DM Quality Consulting, LLC

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1 DM Quality Consulting, LLC Providing an honest, compliant, quality service Medicare Provider Enrollment Paper Applications Physicians, non-physician practitioners, suppliers, hospitals and clinics must enroll and maintain their Medicare enrollment in the program to be eligible to receive Medicare payments for covered services furnished to Medicare beneficiaries. Enrollment into the Medicare program is accomplished through completion of paper application forms or entering information directly into the internet-based Provider Enrollment, Chain and Ownership System (PECOS). PECOS is a national database of Medicare provider, physician, and supplier enrollment information. PECOS is used to collect and maintain the data submitted on CMS 855 paper enrollment forms and electronically. The Centers for Medicare and Medicaid (CMS) maintain the Medicare enrollment applications on their Forms Website. The following are enrollment applications and their descriptions: CMS-855A (Institutional Providers). This includes hospitals and Federally Qualified Health Centers (FQHC). CMS-855B (Clinics/Group Practices and Certain Other Suppliers). This application is used for clinics, independent ambulance providers and Ambulatory Surgical Centers (ASC). When establishing a new clinic, in addition to the CMS-855B, you must send at least one provider application (CMS-855I and CMS-855R). These must all be submitted in the same envelope. CMS-855I (Physicians and Non-Physician Practitioners). Required if provider is not actively enrolled with PECOS and/or the Part B Medicare Administrative Contractor (MAC) for which provider services will be submitted. CMS-855R (Reassignment of Medicare Benefits). Required for all physicians and nonphysician practitioners that are enrolling to work in a group/clinic practice. The only exception is for Physician Assistants (PA), whose reassignment is contained in Section 2E of the CMS-855I application. CMS-8550 (Ordering/Referring Physicians). This application is used for providers who cannot bill Medicare for their services but may order diagnostic tests or supplies for Medicare patients. Example: Dentists. CMS-855S (Durable Medical Equipment (DME)). This application is for obtaining a DME supplier number in order to bill for DME supplies and/or drugs. This application is submitted to the DME National Supplier Clearinghouse and not to the local MAC. DISCLAIMER - The information in these publications are provided "as is" without any expressed or implied warranty. While all information in these documents are believed to be correct at the time of writing, these documents are for educational purposes only and do not purport to provide legal or medical advice. It is the provider's responsibility to stay current with CMS and the Medicare Administrative Contractor's (MAC) guidelines. CPT codes, descriptors, and other data only are copyright 2013 American Medical Association. All rights reserved, Applicable FARS/DFARS apply. Published October 2014 DM

2 Be sure to submit the current enrollment application version. Application Fees IHS hospitals, FQHCs, ambulance, ASCs and DME suppliers initially enrolling in Medicare, adding a practice location (Part A) or revalidating their enrollment information must submit with their application: Proof of payment of the application fee in an amount prescribed by CMS. And/or, A request for a hardship exception to the application fee. The hardship request must be received with the application to be considered. CMS will review the circumstance and make a determination regarding the fee. The application will not process until CMS has made a decision. The provider must make a strong argument to support its request, including providing comprehensive documentation (which may include, without limitation, historical cost reports, recent financial reports such as balance sheets and income statements, cash flow statements, tax returns, etc.). The application fee for 2014 is $542. The fee does not apply to Part B physician clinics or individual providers enrolling in a clinic, or their revalidation. Payment of the application fee can be made through: Intra-Government Payment and Collection System (IPAC). Pay.gov which is the PECOS on-line application fee payment system. IHS locations using the IPAC system will need to provide: CMS Agency Location Code (ALD) An explanation of the payment (i.e., provider enrollment fee). The Treasury Account Symbol as 75X0511. Processing Timeline CMS provides mandated timeframes for processing enrollment applications. Processing timeframes are contingent on the submitted application and if all required information is provided. If an application requires additional information (i.e. development letter sent to submitter) or a site visit, this will cause a delay in processing. The following are current CMS timeframes for enrollment applications: Paper Applications calendar days (unless a site visit is required; then it could take up to 210 days). Page 2 of 10

3 Internet-Based PECOS Confirmation calendar days (unless a site visit is required; then it could take up to 120 days). After a new enrollment application is approved and finalized, a confirmation or notification letter will be sent to either the contact person or provider. The confirmation letter provides: Provider Transaction Account Number (PTAN). NPI. Provider name. Provider specialty. Effective date for billing. CMS states that once a provider has enrolled in Medicare, he has four quarters (one year), from the effective date of the PTAN, to submit a claim. The claim must be received in the processing system and be paid or denied. Unprocessable or rejected claims will not count towards this requirement as they are not considered denied. If a PTAN is deactivated for no claims submission, the enrollment process must start over and a new PTAN and effective date will be issued. Ordering/Referring Providers As a result of the Affordable Care Act (ACA), providers must be enrolled in the Medicare program if they order or refer services for their Medicare patients (i.e. ordering diagnostic tests), even if the services they perform are not covered by Medicare (i.e. Dentist). CMS issued change requests 6417 and 6421 regarding the requirement for the ordering provider s NPI to be in PECOS. The CMS-855O application is used to enroll providers into the PECOS system only; and not to enroll for billing purposes. Medicare claims requiring an ordering/referring provider s name and NPI will deny if that ordering/referring provider is not in PECOS. The claim will reject if the ordering/referring provider s name and NPI do not match what is in PECOS for that provider. Revalidation The revalidation project is an effort by CMS to verify all information on file for existing Medicare providers, and to ensure they meet all standards associated with the new screening criteria in Section 6028 of the ACA. All providers enrolled with Medicare prior to March 25, 2011, must revalidate their enrollment information, but only after receiving notification from Medicare. Newly enrolled providers who submitted applications on or after March 25, 2011, will not be affected. However, providers will be required to revalidate every 5 years on the anniversary of their approved PECOS enrollment. Durable Medical Equipment (DME) Page 3 of 10

4 suppliers will be required to revalidate every 3 years. Medicare Contractors will notify providers/suppliers at least 60-days prior to their revalidation date. Between now and March 2015, Medicare will send notices to those providers requiring revalidation. Providers have 60 days to respond to the revalidation letter. Failure to respond will cause the PTAN to be deactivated. Follow all instructions provided with the revalidation letter. Failure to do so could jeopardize processing. Provider Credentialing Payment of Medicare and Medicaid funds are to only be made when services are provided by qualified, licensed/certified, practitioners. Prior to employing a provider (i.e. physician, nonphysician practitioner, pharmacists, nurses, techs), check the OIG s exclusion database. If the provider is listed, their services are excluded from treating Medicare and/or Medicaid patients and receiving reimbursement. Anyone who hires an individual on the OIG exclusions list may be subject to civil monetary penalties. The exclusions database is updated monthly and can be found at: If a provider is on the exclusions list and has been hired by a facility, that facility can report to the OIG, under the provider self-disclosure protocol: Internal Tracking System A provider enrollment tracking system should be developed to assist your provider credentialing department. This is not a requirement but simply a way to track provider enrollment. The following is an example of an enrollment tracking system: Provider Name NPI Date Medicare App Sent Paper or PECOS PTAN Eff. Date Term Date Revalidation Date Doe, John ########## 01/10/14 PECOS 8HZ### 12/20/13 Smith, Jane Smith, John ########## 09/25/14 PECOS 8HX### 10/01/14 ########## 10/01/12 PAPER 8HH### 10/15/12 11/15/13 Page 4 of 10

5 Change of Information The Medicare enrollment process is not just for new providers. Any time there is a change in the originally submitted information, an updated application must be submitted. By reporting changes as soon as possible, providers will help ensure their claims are processed correctly. 30-day reportable events include: Change in practice location. Change in final adverse action. Change in ownership or managing interest control. 90-day reportable events include Change in authorized or delegated official(s). Change in legal business name or tax ID. Change in banking arrangements or payment information. For additional reportable changes and timeline, refer to the CMS Internet Only Manual (IOM), Medicare Program Integrity; Chapter 15, Medicare enrollment. Completing the Paper Application Completing the enrollment process can be confusing and frustrating if you are not familiar with the application. To begin the process, you must first determine what type of facility or provider you are and what you are wanting to do. For example: Are you a clinic hiring a new physician? If so, complete the CMS-855I and CMS-855R. If the provider has an active enrollment with the designated Part B MAC, then all that needs to be submitted is the CMS-855R. Example: Dr. John Doe currently works for the neighboring IHS clinic, but within the next 30 days he will also begin working a couple of days at your clinic. Are you a clinic hiring a Physician Assistant (PA)? If so, only complete the CMS-855I. At the top of Section 1A, complete the information with the PA s NPI. The reassignment for a PA is located in Section 2E of the application. The remainder of the application will be completed just like any other provider. If you submit the CMS-855R, it will be returned to you. Are you a Critical Access Hospital (CAH) wanting to add a swing-bed unit? If so, complete the CMS-855A by checking Section 1A with a change of information and Section 1B with practice location information. Complete all the sections that Section 1B advises. Be prepared to pay the application fee. Page 5 of 10

6 When hiring new practitioners at a clinic, the application submission should be within 30 calendar days of the provider seeing their first Medicare patient (which is furnished in Section 1 of the CMS-855R). Examples: Dr. John Doe to begin work at clinic on June 1 st. Clinic submits enrollment application on May 20 th. Once enrollment approved, the effective date for billing was established as June 1 st. Dr. John Doe began working at clinic on June 1 st. Clinic submitted application on June 15 th but it was returned on June 25 th because it was not signed or dated. The clinic resubmitted the application on July 10 th and the MAC stamped it as received on July 17 th. The enrollment was approved with an effective date of June 17 th. National Provider Identifier (NPI) The NPI is a standard unique health identification number used by providers/suppliers billing health insurance companies. The purpose of the NPI is to: Simplify billing. Help with coordination of benefit payments. Become the universal number used to identify the provider/ supplier between the health insurance companies. An NPI must be obtained before submitting an initial application to Medicare. The Medicare application must contain the NPI. There are two types of NPIs: Type 1 The individual s NPI (obtained using an SSN or a sole proprietor using an EIN). Type 2 Group/organization NPI (obtained using a TIN). To apply for an NPI go to the CMS Website: Completing the CMS-855A, CMS-855B and CMS-855I Read each section carefully. If there are sections that do not apply, and there are boxes to check indicating the section does not apply, you must mark those boxes. Section 1 In each application there is a Section 1 - Basic information and the reason for the information. Section 1A Check one box and complete the required sections. If revalidating, attach a copy of the revalidation letter. Page 6 of 10

7 At the top of section 1A there are two questions; one for Physician Assistants and the other for new practitioners enrolling with a clinic/group practice. Complete this section if applicable. Section 1B - If a change of information was selected in 1A, then select what is changing, provide any information, if required, in the second box and then complete the required sections listed in the third box. Section 2 In each application there is a Section 2 which provides all the identifying information regarding the person or entity completing the application. In the CMS-855A and CMS-855B there is a Section 2B1 that asks if the Indian Health facility is attempting to enroll with the designated IHS MAC? IHS facilities and Tribal facilities that are enrolled or enrolling with the designated IHS MAC will answer this Yes. In this section it also asks for the correspondence address, which is the mailing address, phone number and (if applicable) in case Medicare needs to get in touch with the provider. In Section 2 of the CMS-855I, complete all the information pertaining to the type of provider that is enrolling or changing information. Section 2D provides a list of non-physician practitioners that are eligible to enroll in the Medicare program. If the practitioner specialty is not listed, they are not eligible to enroll. CMS requires Medicare contractors to call and verify that the provider can be reached at the phone number listed in Section 2B of the application. The phone number listed in this section must be one where the provider can actually be reached. If Medicare calls the number on the initial call and has to leave a message, the provider must make a return call to Medicare and either speak with the enrollment analyst or leave a message to validate the number. A second outgoing call can be made by Medicare to the contact person listed in Section 13 if no callback is received from the initial outgoing call. If no response has been received after 30 days, the application will be denied. Section 3 This is to notify Medicare if there have been any convictions, revocations or Medicare suspensions. Any convictions, exclusions, revocations, and suspensions must be reported, regardless of whether any records were expunged or any appeals are pending. Do not skip answering this section. Section 4 This is the practice location information. Page 7 of 10

8 In the CMS-855A and B, information regarding the facility will be completed. All sections that apply to the facility should be completed. If a change of information is being submitted, only complete the sections that are required. In the CMS-855I, for providers working in a group/clinic practice, only complete Section 4B and then skip everything else until you get to Section 13. Section 5 This pertains to CMS-855A and B only. This section pertains to the owner or managing control. This will be the IHS/Tribal facility. Complete both Sections 5A and B. Section 6 This pertains to CMS-855A and B only. Complete this section for the Authorizing and/or Delegated official(s). For IHS, the Authorizing official is generally the IHS Area Director. The Delegated official can be the facility s CEO. You can have more than one Authorizing and/or Delegated official. Complete both Sections 6A and B. Section 8 This pertains to CMS-855A and B only. This section is for billing agency information. If there are billing agencies that complete and submit Medicare claims for the facility, their information must be provided. Otherwise, the box must be answered No. Section 13 This information pertains to a contact person. There can be more than one contact person. This individual must be someone that can answer questions or furnish any additional information that may be requested by the MAC. To have two contacts, make a copy of section 13 and submit with the application. It is advised that there should be at least one contact person for each application submitted. Section 15 This is the certification section. In the CMS-855I, the individual practitioner will complete and sign (preferably in blue ink). In the CMS-855A and B, this will be the Authorized official s (from Section 6) information and signature (preferably in blue ink). Page 8 of 10

9 Section 16 If a Delegated official completed Section 6, this individual s information and signature (preferably in blue ink) will be required. Section 17 This is a checklist of documentation that may be required to be submitted with the application. Depending on the reason for the application (new or change of information) will determine the documentation that needs to be submitted. Completing the CMS-855R NOTE: A revised CMS-855R will be required beginning June 1, The revised form will be accepted beginning January 1, 2015, and becomes mandatory June 1, This application is for the reassignment of benefits. Any eligible provider enrolling with a group/clinic must complete this application. The only exception is with the Physician Assistant, in which reassignment is included in the CMS-855I, Section 2E. Section 1 - Reason of the application. Reassigning or terminating employment relationship. Section 2 - Name of the group/clinic the individual provider is joining. Section 3 - Individual reassigning benefits. Section 4 - Signatures of the individual practitioner and Authorizing or Delegated official. Section 7 - Contact person. Returned Applications Provider enrollment applications may be immediately returned to the provider in many instances. The most common reasons are: No signature on the CMS-855 application. Application contains a copied or stamped signature. Signature on the application is not dated. The CMS-855I application was signed by someone other than the individual practitioner applying for enrollment. Applicant completed the form in pencil. Old version of form submitted, or the date in lower left of page not showing on each page. Contractor received the application more than 30 days prior to the effective date listed on the application (this does not apply to certified providers, i.e. Ambulatory Surgical Centers (ASC)). Enrollment Reminders Always list a contact person in Section 13. More than one contact person can be submitted. Sign and date the forms in blue ink. Page 9 of 10

10 Attach all required documentation. Respond to requests for additional documentation. Applications can be denied if information is not received. Make sure the latest version of the application is submitted and that the revision date is shown in the lower left corner of each page. Refer to the designated MAC for any specific IHS enrollment coversheets and/or mailing addresses. Refer to the CMS IOM, , Chapter 15, for provider enrollment guidelines. Page 10 of 10