollment application data.

You cant use PECOS to:

• Change your SSN
• Change a providers or suppliers TIN
• Change an existing business structure, for example:
• Solely owned Professional Association , Professional Corporation , or Limited Liability Company cant be changed to a sole proprietorship
• Sole proprietorship cant be changed to a PA, PC, or LLC

Submit changes noted above using the appropriate paper Medicare enrollment application.

No. All Fee-for-Service providers can apply in PECOS.

Even if you submit your application on a paper form, your MAC creates an enrollment record in PECOS.

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S To Ensure A Speedy Processing Of Your Medicare Provider Application:

Requirement : You Must Have An Individual Npi

There are 2 types of NPIs: Type 1 and Type 2 . Medicare allows only Type 1 NPIs to solely order items or certify services. Apply for an NPI through:

• Online Application: Get an Identity & Access Management System user account. Then apply for an NPI in the National Plan and Provider Enumeration System .
• Paper Application: Complete, sign, and mail the NPI Application/Update Form paper application to the address on the Enumerator form. To request a hard copy application, call 1-800-465-3203 , or email .
• Bulk Enumeration: Apply for Electronic File Interchange access and upload your own Comma-Separated Values or Extensible Markup Language files.

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Requirement : You Must Enroll In Medicare In An Approved Or Opt

When you have an NPI, use PECOS to verify current Medicare enrollment record information, including your NPI and that youre approved, or go to the Opt Out Affidavits list to check your status. To opt-out of Medicare, you must submit an affidavit expressing your decision to opt-out of the program.

We no longer require Part C and Part D providers to enroll in Medicare in an approved or opt-out status.

* We deny certain PMD claims if the ordering provider isnt on Medicares eligible providers list.

Providers Who Solely Order Or Certify

Physicians and other eligible professionals must enroll in the Medicare Program or have a valid opt-out affidavit on file to solely order or certify Medicare patient items or services.

Those physicians and other eligible professionals enrolled solely as ordering or certifying providers dont send billed service claims to a Medicare Administrative Contractor .

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Is Being A Non

Medicare and Insurance |

Ive been getting a few similar questions about the pros and cons of being a Non-Participating Provider with Medicare, and would like to address them here. You can see this post on Medicare for details on what that means if you are not familiar, but just to quickly review

There are three possibilities for a Physical Therapists relationship-status with Medicare:

1) No relationship at all

2) Participating Provider

3) Non-Participating Provider

A little more detail on the Non-Par Status: You can accept self-payment from the beneficiary at the time of service, but you still must send in the claim to Medicare. Medicare will then send any reimbursement directly to the patient. As a Non-Participating Medicare Provider, you can bill the patient up to 115% of the Medicare Fee Schedule.

So what kinds of questions does this status bring up?