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Enroll/Make Changes via PECOS Web

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Enroll in Medicare

Before jumping into Medicare Enrollment applications, it is best to be prepared. To ensure a provider has everything necessary to properly complete a Medicare application(s), check out the below table. Not all topics may apply to each applicant.

Prepare and Get Started

View Enrollment related terms on the Terms and Definitions webpage.

* Required for all applicants

Topic Brief Details
* Is Provider Eligible to Enroll in Medicare?
  • View a list of eligible Part B specialties on the Eligible Specialties webpage. If a specialty is not listed, that specialty is not able to enroll in Medicare.
  • If a provider is unsure of which taxonomy code to choose, he/she should visit the Washington Publishing Company (WPC) website to view the Health Care Provider Taxonomy Code Set. Health Care Provider Taxonomy Codes define a health care service provider type, classification, and area of specialization.
*Obtain NPI via NPPES as it is required for all providers/suppliers * If Eligible, enroll as Group Member, Organization, Sole Owner, or a Sole Proprietor? NPPES - Individuals and organizations use NPPES to apply for NPIs and to keep their NPI information up-to-date, including addresses, phone numbers, and taxonomy codes

NPI: What You Need to Know - Learn more about sole proprietors and difference between Type 1 and Type 2 NPIs

To further help explain the differences, watch our How Do I Determine What I Am? Tutorial.

Individual providers must obtain a Type 1 (Individual) NPI.
Organizations must obtain at least one Type 2 (Organization) NPI. The number of type 2 NPIs an organization obtains is an individual business decision.
  • Type 1 NPI - Physicians and non-physician practitioners
  • Type 2 NPIs - Physician groups, hospitals, nursing homes, group practices, pharmacies (not all-inclusive listing)
When there are changes in information such as name, tax identification number (TIN), address, primary practice location, taxonomy code, contact person and/or authorized officials, providers must update their NPPES information and their Medicare enrollment within 30 days

View the National Provider Identifier (NPI) webpage for more details.

Group Member
  • Individuals who reassign all benefits to an organization or another individual
  • Individuals who have an arrangement with an employer to send in Medicare claims and get paid for your services rendered
Organization
  • Organizations have two or more owners
  • Organizations obtain at least one organizational (Type 2) NPI
  • Organizations bill with a Tax ID
Reassigning Benefits
  • Right to bill Medicare program and receive Medicare payments for services you render are appointed to organization
  • In order to reassign benefits, both organization and provider must be enrolled in Medicare
Sole Owner
  • Owners of a Professional Corporation (PC), Professional Association (PA), or sometimes a Limited Liability Company (LLC)
  • Must obtain both an individual (Type 1) and organizational (type 2) NPI
  • Bills Medicare through corporate business entity. They bill Medicare by using an incorporated EIN
  • Has personal assets that are legally separate from business
  • Chooses Sole Owner of a PA, PC or LLC option when submitting online via Internet-based PECOS
Sole Proprietor
  • Renders services in a facility that they own, lease or rent
  • Must obtain only an individual (Type 1) NPI
  • Is legally one and same with business and is personally responsible for any of business's financial obligations
  • Reports business's income and losses on a personal tax return
  • Has option of billing with their social security number or a non-incorporated Tax ID
  • Chooses Self-Employed/Sole Proprietor option when submitting online via Internet-based PECOS
Is Provider Enrolling to Bill CAH Method II? If providing Part B services in a Critical Access Hospital (CAH), a provider must be reassigned to the CAH Provider Transaction Access Number (PTAN) and NPI(s). Watch our Enrollment on Demand Application Tutorials for proper application instructions.
Is Provider Enrolling to Order, Certify and/or Prescribe Only? If a provider does not want to bill Medicare but is looking to enroll for the sole purpose of ordering, certifying, and/or prescribing Part D drugs, view the Ordering, Certifying, and Prescribing webpage.
PECOS Applicable to providers using PECOS Web to apply or make changes (PECOS Web allows providers to securely submit applications and review/update current file information via the Internet)

I&A is the gateway to PECOS and manages who has access to change those enrollments. Everyone using PECOS must use their own User ID and Password. This User ID and Password combination is managed by the I&A. Use provider NPPES login for the I&A.

To learn more about I&A, PECOS and to access PECOS Web Required Information Checklists, visit our PECOS webpage.

Participate or Not Participate?

Applicable to Organizations, Sole Owners and Sole Proprietors only

To participate or not participate is a personal choice. To make an educated decision, a provider or supplier should carefully read and analyze the advantages and disadvantages of participation. He/she should also carefully evaluate the provider pricing fee schedule, and other fee schedules that may apply, to determine the impact this decision will have on the reimbursement amount.

To participate in the Medicare program means that the provider/organization agrees to accept assignment for all services furnished to Medicare beneficiaries. Becoming a Participant means you agree to accept the amount approved by Medicare as total payment for covered services. More information available on the Participation webpage

A nonparticipating provider is a provider involved in the Medicare program who has enrolled to be a Medicare provider but chooses to receive payment in a different method and amount than Medicare providers classified as participating. The nonparticipating provider may receive reimbursement for rendered services directly from their Medicare patients. They submit a bill to Medicare so the beneficiary may be reimbursed for the portion of the charges for which Medicare is responsible. More information available on the Nonparticipation webpage

* Have Supporting Documents Available

Examples

  • Copies of licenses and/or certifications
  • Copy of provider IRS document containing full legal business name and Tax ID number (IRS Letter 147C, CP 575)
  • Voided check or signed bank letter for Organizations, Sole Owners and Sole Proprietors only

 

Required Applications and Tips

Providers may submit applications in one of two ways.

  1. Internet-based PECOS (highly encouraged method) - PECOS Web allows providers to securely submit applications and review/update current file information via the Internet. Prior to submission, providers must upload all required supporting documentation and electronically sign the certification statement
  2. Paper - Access all forms, view tutorials and read application instructions from the Noridian Forms webpage
  3. Enrollment on Demands (EoDs) - Step-by-step self-paced tutorial to help providers complete an application. For more information, view the Enrollment on Demand (EoD) Tutorials for Part B Specialties webpage.
Provider Type Required Application(s) Tips

Group Member

  • PECOS application
  • Approved providers reassigning benefits: CMS-855R
  • New providers reassigning benefits: CMS-855I, CMS-855R
  • Physician Assistant (PA): CMS-855I only
  • After starting an application, choose "Individual Physician" or "Non-Physician Practitioner" and select "Group Member Only."
  • Complete sections 1, 2, 3, 4B, 13, and 15 of CMS-855I
  • Physician Assistants (PAs) complete sections 1, 2, 2E, 13 and 15 of CMS-855I
  • List all reassignments, Provider Transaction Access Numbers (PTANs) and National Provider Identifiers (NPIs) in which provider will render services
  • Attach all supporting documentation such as Diploma and Certification

Organization

  • PECOS application
  • CMS-855B
  • CMS-588 EFT
  • CMS 460 (if applicable)
  • After starting an application, select "Clinics/Group Practices and Certain Other Suppliers"
  • Complete all sections of CMS-855B
  • Attach all supporting documentation such as IRS document, CMS 588 EFT and voided check/bank letter
  • List all current, active practice locations
  • List all directors, board members, and contracted or W-2 managing employee
  • Ensure that someone is marked as a contracted or W-2 managing employee
  • Fees may be required. View Application Fee webpage to see if this applies

Organization must have at least one rendering provider
If provider not enrolled, submit CMS-855I and CMS-855R
If provider is actively enrolled, submit CMS-855R

Sole Owner

  • PECOS application
  • CMS-855I
  • CMS-588 EFT
  • CMS 460 (if applicable)
  • A group application along with an individual application will need to be submitted. See Group Member information and Organization information
  • Complete sections 1, 2, 3, 4A-4H, 6, 8, 13, and 15 of CMS-855I
  • Attach all supporting documentation such as Diploma, Internal Revenue Service (IRS) document, Certification, CMS-588 Electronic Funds Transfer (EFT) and voided check/bank letter
  • List all current, active practice locations

Sole Proprietor

  • PECOS Application
  • CMS-855I
  • CMS-588 EFT
  • CMS 460 (if applicable)
  • After starting an application, choose "Clinics/Group Practices and Certain Other Suppliers and select "Self-Employed/Sole Proprietor"
  • Complete sections 1, 2, 3, 4C-4H, 6, 8, 13, and 15 of CMS-855I
  • Attach all supporting documentation such as Diploma, IRS document (if billing with EIN), Certification, CMS-588 EFT, voided check/bank letter
  • List all current, active practice locations

 

  • If provider has completed the e-signature process in PECOS, there is no need to sign and mail a paper signature as well
  • Ensure correspondence address is up to date and a location that is regularly monitored
  • If provider receives an email regarding being active in another state and is still active in that state, it may be disregarded. However, if no longer providing services in those states, send an application to terminate. See Withdraw from Medicare webpage for details

What a Provider Should Expect After Application Submission

Application Type Processing Time with an Onsite Visit Processing Time without an Onsite Visit
PECOS It can take 80-120 calendar days before application is completed It can take 45-90 calendar days before application is completed
Paper It can take 80-210 calendar days before application is completed It can take 60-180 calendar days before application is completed

 

  • When a provider application is completed, a notification letter will be sent. Letter will state whether application has been approved, rejected or denied
  • Corrections or additional information may be required to complete the processing of an application. Requests will be sent to contact person on application, if provided. Information must be submitted within 30 days of date of request
  • A PTAN will be issued and shown on the approval letter. See Provider Transaction Access Number (PTAN) webpage for details.

Provider may begin billing:

  • Enroll with Electronic Data Interchange (EDI) to bill electronically, visit EDISS for more information. Select state you are enrolled in
  • If there are any changes that must be made to enrollment following approval, complete a new form with any changes within 30 days to avoid revocation

CMS requires providers/suppliers to revalidate every five years. View the Revalidation webpage for details.

 

Last Updated Feb 01, 2018