Medicare Enrollment for Physicians, Non-Physician Practitioners

Medicare Enrollment for Physicians,

Non-Physician Practitioners and

Other Health Care Suppliers

INFORMATION ABOUT ENROLLING IN THE MEDICARE PROGRAM

Physicians, non-physician practitioners, and other health care suppliers must enroll in the Medicare program

to be eligible to receive Medicare payment for covered services provided to Medicare beneficiaries.

The Medicare enrollment application is used to collect information about you and to secure the necessary

documentation to ensure you are qualified and eligible to enroll in the Medicare program. Suppliers, other than

suppliers of Durable Medical Equipment, Prothetics, Orthotics, and Supplies (DMEPOS), use three different

enrollment application forms to enroll or change their Medicare enrollment information. They are:

n Medicare Enrollment Application for Physicians and Non-Physician Practitioners (Form CMS-855I)—

This application is used by individual physicians or non-physician practitioners to initiate the Medicare

enrollment process or to change their Medicare enrollment information.

n Medicare Enrollment Application for Clinics/Group Practices and Certain Other Suppliers

(Form CMS-855B)—This application is used by group practices or other organizational suppliers, except

DMEPOS suppliers, to initiate the Medicare enrollment process or to change their Medicare enrollment

information.

n Medicare Enrollment Application for Reassignment of Medicare Benefits (Form CMS-855R)—This

application is used to initiate a reassignment of a right to bill the Medicare program and receive Medicare

payments (Note: only individual physicians and non-physician practitioners can reassign the right to bill the

Medicare program).

HOW TO ENROLL

Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change in

their enrollment information using either:

n The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or

n The paper enrollment application process (e.g., CMS-855).

CMS will make Internet-based PECOS to all other providers and suppliers (except durable medical equipment,

prosthetics, orthotics, and supplies (DMEPOS) suppliers) later this year.

For additional information regarding the Medicare enrollment process, including Internet-based PECOS, go to

http://www.cms.hhs.gov/MedicareProviderSupEnroll.

HOW TO REPORT CHANGES

Physicians and non-physician practitioners can submit a change of information using Internet-based PECOS or

the same application used to initiate the Medicare enrollment process. Physicians, non-physician practitioners,

physician and non-physician practitioner organizations, and Independent Diagnostic Testing Facilities must

report a change of ownership or control, change in practice location, or final adverse action within 30 days of the

reportable event. All other changes must be submitted within 90 days of the reportable event.

All other healthcare suppliers must report a change of ownership or control within 30 days of the reportable event.

All other changes must be submitted within 90 days of the reportable event.

WHAT IS PARTICIPATION

In Medicare, “participation” means you agree to always accept assignment of claims for all services you furnish

to Medicare beneficiaries. By agreeing to always accept assignment, you agree to always accept Medicare-allowed

amounts as payment in full and to not collect more than the Medicare deductible and coinsurance from the

beneficiary. Unlike many private insurance plans, the Social Security Act requires you to submit claims for

Medicare beneficiaries whether you participate or not.

BENEFITS OF PARTICIPATION

If you decide to participate in the Medicare program as a participating supplier, submit a participation agreement,

using the “Medicare Participating Physician or Supplier Agreement,” (Form CMS-460). It should be submitted

simultaneously with the Medicare enrollment form. Although you have up to 90 days to submit the agreement,

your physician benefits will not start until the agreement is submitted. There is a CMS annual enrollment period,

which is generally conducted in November. The benefits of Medicare participation include:

n Medicare reimbursement is 5 percent higher than it is for those who do not participate.

n Medicare payments are issued directly to the physician/supplier because the claims are always assigned.

n Claim information is forwarded to Medigap (Medicare supplemental coverage) insurers.

ENROLLMENT AND ENUMERATION

The National Provider Identifier (NPI) will replace health care provider identifiers in use today in standard health

care transactions. Suppliers must obtain their NPI prior to enrolling in the Medicare program. Enrolling in

Medicare authorizes you to bill and be paid for services furnished to Medicare beneficiaries.

You may apply for an NPI at https://nppes.cms.hhs.gov or by calling the Enumerator at 1-800-465-3203 or

TTY 1-800-6922326.

ADDITIONAL INFORMATION

When you are ready to enroll or make changes to your enrollment information, visit the CMS provider enrollment

web site at http://www.cms.hhs.gov/MedicareProviderSupEnroll to access Internet-based PECOS. In addition,

you can download a paper-based Medicare enrollment application, find responses to commonly asked questions, or

find telephone and mailing address information for the fee-for-service contractor serving your area.

Anesthesiology Assistant

Audiologist

Certified Nurse Midwife

Certified Registered Nurse Anesthetist

Clinical Nurse Specialist

Clinical Social Worker

Nurse Practitioner

Occupational Therapist in Private Practice

Physical Therapist in Private Practice

Physician Assistant

Psychologist, Clinical

Psychologist billing independently

Registered Dietitian or Nutrition Professional

Suppliers, other than Durable Medical Equipment Prosthetics, Orthotics and Supplier (DMEPOS), include:

Ambulance Service Supplier

Ambulatory Surgical Center

Clinics/Group Practices

Hospital Departments

Multi-Specialty Clinic

Physical/Occupational Therapy Group in Private Practice

Public Health/Welfare Agency

Single Specialty Clinic

Competitive Acquisition Program (CAP) Part B Drug Vendor

Independent Clinical Laboratory

Independent Diagnostic Testing Facility

Mammography Center

Portable X-ray Facility

Radiation Therapy Center

Slide Preparation Facility

Voluntary Health/Charitable Agency

Pub. No. CMS-11048

January 2009

If your supplier type is not listed above, contact the designated fee-for-service contractor (i.e., carrier) before you complete and submit the

Medicare enrollment application.