Completing the Medicare Provider Enrollment Process

This article will outline some of the key steps in the Medicare enrollment process for a single physician, John James MD, starting a new practice.  This enrollment example assumes the physician has formed a legal business entity under which he will practice, XYZ, LLC.  This example illustrates using the paper application process, and highlights sections that would cause an application to be denied if not fully completed.

Overview of forms needed:

1. CMS855I – Medicare Enrollment Application – Physicians and Non-Physician Practitioners
2. CMS460 – Medicare Participating Physician or Supplier Agreement
3. CMS588 – Electronic Funds Transfer (EFT) Authorization Agreement

Supporting Documents Required:

1. CP575 or Letter 147C from the IRS to verify the tax id# of the business
2. Pre-printed voided check, or a bank letter of account verification, that exactly matches the legal business name on the IRS CP575 or letter 147C.

Dr. James will need to obtain a Medicare number, referred to as a Provider Transaction Identification Number or “PTAN”, for both himself and his legal business entity.  This will allow all payments from Medicare to be made to his business under the business tax id#.  Since Dr. James is the sole owner of XYZ, LLC, he can obtain both the Group PTAN and his Individual PTAN using the individual enrollment application CMS855I.  The CMS855I contains 17 sections and 27 pages.

Section 1: Dr. James marks the box “You are a new enrollee in Medicare”

Section 2A, 2B: Identifying Information and Correspondence Address

The correspondence address cannot be the address of a billing company or other third party, it must be a direct connection to the provider.

Section 2C:

Dr. James selects that he is not in a residency or fellowship program

Section 2D:

Dr. James selects his primary specialty

Section 3: Adverse events, Dr. James selects “NO” to attest that he has no adverse legal action history

Section 4:

Practice Location Information begins collecting the details about the business entity, service locations, and payment address.

Part A is for identifying the name, tax id, and type 2 NPI for the legal business entity.  Be certain that the name appears exactly as it is on file with the IRS.

Section 4C is the service location information and should be filled out completely.  The practice location name should be filled out if the practice does business as a name other than the full legal business name previously entered.

Part E identifies your special payments address (where claims payment communication is mailed)

Section 6: Individuals having managing control:

This section must list the name and identifying information of Dr. James.  Dr. James would also need to make an additional copy of this page for an office manager or any other person who is responsible for managing the business of the practice.

The Remaining sections of the 855I form include providing information on your billing company if applicable, contact information for the person completing the enrollment form, and signatures for the application.  In addition to the 855I, Dr. James will submit a form 460 to elect participation in the program.  The 460 is a simple one page form.  The final form to be submitted is form 588 to establish Electronic Funds Transfer for payment.  The CMS588 is a simple one page form of information and signature on page 2.

Things to remember

Review your application and supporting documents to ensure the following items won’t cause a delay in your application:

• Always sign the form in BLUE ink, never black ink.  We have had applications rejected because the processor claims the black ink signature was a signature stamp when it was in fact a personally signed document.  We had to resubmit signature pages in blue ink.  This is not uncommon.
• Failure to date your signature page
• Entering an individuals name that is different than shown on the Social Security Administration records
• Entering a business name that is different than shown by the IRS (including entity designations such as LLC, Inc, PLLC, etc – the business name must match EXACTLY the name shown on your CP-575)
• Not checking the box in any section related to adverse actions against the applicant
• Incomplete demographic information in section 2
• Listing a home address for a place of service if your application is for an outpatient clinic
• Not providing a direct correspondence and phone number for the provider applicant (the correspondence address cannot be a billing company or other third party)
• Providing a voided check or bank account verification letter that does not list the company name exactly as shown on the CP575

Summary

Enrolling in the Medicare program can be time consuming and frustrating.  Using the PECOS online enrollment system is often more efficient than a paper application.  However, some of the MACs have proven problematic at accurately transferring application information to and from PECOS.  NGS Medicare is one such MAC that has repeatedly had IT issues that caused serious delays in application processing via PECOS.  So, whether submitting on paper or online, remember that timely follow up and accurate documentation are important during your enrollment process.  Be sure to respond to any requests for additional information from a Medicare representative.  Failure to respond will cause your application to be rejected.