If you write prescriptions for covered Part D drugs and you are not already enrolled in Medicare in an approved status or have a valid record of opting out, you should submit an enrollment application or an opt-out affidavit to your Medicare Administrative Contractor (MAC) by January 1, 2016, or earlier, so that the prescriptions you write for Part D beneficiaries are coverable on and after June 1, 2016.
The Medicare final rule, CMS-4159-F, requires virtually all physicians and other eligible professionals, including dentists, who write prescriptions for Part D drugs to be enrolled in an approved status or to have a valid opt-out affidavit on file for their prescriptions to be coverable under Part D, except in very limited circumstances. To allow sufficient time for the prescribers to enroll in Medicare and the Part D sponsors and the Pharmacy Benefit Managers (PBMs) to make the complex system enhancements needed to comply with the prescriber enrollment requirements, CMS announced a delay in enforcement of this rule until June 1, 2016. Nevertheless, prescribers of Part D drugs should submit their Medicare enrollment applications or opt-out affidavits to their Part B Medicare Administrative Contractors (MACs) by January 1, 2016, or earlier, to ensure that MACs have sufficient time to process the applications and opt-out affidavits and avoid their patients’ prescription drug claims from being denied by their Part D plans, beginning June 1, 2016(Enrollment functions for physicians and other prescribers are handled by MACs).
The purpose of these rules are to ensure that Part D drugs are prescribed only by physicians and eligible professionals who are qualified to do so under state law and under the requirements of the Medicare program and who do not pose a risk to patient safety. By implementing these rules, CMS is improving the integrity of the Part D prescription drug program by using additional tools to reduce fraud, waste, and abuse in the Medicare program. Prescribers who are determined to have a pattern or practice of prescribing Part D drugs that are abusive and represents a threat to the health and safety of Medicare enrollees or fails to meet Medicare requirements will have their billing privileges revoked under 42 USC 424.535 (a)(14).
Enrollment with Medicare can be accomplished using the internet based Provider Enrollment, Chain, and Ownership System (PECOS) or by completing the paper CMS-855O application for enrollment for ordering purposes only, or CMS-855I and CMS-855R to enroll to bill for services.
More information can be found on the MLN article revised 10/20/15.
nCred has helped thousands of providers nationally to enroll in the Medicare program. If you need assistance with the enrollment process, give us a call to discuss how our provider enrollment services can help your organization.
