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Medicare Managed Care Provider Participation

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The Medicare enrollment process is a simpler, easier and faster process than in the past. Many providers don't know that even though claims can still be submitted to Medicare without enrolling, there are several benefits to becoming a Medicare Participating Provider:
  1. Medicare reimbursement is 5% higher for participants
  2. Automatic claims crossover to Medigap coverage
  3. Listing on the Medicare Participating Physician Directory

There are four steps to successful Medicare enrollment.

Step 1: Obtain a National Provider Identifier (NPI)

Prior to applying for enrollment in the Medicare program, providers which includes physicians, other clinical professionals, medical office practices and certain suppliers must obtain an NPI.

The National Provider Identifier or NPI is a 10 digit, unique identification number used to take the place of provider identifiers such as a Unique Provider Identification number (UPIN) in HIPAA standard transactions. Health care providers are required by regulation of HIPAA to obtain an NPI.

If you do not already have an NPI, apply for one at nppes.cms.hhs.gov or call the NPI Enumerator at 1-800-465-3203.

Step 2: Gather all supporting documentation

Any applicable supporting documentation must be submitted with your Medicare Enrollment Application. A detailed list specific to the type of application will be listed within the final pages of the application. For the Medical Office, supporting documentation can include:

  • Written confirmation from the IRS confirming your Tax Identification Number with the Legal Business
  • Completed Form CMS-588, for Electronic Funds Transfer Authorization Agreement.
  • Copy(s) of all documentation verifying IDTF Supervisory Physician(s) proficiency and/or State licenses or certification for IDTF non-physician personnel.
  • Copy(s) of all documentation verifying the State licenses or certifications of the laboratory Director or non-physician practitioner personnel of an independent clinical laboratory.
  • Copy of IRS Determination Letter, if supplier is registered with the IRS as non-profit.
  • Written confirmation from the IRS confirming your Limited Liability Company (LLC) is automatically classified as a Disregarded Entity. (e.g., Form 8832).
  • Statement in writing from the bank that the bank has agreed to waive its right of offset for Medicare receivables.
  • Copy(s) of all final adverse action documentation (e.g., notifications, resolutions, and reinstatement letters).
  • Completed Form(s) CMS 855R, Reassignment of Medicare Benefits.
  • Completed Form CMS-460, Medicare Participating Physician or Supplier Agreement.
  • Copy of an attestation for government entities and tribal organizations.
  • Copy(s) of comprehensive liability insurance policy (IDTFs only).

Step 3: Complete the Medicare Enrollment Application

There are two ways to complete the Medicare enrollment process.

  1. The Medicare Provider Enrollment, Chain, and Ownership System (PECOS) allows providers to submit an electronic application, view or update information, and view application status.
  2. Medicare Enrollment Application Form CMS 855 is the paper enrollment application process. The provider can choose one of the following:
    • CMS 855A--Medicare Enrollment Application for Institutional Providers
    • CMS 855B--Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers
    • CMS 855I --Medicare Enrollment Application for Physicians and Non-Physician Practitioners
    • CMS 855R--Medicare Enrollment Application for Reassignment of Medicare Benefits
    • CMS 855O--Medicare Enrollment Application for Eligible Ordering and Referring Physicians and Non-physician Practitioners
    • CMS 855S--Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers

Step 4: Pay Application Fee

CMS will not process a Medicare Enrollment Application for a medical office without proper payment. Payments can be made electronically through www.pay.gov by credit or debit card. It is suggested that your receipt be submitted with your application to ensure timely processing.

Note: Physicians, other clinical professionals and non-physician organizations are not required to pay an application fee.

Other Pertinent Information

Some of the information in this article was obtained directly from the cms website, www.cms.gov.

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