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MEDICARE PROVIDER ENROLLMENT

What’s Changed?

  • Added site visit information to Enrollment, Step 3













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.

Application Fee Amount

The enrollment application fee sent January 1, 2021, through December 31, 2021, is $599.

For more information, refer to the Medicare Application Fee webpage.

Whether you apply for Medicare enrollment online or use the paper application, you must pay the application fee online:

  • Online PECOS Application: During the application process, Provider Enrollment, Chain, and Ownership System (PECOS) prompts you to pay the application fee
  • CMS Paper Application: Go to the Medicare Provider Application Payment webpage to submit the application fee online

You may request a hardship exception when submitting your Medicare enrollment application via either PECOS or CMS paper form. You must submit a written request with supporting documentation with your enrollment that describes the hardship and justifies an exception instead of paying the application fee. CMS grants exceptions on a case-by-case basis.

MACs don’t process applications without the proper application fee payment or an approved hardship exception.

NOTE

If you don’t pay the fee or submit a hardship exception request, your MAC sends a letter allowing you 30 days to pay the fee. If you don’t pay the fee on time, the MAC may reject or deny your application or revoke billing privileges as appropriate.









ENROLLMENT

Health care providers must enroll in the Medicare Program to get paid for providing covered services to Medicare patients. Learn how to determine if you’re eligible to enroll and how to do it.

Medicare lists institutional providers on the Medicare Enrollment Application: Institutional Providers (Form CMS-855A). Institutional providers include:

  • Community Mental Health Centers (CMHCs)
  • Comprehensive Outpatient Rehabilitation Facilities (CORFs)
  • Critical Access Hospitals (CAHs)
  • End-Stage Renal Disease (ESRD) Facilities
  • Federally Qualified Health Centers (FQHCs)
  • Histocompatibility Laboratories
  • Home Health Agencies (HHAs)
  • Hospice Organizations
  • Hospitals
  • Indian Health Service (IHS) Facilities
  • Organ Procurement Organizations
  • Opioid Treatment Programs (OTPs)*
  • Outpatient Physical Therapy/Occupational Therapy/Speech Pathology Services
  • Religious Non-Medical Health Care Institutions
  • Rural Health Clinics (RHCs)
  • Skilled Nursing Facilities (SNFs)

* OTPs are institutional providers and pay an application fee; however, they use Form CMS-855B to enroll.

Physicians, Non-Physician Practitioners (NPPs), clinics/group practices, and specific suppliers who can enroll as Medicare Part B providers, defined in enrollment Forms CMS-855I and CMS-855B.

Who Is an NPP?

NPPs include nurse practitioners, clinical nurse specialists, and physician assistants who practice with or under the supervision of a physician.

Physicians/NPPs/Suppliers (Form CMS-855I)

  • Anesthesiology Assistants
  • Audiologists
  • Certified Nurse-Midwives
  • Certified Registered Nurse Anesthetists
  • Clinical Nurse Specialists
  • Clinical Social Workers
  • Mass Immunization Roster Billers, individuals
  • Nurse Practitioners
  • Occupational/Physical Therapists in private practice
  • Physicians (Doctors of Medicine or Osteopathy, Doctors of Dental Medicine; Dental Surgery; Podiatric Medicine; Chiropractic Medicine or Optometry)
  • Physician Assistants
  • Psychologist, Clinical
  • Psychologists billing independently
  • Registered Dietitians or Nutrition Professionals
  • Speech-Language Pathologists

Clinics/Group Practices and Specific Suppliers (Form CMS-855B)

  • Ambulance Service Suppliers
  • Ambulatory Surgical Centers (ASCs)
  • Clinics/Group Practices
  • Hospital Department(s)
  • Home Infusion Therapy Suppliers
  • Independent Clinical Laboratories
  • Independent Diagnostic Testing Facilities (IDTFs)
  • Intensive Cardiac Rehabilitation Suppliers
  • Mammography Centers
  • Mass Immunization Roster Billers, entities
  • Opioid Treatment Programs (OTPs)
  • Pharmacy
  • Physical/Occupational Therapy Group in Private Practice
  • Portable X-ray Suppliers
  • Radiation Therapy Centers

Medicare Diabetes Prevention Program (MDPP) Suppliers

MDPP suppliers must use Form CMS-20134 to enroll in the Medicare Program.

If you don’t see your provider type listed, contact your MAC’s provider enrollment center before submitting a Medicare enrollment application. For your state’s MAC contact information, refer to the Medicare Fee-For-Service Provider Enrollment Contact List.

Medicare provider and supplier organizations have business structures, such as corporations, partnerships, Professional Associations (PAs), or Limited Liability Companies (LLCs) that meet the “provider” and “supplier” definitions. Provider and supplier organizations don’t include organizations the IRS defines as sole proprietorships.

Examples of provider and supplier organizations include:

  • Hospitals
  • Medical group practices and clinics
  • Portable X-Ray Suppliers (PXRSs)
  • ASCs
  • Hospices
  • SNFs

You must have a provider or supplier Employer Identification Number (EIN) to enroll in Medicare. An EIN is the same as the provider or supplier organization’s IRS-issued Taxpayer Identification Number (TIN).

Sole Proprietorships and Disregarded Entities

For more information about “sole proprietorships” and “disregarded entities,” refer to the Medicare Program Integrity Manual Chapter 15, Section 15.2 (A) and 15.5.5 (5)(i), respectively.

Medicare “participation” means you agree to accept claims assignment for all Medicare-covered services to your patients. By accepting assignment, you agree to accept Medicare-allowed amounts as payment in full. You may not collect more from the patient than the Medicare deductible and coinsurance or copayment. The Social Security Act says you must submit patient Medicare claims whether you participate or not.

To participate as a Medicare Program provider or supplier, submit the Medicare Participating Physician or Supplier Agreement (Form CMS-460) upon initial enrollment. You’ve 90 days after your initial enrollment approval letter is sent to decide if you want to be a participating provider or supplier. The only other time you may change your participation status is during the open enrollment period, generally from mid-November through December 31 of each year.

Participating Provider or Supplier

  • Medicare pays 5% more to participating physicians and other suppliers
  • Because these are assigned claims, Medicare pays you directly
  • Medicare forwards claim information to Medigap (Medicare supplement coverage) insurers



Non-Participating Provider or Supplier

  • Medicare pays 5% less to non-participating physicians and other suppliers
  • You can’t charge the patient more than the limiting charge, 115% of the Medicare Physician Fee Schedule amount
  • You may accept assignment on a case-by-case basis
  • You have limited appeal rights

For more information, refer to the Medicare Claims Processing Manual, Chapter 12.

Step 1: Get a National Provider Identifier (NPI)

You must get an NPI before enrolling in the Medicare Program. Apply for an NPI in 1 of 3 ways:

  1. Online Application: Get an 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 NPI Enumerator form. To request a hard copy application, call 1-800-465-3203, 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.

Not Sure If You Have an NPI?

Search for your NPI on the NPPES NPI Registry.

Multi-Factor Authentication

To better protect your information, CMS started I&A System Multi-Factor Authentication (MFA) for the following 4 public facing applications:


  • I&A (started September 2019)
  • NPPES (started December 2019)
  • PECOS and EHR will require MFA soon

CMS Provider Enrollment Systems:

Institutional providers must choose an I&A System Authorized Official (AO) to work in CMS systems. An AO may authorize I&A Access Managers, surrogates, and Staff End Users (SEUs) to work in CMS systems.

Step 2: Complete the Proper Medicare Enrollment Application

After you get an NPI, you can complete the Medicare Program enrollment, revalidate your enrollment, or change your enrollment information. Before applying, be sure you have the necessary enrollment information. Complete the actions using PECOS or the paper enrollment form.

A. Online PECOS Application

After CMS approves your I&A System registration, submit your PECOS application.

PECOS offers a scenario-driven application. It asks questions to recover the information needed for your specific enrollment scenario. You can use PECOS to submit all supporting documentation. Follow these instructions:

  1. Log in to PECOS.
  2. Continue with an existing enrollment or create a new application.
  3. When PECOS determines your enrollment scenario and you confirm it's correct, it shows the topics for submitting your application. To complete each topic, enter the necessary information.
  4. At the end of the data entry process, PECOS:
    • Confirms you entered all necessary data
    • Lists the MAC documents to submit for review
    • Gives the option to electronically sign and certify
    • Shows your MAC’s name and mailing address
    • Allows you to print a copy of your enrollment application for your records; don't submit a paper copy to the MAC
    • Sends the application electronically to the MAC
    • Emails you to confirm the MAC got the application

When you electronically submit your PECOS application, it’s “locked,” meaning you can’t edit it unless your MAC requests corrections.

Enrolling physicians, NPPs, or other Part B suppliers must choose 1 of the application descriptions below. Choose the “Group Member Only” if you’re re-assigning all your benefits to a group practice or clinic.

  • Sole Owner of a Professional Association (PA), Professional Corporation (PC), or Limited Liability Company (LLC): You're the only owner of a business, set up as a corporation, where you provide health care services. Your business is legally separate from your personal assets.
  • Self-Employed/Sole Proprietor: You provide all health care services from a facility you own, lease, or rent. You're the only owner of a business that provides health care services. You and your business are legally one and the same. You're personally responsible for the business’ financial obligations. You report the business’ income and losses on your personal tax return.
  • Group Member Only: You provide all health care services as an employee of a group practice or clinic. You have an arrangement with your employer to send in Medicare claims and get paid for your services.
  • Group Member and Is Self-Employed: You provide health care services as an employee of a group practice or clinic. You agreed with your employer to send in Medicare claims and get paid for your services. You also provide health care services from a facility that you own, lease, or rent. The income you make through self-employment is part of your personal assets.
  • Disregarded Entity: You're the only owner of a business, set up as a corporation, where you provide health care services. Your corporation doesn't file taxes; instead, you file taxes on your personal tax filing.

B. Paper Medicare Enrollment Applications

You may submit the appropriate paper enrollment application if you're unable to use PECOS. Carefully review the paper application instructions to decide which form is right for your practice. The Medicare paper enrollment application collects your information, including the documentation verifying your Medicare Program enrollment eligibility.

NOTE

If you submit a paper application, your MAC processes your approved Medicare Enrollment and creates a PECOS record.

After you submit an enrollment application and all required supporting documentation to your MAC, they will send their recommendations to the State Survey Agency and CMS’ Regional Office (RO). The CMS RO decides if specific types of providers meet Medicare enrollment conditions.

After a MAC makes a recommendation, the State Survey Agency or a CMS-recognized Accreditation Organization conducts a survey. Based on the survey results, the agency or organization recommends the RO approve or deny the enrollment (a certification of compliance or non-compliance).

Certain institutional provider types may elect voluntary accreditation by a CMS-recognized Accrediting Organization instead of a State Survey Agency. You must notify the State Survey Agency of the Accrediting Organization’s decision.

The State Survey Agency forwards survey results to the CMS RO Division of Survey & Certification. The CMS RO approves or denies the enrollment application, supporting documentation, and survey results, and works with the Office for Civil Rights to get necessary clearances.

If approved, you must sign a provider agreement.

Electronic Funds Transfer (EFT)

If enrolling in Medicare, revalidating, or making certain changes to their enrollment, CMS requires EFT. The most efficient way to enroll in EFT is to complete the PECOS EFT information section. When submitting a PECOS web application:

  • Complete the EFT information for your organization (if appropriate) or as an individual
  • Include a copy of a voided check or bank letter that has your individual or business legal name
  • Include applicable account and routing numbers

Step 3: Respond to MAC Requests for More Information

MACs pre-screen and verify enrollment applications but 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 (if applicable), 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 without logging in, go to the PECOS homepage and under “Helpful Links” click “Application Status.”

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

Provider Enrollment Site Visits

In 2011, CMS implemented a site visit verification process using a National Site Visit Contractor (NSVC). A site visit is a screening to prevent questionable providers and suppliers from enrolling or staying enrolled in the Medicare Program. The NSVC conducts unannounced site visits for all Medicare Part A and B providers and suppliers, including DMEPOS suppliers. The NSVC may conduct an observational site visit or a detailed review to verify enrollment-related information and collect other details based on pre-defined CMS checklists and procedures.

During an observational visit, the inspector has minimal contact with the provider or supplier and doesn’t hinder the facility’s daily activities. The inspector may take facility photographs as part of the site visit. During a detailed review, the inspector enters the facility, speaks with staff, takes photographs, and collects information to confirm the provider’s or supplier’s compliance with CMS standards.

Inspectors performing site visits will carry a photo ID and a CMS-issued signed letter of authorization the provider or supplier may review. If the provider or its staff want to verify CMS ordered a site visit, contact your MAC.

Make your office staff aware of the site visit verification process. An inspector’s inability to perform a site visit may result in your Medicare enrollment application denial or Medicare billing privileges revocation.

Step 4: 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 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 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.

 








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:

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.

NOTE

In 2020, CMS renamed the role “Delegated Official (DO)” to “Access Manager.”

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.

Table 1. User Roles & Responsibilities
Role Represent an Organization Manage Staff Approve or Manage Connections Act on Behalf of Provider in CMS Systems
Individual Provider Yes Yes Yes Yes
Authorized Official (AO) Yes Yes Yes Yes
Access Manager Yes Yes Yes Yes
Staff End User (SEU) No No No Yes
Surrogate No No No Yes

NOTE

CMS recommends using the same I&A System-appointed AO and any PECOS Access Managers. The assigned AO and Access Managers must have the right to legally bind the company, are responsible for approving the system staff, and are CMS approved in the I&A System.

Only AOs can sign an initial organization enrollment application. An Access Manager can sign changes, updates, and revalidations.

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









PECOS Technical Help

Using the Provider Enrollment, Chain, and Ownership System (PECOS) may require technical support. Knowing which CMS contractor to contact is the first step toward a solution.

Common Problems and Who to Contact

When you experience: system-generated error messages, trouble navigating through PECOS screens, issues accessing PECOS, printing problems, or you have a valid Identity & Access Management (I&A) System user ID and password but can't access PECOS because of malfunction (for example, the website operates slowly or not at all, or a system-generated error message prevents data entry).

NOTE

A system-generated error message doesn't include messages created when you enter data incorrectly or ignore system prompts.

Solution: Contact CMS EUS Help Desk

Find information on common problems, ask a question, or look up previous support history on the External User Services (EUS) website.

Phone: 866-484-8049 (TTY 866-523-4759)

Email: EUSSupport@cgi.com

Live Chat: Go to the EUS website screen, and on the right side choose “Live Chat.”

EUS Hours of Operation: Monday–Friday, 6 am–6 pm CT; Saturday–Sunday, closed

Before you log in to PECOS, you need a valid I&A System user ID and password.

NOTE

Passwords expire every 60 days. You can't log in to the I&A System (and PECOS) until you reset your password. The I&A System tells you the number of days until your password expires. Go to the “My Profile” tab and see the password section. If you attempt to log in to PECOS with an expired password, the system redirects you to the I&A System to reset your password.

Solution: Access I&A System or Contact I&A System Help

The I&A System website lets you create an I&A System user ID and password, change your password, and recover forgotten login information. Additionally, you can access several resources:

On the I&A System website, choose the “Help” button in the upper right corner of any webpage for more information on the topic of that webpage.

While using PECOS, you have questions, experience problems enrolling, or need guidance on completing specific sections of the PECOS enrollment application.

Solution: Contact Your Medicare Enrollment Contractor

For detailed enrollment contact information, refer to Medicare Provider Enrollment Contact List or if you have questions, contact your MAC.

Solution: Refer to the CMS Provider Enrollment Assistance Guide

If you don't know who to call for help, refer to the “Who should I call?” CMS Provider Enrollment Assistance Guide.

For detailed enrollment contact information, refer to Medicare Provider Enrollment Contact List or if you have questions, contact your MAC.









PECOS FAQs

CMS uses several provider enrollment systems. Specifically, the Identity & Access Management (I&A) System allows you to:

Before completing enrollment in PECOS, you must have an I&A System account. Organizational providers and suppliers must designate an Authorized Official (AO) to work in these systems.

Organizational providers and suppliers must designate a provider enrollment AO to work in CMS systems. These systems include the I&A System, NPPES, and PECOS. The AO may also authorize Access Managers, surrogates, and Staff End Users (SEUs) to use PECOS. Individual providers and suppliers don't require an AO but can authorize surrogates and SEUs to work in PECOS. For more information on registering for an I&A System account or enrolling as an AO, refer to the I&A System Quick Reference Guide and I&A FAQs.

Use the same information to enroll in Medicare using PECOS as you do for a paper enrollment application. If you don't have an I&A System account, create your user name and password. Use your user name and password to log in to NPPES to register for an NPI. All Medicare provider enrollees must have an active NPI.

Not Sure If You Have an NPI?

Search for your NPI on the NPPES NPI Registry.

Based on your provider type, you may also need the following information:

  • Personal identifying information; this includes your legal name on file with the SSA, date of birth, and SSN
  • Legal Business Name (LBN) of the provider or supplier organization
  • Tax Identification Number (TIN) of the provider or supplier organization
  • Professional information, such as:
    • Professional license information
    • School degrees
    • Certificates
  • Accreditation information
  • Surety Bond information
  • Specialty and secondary specialty information
  • Practice location information including:
    • Current medical practice location
    • Federal, state, and local (city or county) business and professional licenses, certificates, and registrations specifically required to operate as a health care facility
    • Medical record storage information
    • Special payment information
  • Bank account information
  • Information about relevant final adverse actions, which may include:
    • A Medicare-imposed revocation of Medicare billing privileges
    • A suspension, termination, or revocation of a license to provide health care by a state licensing authority or the Medicaid Program
    • A conviction of a federal or state felony within the 10 years preceding enrollment, revalidation, or re-enrollment
    • An exclusion or debarment from federal or state health care program participation by the Office of Inspector General (OIG) or other federal or state offices with authority to exclude or sanction a provider

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

You can't use PECOS to:

  • Change your SSN
  • Change a provider’s or supplier’s TIN
  • Change an existing business structure, for example:
    • A solely owned Professional Association (PA), Professional Corporation (PC), or Limited Liability Company (LLC) can’t be changed to a sole proprietorship
    • A sole proprietorship can’t 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 (FFS) providers can apply in PECOS.

The PECOS Provider Interface is available 24 hours a day, Monday through Saturday, with scheduled downtime on Sunday. CMS technical support is available daily 5 am to 8 pm CT.

CMS prefers that you submit your enrollment application through PECOS because it’s faster and easier, but you may complete and mail the appropriate paper Medicare enrollment application to the address on the Medicare Fee-For-Service Provider Enrollment Contact List:

  • Parts A and B Providers: Send forms to your Part A or Part B MAC
  • Home Health and Hospice Providers: Send forms to the Home Health and Hospice Contractor
  • Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers: Send forms to the National Supplier Clearinghouse (NSC)

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

When you electronically submit your Medicare enrollment application, you’ll get a “Submission Confirmation” page. The “Submission Confirmation” page reminds you that the individual provider, or the provider or supplier organization AO/Access Manager, must electronically sign the application or upload their signature. PECOS emails each address in the “Contact Person” section of the application of the web tracking ID for the submitted application. Remember to verify all your completed signatures with either an electronic signature or uploading certification. Mail required supporting documentation not uploaded before submission to the MAC with reference to the PECOS tracking ID.

When to create a new enrollment:

  • If you change your services, such as changing specialties
  • If you change your location where new state surveys and other documentation may be required by your MAC (your MAC can determine if you need a new enrollment based on a new state survey or other documentation)
  • If you have provider-based vs. freestanding requirements. For more information, contact your MAC.

Application Fee and Supporting Documentation

Institutional providers and 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. Use the Application Fee Requirements for Institutional Providers to verify which providers need to pay a fee and when.

An approved hardship exception exempts you from paying the application fee for the current application. If you request a hardship exception, you must submit the written request (and supporting documentation) describing the hardship and why the hardship justifies an exception with your CMS paper application or PECOS application. CMS decides whether to grant these requests on a case-by-case basis.

MACs won’t process applications without the proper application fee or an approved hardship exception.

If you don’t pay the fee or submit a hardship exception request when you submit your enrollment application, your MAC will send a letter explaining if you don’t pay the application fee through the Medicare Enrollment Application Information webpage within 30 days from the date of the letter, Medicare may reject your application or revoke your existing billing privileges.

If you pay the fee during the 30-day period, the MAC processes the application in the usual manner.

No. When you electronically submit the provider or supplier organization Medicare enrollment application, a page appears that lists the supporting documentation to complete the enrollment. You may submit all this documentation electronically through PECOS.

Yes, either one is acceptable. You must send this information either electronically (as supporting documentation uploaded into PECOS).

During the PECOS application process, the “Penalties for Falsifying Information” page has the same text as the paper Medicare enrollment application, and lists the consequences for providing false information. These consequences include criminal and civil penalties, fines, civil monetary penalties, exclusion from federal health care programs, and imprisonment, among others. You must acknowledge the “Penalties for Falsifying Information” page by clicking the “Next Page” button before continuing the PECOS submission process.

Enrollment Application Issues

First, make sure you entered your correct SSN, legal name, and date of birth. If you believe you entered the correct information, but PECOS doesn't accept this information, contact SSA.

You must report an SSN to enroll in Medicare. If you don't want to report your SSN over the web, use the appropriate paper Medicare enrollment application.

An “Invalid Address” error indicates the address entered doesn't comply with the U.S. Postal Service address standards. This page lets you continue by either saving the address you entered or by selecting the address PECOS displays.

As a security feature, PECOS will time out if you’re inactive (you don’t hit any keys on your computer keyboard) for 15 minutes. The system warns you of inactivity after 10 minutes, and if it gets no response after 5 additional minutes, the system automatically logs you off. Save your work if you anticipate inactivity while applying in PECOS. If you don’t save your work and the system times out, you must restart from the beginning.

Submitting Reportable Events

No. If you report a change to existing information, check “Change,” include the effective date of change, and complete the appropriate fields in the sections that changed.

Yes. Following your initial enrollment, you must report certain changes (reportable events) to the MAC within 30 calendar days of change. Report all other changes to your MAC within 90 days.

Report a Medicare enrollment change using PECOS. Physicians and NPPs 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 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.

Since Medicare pays claims by EFT, the Special Payments address should indicate where all other payment information must go (for example, paper remittance notices or special payments).

Providers and suppliers should report most changes using PECOS or the applicable paper Medicare enrollment application.

No. If you have a new business location, complete a new PECOS or paper application. Each DMEPOS enrollment record can only have 1 current business location.

Revalidations

Revalidation means resubmitting and recertifying your enrollment information.

DMEPOS suppliers must revalidate every 3 years. All other providers and suppliers generally revalidate every 5 years. CMS can also conduct off-cycle revalidations according to 42 CFR Section 424.515. You can revalidate using PECOS or by submitting the appropriate Medicare enrollment application.

If currently enrolled, check 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 will also send you a revalidation notice.

Due dates are:

  • Updated in the Medicare Revalidation Lookup Tool every 60 days at the beginning of the month
  • Listed up to 7 months in advance or listed as to be determined (TBD) if more than 7 months prior to the due date

Yes. Your MAC will send a revalidation notice as early as possible, generally no later than 3–4 months prior to your revalidation due date.

If there’s no listed due date on the Medicare Revalidation Lookup Tool or you didn’t get a MAC letter requesting revalidation, don’t submit your revalidation application. Your MAC will return these revalidation applications to you.

However, if you’re within 2 months of the due date listed on the Medicare Revalidation Lookup Tool and didn’t get a MAC notice to revalidate, submit your revalidation application.

Yes. Using PECOS to revalidate allows you to review information currently on file and update and submit your revalidation electronically. If you use PECOS, you only need to update changed information.

If you submit your revalidation after the due date, the MAC may place a hold on your Medicare payments or deactivate your Medicare billing privileges. If the MAC requests additional documentation, respond within 30 days; otherwise, they may deactivate your Medicare billing privileges.

Revalidation ensures all provider enrollment records are accurate and up to date. Generally, CMS doesn't take administrative action against a provider or supplier for updating their records even though it wasn't timely. However, CMS could take administrative actions, including recovery of prior Medicare payments, where a provider or supplier failing to report the change would cause Medicare Program enrollment ineligibility.

NOTE

PECOS users can no longer mail documents that require a signature. When submitting your application, be prepared to send an e-signature or upload your signed documents.

 








Protect Your Identity and Privacy

You can help protect your health care professional medical identifiers from identity thieves attempting to defraud the Medicare Program.

PECOS is an electronic Medicare enrollment system where providers and suppliers can:

  • Submit Medicare enrollment applications
  • View and print enrollment information
  • Update enrollment information
  • Complete the enrollment revalidation process
  • Withdraw from the Medicare Program voluntarily
  • Track a Medicare enrollment application

This protects your Medicare enrollment information.

Keep PECOS Enrollment Information Up to Date

Log in to PECOS and review your Medicare enrollment information several times a year to ensure there are no unauthorized changes.

PECOS Provides Security

Only you, authorized surrogates, authorized CMS officials, and MACs may enter and view your Medicare PECOS enrollment information. CMS officials and MACs get security standards training and must protect your information. CMS doesn't disclose your Medicare enrollment information to anyone, except when authorized or required by law.

Review and Protect Enrollment Information

Review your Medicare enrollment information in PECOS frequently to ensure it's accurate, current, and unaltered.

Protect Yourself and CMS Programs from Fraud

Your National Provider Identifier (NPI) and Tax ID are publicly available information. Use extra caution to monitor and protect your professional and personal information to help prevent fraud and abuse. You must also ensure your patients’ personal health information is secure. CMS has the following resources:

Use your Identity & Access Management (I&A) System user ID and password to access PECOS. Keep your ID and password secure. Take these steps to verify your Medicare enrollment information:

Step 1: Log in to PECOS

PECOS Login Webpage


Step 2: View Your Medicare Account

Locate Your Enrollments


Step 3: View Existing Enrollments

Locate Your Enrollments


Step 4: Check for False Applications and Enrollments

Existing Medicare Applications and Enrollments

Ensure Your Enrollment Record is Accurate

Accurate and complete PECOS data is critical to CMS business functions, including the ability to:

  • Combat fraud, waste, and abuse in Medicare and other health care programs
  • Make informed provider enrollment decisions
  • Pay claims accurately

Update and review your provider enrollment information whenever you make a change to your practice, including address changes.

Report suspicious information (for example, information you did not submit) to your MAC provider enrollment division.


Step 5: Report Identity Theft

Existing Medicare Applications and Enrollments

If you suspect your PECOS profile is incorrect due to unauthorized account access, contact your MAC, law enforcement authorities, and your bank. Your MAC and bank can flag your respective accounts for possible fraudulent activity and law enforcement can begin investigating if and how your accounts were compromised.

Additional Privacy Tips

Take the following additional actions to protect your Medicare enrollment information:

  • Change your password in the I&A System before accessing PECOS the first time. You can't change your user ID, but you must change your password every 60 days.
  • Review your Medicare enrollment information several times a year to ensure no one altered information without your knowledge. Immediately report changes you didn't submit.
  • Maintain your Medicare enrollment record. You must report Medicare enrollment changes known as reportable events. Reportable events include change of ownership or control, change in practice location, banking arrangements, and any final adverse legal actions.
  • Store PECOS copies or paper enrollment applications in a secure location. Don't allow others access to this information. It contains your personal information, including your date of birth and SSN. Don't leave copies on a copy machine or on your workspace.
  • Enroll in electronic Medicare payments and ensure they deposit directly into your bank account. CMS requires all providers to use Electronic Funds Transfer (EFT) if enrolling in Medicare, revalidating, or making changes to their enrollment. The most efficient way to enroll in EFT is to complete the EFT information section in PECOS and provide required supporting documentation. Using EFT allows Medicare to send payments directly to your bank account.
 








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.

Ordering and Certifying Terms

Medicare Part B claims use the term “ordering/certifying provider” (previously “ordering/referring provider”) to identify the professional who orders or certifies an item or service reported in a claim. The following are technically correct terms:

  • A provider orders non-physician patient items or services, such as Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); clinical laboratory services; or imaging services.
  • A provider certifies patient home health services.

The health care industry uses the terms “ordered,” “referred,” and “certified” interchangeably. To see terminology comments, refer to the Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements Final Rule.

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

NOTE

Organizational NPIs don’t qualify and you can’t use them to order or certify.

Denial of Ordering or Certifying Claims

If claims lack a valid individual NPI, MACs deny them if they are:

  • Claims from clinical laboratories for ordered tests
  • Claims from imaging centers for ordered imaging procedures
  • Claims from DMEPOS suppliers for ordered DMEPOS
  • Claims from Part A HHAs that aren't ordered or certified by a Doctor of Medicine (MD), Doctor of Osteopathy (DO), or Doctor of Podiatric Medicine (DPM)

If you bill a service that needs an eligible provider and one isn’t on the claim, the MAC denies the claim. The claim must have a valid NPI, and the eligible provider’s name as it appears in the PECOS.

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

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.

Table 2. Options to Verify Your Current Enrollment Record Exists in PECOS
Verification Option Enrollment Record Is Current If:
Refer to the Medicare Order and Referring files.* You're on 1 of these reports.
Refer to PECOS to locate your enrollment record. Your enrollment record displays a status of “approved.”
If you submitted an enrollment application as 1 of the eligible provider types on paper (Form CMS-855O) or using PECOS and want to check the status, refer to the Initial Physician Applications Pending Contractor Review and Initial Non-Physician Applications Pending Contractor Review datasets. Your enrollment application is pending contractor review if you're on 1 of these reports.

* Medicare denies certain PMD claims if ordering provider isn’t on Medicare’s eligible providers list.

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.

Interns and Residents

Claims for items or services ordered or certified by licensed or unlicensed interns and residents must specify the NPI and name of a teaching physician. State-licensed residents may enroll to order or certify, and claims may list them. If states offer provisional licenses or otherwise permit residents to order or certify, CMS allows interns and residents to enroll consistent with state law.

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.

Rebuttal Process

MACs issue Medicare billing privilege deactivations and CMS permits providers/suppliers to file a rebuttal.

For more information refer to:

Large Group Coordination

Groups with more than 200 members can use the Medicare Revalidation Lookup Tool and search by their organization’s name to download group information. They will get a letter and spreadsheet from their MAC listing the providers linked to their group who must revalidate within 6 months. Large groups should work together to ensure they submit only 1 application from each provider/supplier.









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.

 
Table 3. Learn About Medicare Enrollment
Topic Title
Provider-Supplier General Information Provider Enrollment and Certification
Application Fee

Application Fee Information (PECOS)

Application Fee Requirements for Institutional Providers

Reporting Changes Timely Reporting of Provider Enrollment Information Changes
Table 4. Revalidation Information
Topic Title
Revalidation Overview

Provider Enrollment and Certification: Revalidations

Provider Enrollment Revalidation – Cycle 2

Provider Enrollment Revalidation Cycle 2 FAQs

Revalidation Due Dates Medicare Revalidation Lookup Tool

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
Table 5. Help with Enrollment
Topic Title
Online Enrollment System PECOS System
PECOS Tutorials PECOS Enrollment Tutorial Videos
FAQs PECOS FAQs
Submit provider National Provider Identifier (NPI) Applications and Update Information Electronically in NPPES Electronic File Management Main Page
Register for Usernames and Passwords to Access NPPES, PECOS, and the EHR Incentive Program

I&A System

I&A System Quick Reference Guide

I&A FAQs

Get an NPI

NPPES Registered User Sign In

What’s New in NPPES 3.0

Search NPI Records, Including the Provider’s Name, Specialty, and Practice Address NPPES NPI Registry

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:

Problems Enrolling?

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

Table 6. Medicare Contractors That Can Help with Problems
Topic Contact
Navigating/Accessing PECOS Website

CMS External User Services (EUS): Help Desk

“Who should I call?” CMS Provider Enrollment Assistance Guide

Paper Applications, Questions on Application Not Related to PECOS Medicare Fee-for-Service Provider Enrollment Contact List
Application for NPI NPPES Home Page/Sign In Page Help
Provider Site Visit National Site Visit Contractor (NSVC)
Institutional and Other Providers State Survey State Survey Agency Directory
All Other Enrollment-Related Questions Contact your MAC

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.

Table 7. CMS Enrollment Forms
Form Form Number
Electronic Funds Transfer (EFT) Authorization Agreement CMS-588
Health Insurance Benefit Agreement CMS-1561
Medicare Enrollment Application: Clinics/Group Practices and Certain Other Suppliers CMS-855B
Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers CMS-855S
Medicare Enrollment Application: Eligible Ordering, Certifying, and Prescribing Physicians and Other Eligible Professionals CMS-855O
Medicare Enrollment Application: Institutional Providers CMS-855A
Medicare Enrollment Application: Physicians and Non-Physician Practitioners CMS-855I
Medicare Enrollment Application: Re-assignment of Medicare Benefits CMS-855R
Medicare Enrollment Application: Medicare Diabetes Prevention Program (MDPP) Suppliers CMS-20134
Medicare Participating Physician or Supplier Agreement CMS-460
National Provider Identifier (NPI) Application/Update Form CMS-10114

Additional Resources

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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