MEDICARE PROVIDER ENROLLMENT PRINT-FRIENDLY VERSION

What’s Changed?

Application Fee

Physicians, non-physician practitioners (NPPs), physician organizations, and non-physician organizations don’t pay an application fee.

Institutional providers and suppliers like Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers, Opioid Treatment Programs (OTPs), and Medicare Diabetes Prevention Program (MDPP) suppliers, in general, pay an application fee when enrolling, re-enrolling, revalidating, or adding a new practice location.

Verify which providers pay a fee and when, using the Application Fee Requirements for Institutional Providers.

PECOS Users

CMS allows various organizations and users to work in their systems. The type of user depends on the individual’s relationship with you and the duties they perform in your practice.

You may choose other users to act for your organization to manage connections and staff, including appointing and approving other system-authorized users. Depending on your professional relationships with other providers, the CMS External User Services (EUS) Help Desk may ask you for additional information for validation.

One Account, Multiple Systems

CMS uses several provider enrollment systems. Organizational providers and suppliers must use the Identity & Access Management (I&A) System to name an Authorized Official (AO) to work in CMS systems. The I&A System allows you to:

• Use the National Plan and Provider Enumeration System (NPPES) to apply for and manage National Provider Identifiers (NPIs)
• Use PECOS to complete Medicare enrollment or update or revalidate your current enrollment information
• Register to get Electronic Health Record (EHR) incentive payments for eligible professionals and hospitals that adopt, use and upgrade, or demonstrate meaningful EHR technology

Authorized Officials, Access Managers, Staff End Users and Surrogates

Organizational providers or suppliers must appoint and authenticate an Authorized Official (AO) through the I&A System to work in PECOS for them. That individual must meet the AO regulatory definition. For example, an AO is a chief executive officer, chief financial officer, general partner, chair of the board, or direct owner to whom the organization allows legal authority to enroll in the Medicare Program.

Respond to your employer’s AO invitation or initiate the request yourself. After you're the confirmed AO, use PECOS for your provider or supplier organization. As an AO, you're responsible for approving PECOS user system requests to work on behalf of the provider or supplier organization. Regularly check your email and take the requested actions.

AOs may delegate their responsibilities to an Access Manager, who can also initiate or accept connections, and manage staff for their organizations.

AOs or Acess Managers may invite a Staff End User (SEU) or Surrogate to access PECOS for their organization. Once registered, an SEU or Surrogate may log in to access, view, and modify CMS system information, but they may not represent the practice, manage staff, sign enrollment applications, or initiate or accept connections.

For detailed instructions on managing system users, refer to the I&A System Quick Reference Guide.

DMEPOS Supplier Requirements

DMEPOS Supplier Standards, Accreditation, and Surety Bond

To enroll or keep your Medicare billing privileges, all DMEPOS suppliers (except certain exempted professionals) must meet supplier and DMEPOS Quality Standards to become accredited. Certain DMEPOS suppliers must also submit a surety bond.

DMEPOS suppliers (except those exempted eligible professionals and “other persons”) must have accreditation from a CMS-approved Accrediting Organization prior to submitting a Medicare enrollment application to the National Supplier Clearinghouse (NSC). For more information on these conditions, refer to the CMS DMEPOS Enrollment webpage or review the DMEPOS Accreditation fact sheet. It lists exempted eligible professionals.

Each enrolled DMEPOS supplier covered under the Health Insurance Portability and Accountability Act (HIPAA) must name each practice location (if it has more than one) as a sub-part and make sure each sub-part gets its own NPI.

Individual DMEPOS Suppliers (for example, sole proprietorships)

Physicians, NPPs, and DMEPOS suppliers may use their I&A System user ID and password to access PECOS. If you do not already have an I&A System account, refer to the I&A System User Registration page and enter the information to open an account. For help, refer to the I&A System Quick Reference Guide and click the “How to Setup Your Account if you are a Sole Owner” link.

As an individual DMEPOS supplier, you don’t need an Authorized Official (AO) or other authorized user.

Organizational DMEPOS Suppliers System Users

A DMEPOS supplier organization must appoint an AO to manage connections and staff, including appointing and approving other authorized PECOS users. The organization must identify the AO in the enrollment application. The AO must have ownership or managing control in the DMEPOS supplier organization.

Providers Who Solely Order or Certify

Recent legislation says 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 don't send billed service claims to a MAC.

Who Are Eligible Ordering or Certifying Providers?

Physicians or eligible professionals who order or certify Part A or Part B services but don't want to submit Medicare claims.

An individual already enrolled as a Medicare Part B provider may submit claims listing themselves as the ordering or certifying provider without re-enrolling using Form CMS-855O.

Those who enroll as eligible providers using Form CMS-855O may not bill Medicare or get paid by Medicare for their services. They have no Medicare billing privileges.

Eligible providers must meet these 3 basic conditions:

1. Have an individual National Provider Identifier (NPI)
2. Be enrolled in Medicare in either an “approved” or an “opt-out” status
3. Be an eligible specialty type to order or certify

Requirement 1: You Must Have an Individual NPI

There are 2 types of NPIs: Type 1 (individual) and Type 2 (organizational). Medicare allows only Type 1 NPIs for solely ordering items or certifying services. Apply for an NPI in 1 of 3 ways:

1. Online Application: Get an Identity & Access Management (I&A) System user account. Then apply in the National Plan and Provider Enumeration System (NPPES) for an NPI.
2. Paper Application: Complete, sign, and mail the NPI Application/Update Form (Form CMS-10114) paper application to the address on the Enumerator form. To request a hard copy application, call 1-800-465-3203 or TTY 1-800-692-2326, or email customerservice@npienumerator.com.
3. Bulk Enumeration: Apply for Electronic File Interchange (EFI) access and upload your own comma-separated values (CSV) files.

Requirement 2: You Must Enroll in Medicare in an “Approved” or “Opt-Out” Status

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

Since June 15, 2018, CMS no longer says Part C and Part D providers must enroll in Medicare in an “approved” or “opt-out” status.

* Medicare denies certain PMD claims if the ordering provider isn't on Medicare’s eligible providers list. For more information, refer to MLN Matters® Article MM2398.

Requirement 3: You Must Be Eligible to Order or Certify

The physicians and eligible professionals who may enroll in Medicare solely for ordering or certifying include, but aren't limited to, those physicians and eligible professionals who are:

• Department of Veterans Affairs (DVA) employees
• Public Health Service (PHS) employees
• Department of Defense (DOD)/TRICARE employees
• Indian Health Service (IHS) or a Tribal Organization employee
• Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), or Critical Access Hospitals (CAHs) employees
• Licensed Residents in an approved medical residency program defined in 42 CFR Section 413.75(b)
• Dentists, including oral surgeons
• Pediatricians
• Retired, licensed physicians

If you're unsure whether your specific provider specialty qualifies to enroll as an ordering or certifying provider, refer to Section 4 of Form CMS-855O or contact your MAC before submitting a Medicare enrollment application.

Requirement 4: Respond to MAC Requests for More Information

MACs pre-screen and verify enrollment applications. During processing, your MAC may need additional information. Respond to information requests within 30 days; otherwise, the MAC may reject your enrollment.

Your MAC won't fully process your PECOS enrollment application without your electronic or uploaded signature, application fee, and necessary supporting documentation. The effective application enrollment filing date is when the MAC gets your enrollment application.

You can check your PECOS enrollment application status 2 ways:

1. Log in to PECOS and click the “View Enrollments” link. In the “Existing Enrollments” section, find the application. The system shows the application status.
2. To see your enrollment status, go to the PECOS homepage and under “Helpful Links” click “Application Status.” You don't need to log in to PECOS to use this application status feature.

When your MAC approves your application, it switches the PECOS record to an “approved” status and sends you an approval letter.

Requirement 5: Use PECOS to Keep Enrollment Information Up to Date

Report a Medicare enrollment change using PECOS. Providers and suppliers 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 change and report all other changes within 90 days of the change.

DMEPOS suppliers must report any changes in information on their enrollment application within 30 days of the change.

Independent Diagnostic Testing Facilities (IDTFs) must report changes in ownership, location, general supervision, and adverse legal actions within 30 days of the change and report all other changes within 90 days of the change.

MDPP providers must report changes in ownership including AO or Access Manager, location, coach roster, and adverse legal actions within 30 days, and report all other changes within 90 days of the change.

For more information, refer to MLN Matters Article® SE1617.

Revalidation

Revalidation, or re-submitting and recertifying enrollment information accuracy, is an important anti-fraud tool. All Medicare-enrolled providers and suppliers must periodically revalidate their enrollment information.

Generally, physicians, including physician organizations, Opioid Treatment Programs (OTPs), Medicare Diabetes Prevention Program (MDPP) suppliers, and institutional providers revalidate enrollment every 5 years or when CMS requests it. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers must revalidate their enrollment information every 3 years.

PECOS is the most efficient way to revalidate information.

If you're currently and actively enrolled, go to 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 notifies you to revalidate. If you submit your revalidation application after the due date, the MAC may hold your Medicare payments or deactivate your billing privileges.

For more information refer to:

• Medicare Provider-Supplier Enrollment and Certification: Revalidations webpage
• Provider Enrollment Revalidation – Cycle 2 MLN Matters® Article SE1605
• Provider Enrollment Revalidation Cycle 2 FAQs

Key Takeaways & Resources

Key Takeaways

• Institutional providers pay an application fee when enrolling, re-enrolling, revalidating, or adding a new practice location. Generally, individual providers don’t pay an application fee.
• Health care providers must enroll in the Medicare Program to get paid for providing covered services to Medicare patients. Multiple CMS systems work together to process enrollment functions.
• CMS allows various organizations and users to work in their systems. The type of user depends on the individual’s relationship with you and the duties they perform in your practice.
• Technical help is available if you experience problems with the automated CMS enrollment systems.
• You can help protect your health care professional medical identifiers from identity thieves attempting to defraud the Medicare Program.
• To enroll or keep Medicare billing privileges, all DMEPOS suppliers (except certain exempted professionals) must meet supplier and DMEPOS Quality Standards to become accredited.
• Some physicians and other eligible professionals don’t bill Medicare services but must enroll in the Medicare Program or have a valid opt-out affidavit on file to solely order or certify patient items or services.
• You must periodically revalidate your Medicare enrollment information.

Resources

Use these resources to learn how to enroll in the Medicare Program, revalidate your enrollment, or change your enrollment information. You must enroll in the Medicare Program to get paid for providing covered services to Medicare patients. You must enroll if you solely order items or certify services, and you won’t submit claims for these services.

You can enroll online by using the Provider Enrollment, Chain, and Ownership System (PECOS) or the appropriate paper enrollment application submitted to a MAC. CMS wants providers to use PECOS instead of the paper Medicare enrollment application.

1. Get an Identity & Access Management (I&A) System user account.
2. Apply for your National Provider Identifier (NPI) in the National Plan and Provider Enumeration System (NPPES).
3. Enroll in PECOS.

Enroll in Medicare

Medicare enrollment varies for each provider or supplier type. This tool sends you to the enrollment forms, process descriptions, and resources appropriate to your provider or supplier type.

We encourage you to use PECOS instead of the Medicare paper enrollment application. PECOS advantages include:

• Paperless process, including electronic signature and digital document feature
• Faster enrollment
• Submitting only relevant information
• More control over your enrollment information, including re-assignments
• Easy to check and update information
• Less staff time and administrative costs

Protect Your Identity and Information

NPIs and Tax IDs are publicly available information. Use extra caution to monitor and protect professional and personal information to help prevent fraud and abuse. This includes securing your patient's personal health information. CMS has the following resources:

• Medicare Fraud & Abuse: Prevent, Detect, Report
• Office of Inspector General
• Help Fight Medicare Fraud (for patients)

Problems Enrolling?

You may have questions or problems that need additional help or technical support.

Enrollment Forms

Medicare makes enrollment forms as fillable PDF files. If you enroll using a paper application instead of PECOS, search the CMS Forms List for the form you need, select a form, and read “Who Should Complete This Application” on page 1 of the CMS-855 form. Check to ensure you use the correct application.

Additional Resources

• Provider Enrollment and Certification
• MLN Matters® Article MM7350, Implementation of Provider Enrollment Provisions in CMS-6028-FC (Hardship Exception)
• MLN Matters Special Edition Article SE1417, Implementation of Fingerprint-Based Background Checks
• MLN Matters Special Edition Article SE1520, National Site Visit Verification (NSV) Initiative
• MLN Matters Special Edition Article SE17016, Modernized National Plan and Provider Enumeration System

Commonly Used Terms

For a complete list of terms, go to the CMS Glossary.

Centers for Medicare & Medicaid Services (CMS)

CMS is the federal agency that administers the Medicare, Medicaid, State Children’s Health Insurance Program (SCHIP), Health Insurance Portability and Accountability Act of 1996 (HIPAA), Clinical Laboratory Improvement Amendments (CLIA), and several other health-related programs.

CMS-1561

Health Insurance Benefit Agreement is an agreement between a provider and CMS to get Medicare payments.

CMS-460

Medicare Participating Physician or Supplier Agreement describes your willingness to accept assignment for all covered services you deliver to Medicare patients. If you participate, Medicare pays 5% more. Participating providers get timely, direct Medicare payment.

CMS-588

Electronic Funds Transfer (EFT) Authorization Agreement tells you how to get electronic payments or update existing banking information.

CMS-855A

The Medicare Enrollment Application Institutional Providers use to enroll, revalidate enrollment, or change enrollment information.

CMS-855B

The Medicare Enrollment Application Clinics/Group Practices and Certain Other Suppliers, except Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers use to enroll, revalidate enrollment, or change enrollment information.

CMS-855I

The Medicare Enrollment Application Physicians and Non-Physician Practitioners (NPPs) (Individual physicians or NPPs) use to enroll, revalidate enrollment, or change enrollment information.

CMS-855O

The Medicare Enrollment Application Eligible Ordering, Certifying, and Prescribing Physicians and Other Eligible Professionals (Physicians, including dentists and other eligible NPPs), use to enroll to order items or certify Medicare patient services. This includes those physicians and other eligible NPPs who don't and won't send furnished patient services claims to a MAC.

CMS-855R

Medicare Enrollment Application is the form for Re-assignment of Medicare Benefits. It explains how to request a re-assignment of a right to bill the Medicare Program and get Medicare payments. Only individual physicians and NPPs can reassign their right to bill the Medicare Program.

CMS-855S

Medicare Enrollment Application is the form for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers to enroll in Medicare, revalidate enrollment, or change enrollment information.

CMS-20134

Medicare Enrollment Application for Medicare Diabetes Prevention Program (MDPP) Suppliers.

CMS-10114

The National Plan Identifier (NPI) Application/Update Form tells you how to apply or submit NPI updates.

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers

Entities or individuals, including physicians or Part A providers, that sell or rent Medicare Part B covered items to patients and meet the DMEPOS supplier standards.

Electronic File Interchange (EFI)

The EFI process lets CMS-approved EFI Organizations electronically submit provider NPI applications and update NPPES information with minimal manual intervention.

Electronic Funds Transfer (EFT)

Medicare directly pays EFT providers by sending payments to the provider’s financial institution whether they file claims electronically or on paper. All Medicare providers must apply for EFT.

Electronic Health Record (EHR)

An EHR is an electronic version of a patient’s medical history.

External User Services (EUS) Help Desk

The EUS is a dedicated CMS systems online support site. It offers help, including, but not limited to, the Identity & Access Management (I&A) System; Provider Enrollment, Chain, and Ownership System (PECOS); and National Plan and Provider Enumeration System (NPPES).

Identity & Access Management (I&A) System

Users register for usernames and passwords to access PECOS, NPPES, and the EHR Incentive Program.

Institutional Provider

These are providers or suppliers that submit a CMS-855A, CMS-855B (except physician and non-physician practitioner organizations), or CMS-855S form. See page 1 of the respective provider-type forms about who should use them.

Medicare Administrative Contractor (MAC)

A private company that contracts with Medicare to process and pay Medicare Fee-for-Service patient Part A and Part B (A/B) medical or Durable Medical Equipment (DME) claims.

Medicare Application Fee

Institutional providers and suppliers must pay an application fee when they initially enroll in Medicare, add a practice location, or revalidate their enrollment information. CMS defines “institutional provider” as any provider or supplier that submits a CMS-855A, CMS-855B (except physician and non-physician practitioner organizations), or CMS-855S form.

National Plan and Provider Enumeration System (NPPES)

NPPES assigns unique health care providers and health plans National Provider Identifiers (NPIs). NPIs improve the efficiency and effectiveness of electronically submitting health information.

National Provider Identifier (NPI) Registry

NPI is a directory of all active NPI records that displays relevant public portions of the record, including the provider’s name, specialty, and practice address.

National Site Visit Contractor (NSVC)

NSVC performs a site visit to screen and stop questionable providers and suppliers from enrolling or maintaining enrollment.

NPI Enumerator

The NPI Enumerator helps health care providers apply for NPIs and update their information in the National Plan and Provider Enumeration System (NPPES).

Participating Physician or Supplier

A participating physician or supplier agrees to accept patient Medicare services claims assignment. They agree to accept Medicare-allowed amounts as payment in full and to collect only Medicare deductibles and coinsurance. (See CMS-460).

Provider Enrollment, Chain, and Ownership System (PECOS)

PECOS is CMS’ online provider enrollment system. PECOS allows registered users to securely and electronically submit and manage Medicare enrollment information. You can use PECOS instead of Medicare paper enrollment forms.

Re-assignment of Medicare Benefits

Re-assigning your Medicare benefits lets an eligible organization or group submit claims and get payment for Medicare Part B services you provide as a member of the organization or group. (See CMS-855R).

Revalidation

The provider or supplier mandatory resubmission and recertification process to maintain enrollment information accuracy and Medicare billing privileges. The process confirms the Medicare enrollment information on file remains complete and up-to-date and helps fight health care fraud.

State Survey Agency

Performs initial surveys and periodic resurveys of all institutional providers (including laboratories) and certain kinds of suppliers. These surveys determine whether a provider or supplier meets the conditions to participate in the Medicare Program, and evaluates their performance and quality of care.

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