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Medicare Provider Enrollment

There are two ways to enroll with the Medicare program.  First, complete the appropriate Medicare paper applications, or second, use the Medicare Provider Enrollment, Chain, and Ownership System (PECOS).  This article focuses on provider enrollment using PECOS.

In order to use the PECOS system for provider enrollment you must first setup a user account in the CMS Identity & Access Management System (“I&A System”).  A user account with the I&A System will allow the user to login to PECOS for enrollment application processing purposes, login to the NPPES system to manage NPI numbers, enter incentive payment information, and to setup surrogate users to work on any of these on behalf of your organization or an individual provider record.

Gather Information

Once you have a user account for PECOS, you’ll need to have some detailed information to complete an individual provider enrollment application.  Here are some items that you will need:

  • An active National Provider Identifier (NPI).
    • Sole Proprietors only need a type 1 (individual) NPI
    • Solely Owned Organizations need both a type 1 (Individual) NPI and type 2 (Organization) NPI
  • Personal identifying information. This includes:
    • Legal name on file with the Social Security Administration
    • Date of birth
    • Social Security Number
  • Schooling information. This includes:
    • Name of School
    • Graduation year
  • Professional license information. This includes:
    • Medical license number
    • Original effective date
    • Renewal date
    • State where issued
  • Certification information. This includes:
    • Certification number
    • Original effective date
    • Renewal Date
    • State where issued
  • Specialty/secondary specialty information
  • Drug Enforcement Agency (DEA) number
  • If applicable, information regarding any final adverse actions. A final adverse action includes:
    • a Medicare-imposed revocation of any Medicare billing privileges;
    • suspension or revocation of a license to provide health care by any State licensing authority;
    • revocation or suspension by an accreditation organization;
    • a conviction of a Federal or State felony offense (as defined in 42 CFR 424.535(a)(3)(A)(i)) within the last ten years preceding enrollment or revalidation;
    • or an exclusion or debarment from participation in a Federal or State health care program.
  • Practice location information. This information includes:
    • Practitioner’s medical practice location
    • Legal business name of a solely-owned Professional Association, Professional Corporation, or Limited Liability Company (LLC) on file with the Internal Revenue Service and appearing on the IRS CP575
    • Special Payment Information
    • Medical Record Storage Information
    • Billing Agency Information (if applicable)
    • Any Federal, State, and/or local (city/county) business licenses, certifications and/or registrations specifically required to operate as a health care facility.
  • Electronic Funds Transfer documentation – mechanism by which providers and suppliers receive Medicare Part A and Part B payments directly into a designated bank account.

After you login to the PECOS system, you will be guided through a series of steps to select the appropriate application and enter your information.  Similar to selecting the appropriate paper application, it is important to select the proper enrollment type within the PECOS system so that you transfer the appropriate information to Medicare for your enrollment record.  An individual physician enrolling with Medicare for the first time can expect to spend an hour or more completing the application and uploading all relevant supporting documents.

eSign and Upload Documents

Upon completion of the application, you can eSign your enrollment application and upload documents that are required for your enrollment record.  After you complete all data entry, eSign the application, and upload all relevant documents, you can finally submit your application online.  When submitted via PECOS, your application is sent to the Medicare Administrative Contractor (MAC) for your state.  Most MAC’s complete the application within 60 days, but there is certainly no set turnaround time.  Completion of your application therefore depends entirely upon the MAC’s processing capabilities.  There are often situations that causes great delays in application processing times such as when MAC’s take over new territories.

After submitting your application via PECOS, you can check the status of your application online directly with the MAC through their website or via the PECOS application status check page.

Get It Right The First Time

Medicare is often the largest payer for medical organizations and it is important to complete the enrollment process correctly the first time.  The application process can be complicated and time consuming.  nCred has assisted thousands of healthcare practitioners with the Medicare provider enrollment process.  Give us a call today at (423) 443-4525 or request information about our services here.