Thursday, September 22, 2022

How Can I Become A Medicare Provider

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Reassignment Of Benefits Details

Medicare Provider Enrollment Through PECOS

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

  • 1Register with the National Plan & Provider Enumeration System . Youll need to create a user ID that will be used to obtain your National Provider Identifier, and this same log in information will be used to log into the Provider Enrollment, Chain, and Ownership Systems website where you will apply to become a Medicare provider. The process is simple, but once youve chosen a user ID, it cannot be changed. Carefully evaluate the information before finalizing.XResearch source
  • 2Obtain your National Provider Identifier . Once your user name is set up in the NPPES system, youll need to request this provider number. Depending on the type of medical care you provide, you will need to obtain an individual, organizational, or both types of NPI before you can apply as a Medicare provider.
  • Type 1 NPIs are required for individuals applying to accept Medicare coverage.
  • Type 2 NPIs are necessary for organizations, and these have to be obtained prior to any individual providers receiving approval as a member of the organization.
  • Both types of NPI are necessary if you are a sole proprietor of a medical facility.XResearch source
  • Any final adverse action documentation from legal cases against you or the practice you work for.
  • Include banking information as necessary if you have an agreement with a bank to cover pending Medicare payments.
  • 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.

    Read Also: What Is A Medicare Claim Number

    Determining Your Eligibility As A Medicare Provider

  • 1Learn the types of Medicare. Any physician or non-physician medical care or supply provider who offers services or goods necessary for the physical and mental health of those who receive Medicare coverage are eligible to apply as providers. Depending on the type of goods or services you offer, the application process includes a number of steps to ensure eligibility. Its important to review the various types Medicare coverage and how your clinic, practice, hospital, home health, or medical equipment provider fits into each part.
  • Part A, or hospital Medicare, includes hospital treatments, long-term care facilities, home health, and hospice.
  • Part B, or medical treatment Medicare, covers doctor services, preventive care, medical equipment, any outpatient procedures, lab testing, x-rays, clinical and outpatient mental health services, and other similar treatments.
  • Part C is Medicare coverage offered by private insurance providers. Those eligible for Medicare can opt for the Part C plan and pay additional coverage fees, if they want to expand the services and providers included in their treatment plans.
  • Part D covers prescription drugs.XResearch source
  • DMEPOS suppliers will need to complete additional criteria to be considered in compliance with the Clinical Laboratory Improvement Amendments in order to qualify to bill Medicare for the goods provided.XResearch source
  • Determine Eligibility As Medicare Provider

    41 Step Guide to Become a Medicare Provider w/ Screenshots

    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.

    Also Check: How Much Is Medicare B Cost

    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

    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 .

    Step 1: Get an NPI

    If you already have an NPI, skip this step and proceed to Step 2.

    NPIs are issued through the National Plan & Provider Enumeration System . You can apply for an NPI on the NPPES website. Not sure if you have an NPI? Search the NPI Registry.

    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.

    Recommended Reading: Are We Getting New Medicare Cards

    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

    PECOS Enrollment Tutorial Initial Enrollment for an Individual Provider

    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:

  • CMS855I Medicare Enrollment Application Physicians and Non-Physician Practitioners
  • CMS460 Medicare Participating Physician or Supplier Agreement
  • CMS588 Electronic Funds Transfer Authorization Agreement
  • Supporting Documents Required:

  • CP575 or Letter 147C from the IRS to verify the tax id# of the business
  • Pre-printed voided check, or a bank letter of account verification, that exactly matches the legal business name on the IRS CP575 or letter 147C.
  • 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.

    Also Check: Is Unitedhealthcare Dual Complete A Medicare Plan

    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

    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 .

    Step 1: Get an NPI

    If you already have an NPI, skip this step and proceed to Step 2.

    NPIs are issued through the National Plan & Provider Enumeration System . You can apply for an NPI on the NPPES website. Not sure if you have an NPI? Search the NPI Registry.

    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

    Medicare Credentialing: How to Become a Medicare Provider
  • Information about relevant final adverse actions, which may include:
  • Medicare-imposed revocation of billing privileges
  • Suspension, termination, or revocation of a license to provide health care by a state licensing authority or the Medicaid Program
  • Conviction of a federal or state felony within 10 years before enrollment, revalidation, or re-enrollment
  • Exclusion or debarment from federal or state health care program participation by the Office of Inspector General or other federal or state offices with authority to exclude or sanction a provider
  • 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
  • Reassign benefits to an unenrolled PECOS provider
  • 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.

    Read Also: Which Of The Following Is A Medicare Supplement Additional Benefit

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

  • Register with the National Plan and Provider Enumeration System By registering in NPPES, you will create a user ID, this ID will be used to obtain your National Provider Identifier . This will also be used to log in to the PECOS website where you will be applying to become a Medicare provider/supplier. Your user ID cannot be changed, so be careful in choosing one.
  • ObtainYour National Provider Identifier This is a unique 10-digit number and will depend on the medical care you are providing. It may be individual, organizational or both types of NPI. You can obtainyour NPI though the online application HERE or you may download the PDF version of the NPI application. Once youve completed the application form, you may mail it to the NPI Enumerator address listed on the form. For those who cannot access the application online, you may call 465-3203 and request a paper copy.
  • Complete the Medicare Enrollment Application The next step will be to complete the Medicare Enroll Application. You can do this through Provides Enrollment, Chain and Ownership System . You must fill out CMS 855A if you are an institutional provider like home health agencies, outpatient physical therapy services, and hospice. But if you sell supplies or medical equipment, fill out CMS 855S, this is also called the MEA for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies . For, physicians and non-physician practitioners use CMS 855I. For reassignment of Medicare benefits, use CMS 855R.
  • 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:

    Also Check: Is Ibrance Covered By Medicare

    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.

    Table 2. Options to Verify Your Current Enrollment Record Exists in PECOS

    Verification Option
    Youre on 1 of these reports.
    Go to PECOS to find your enrollment record. Your enrollment record displays an approved status.
    If you submitted an enrollment application as 1 of the eligible provider types on paper or using PECOS and want to check the status, go to the Pending Initial Logging and Tracking Non Physicians and Pending Initial Logging and Tracking Physicians datasets. Your enrollment application is pending contractor review if youre on 1 of these reports.

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

    Providers Who Solely Order Or Certify

    Should I become a Medicare Provider

    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 .

    Recommended Reading: Who Must Enroll In Medicare

    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?

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