Enrollment Verification Soon Required for Part D Prescribers

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  • December 15, 2014
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At first glance, a recent announcement by the Centers for Medicare & Medicaid Services (CMS) seems to suggest that prescribers of Medicare Part D drugs have been given a six-month reprieve from certain program requirements that were supposed to go into effect June 1, 2015. If you read the article in its entirety, however, you learn otherwise.
The “Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs” (42 CFR 423.120(c)(6)) final rule, published in the Federal Register on May 23, 2014 requires physicians and other eligible professionals who write Medicare Part D prescriptions for Medicare patients to enroll in an approved status, or to have a valid opt-put affidavit on file for their prescriptions to be covered under Part D.
CMS announced on December 5, 2014 that it is delaying enforcement of this requirement until December 1, 2015. This delay, however, is for Medicare contractors, not prescribers.
“Nevertheless,” CMS states in MLN Matters® special edition article SE1434, “prescribers of Part D drugs must submit their Medicare enrollment applications or opt-out affidavits to their Part B Medicare Administrative Contractors (MACs) by June 1, 2015, or earlier … .”
CMS is only postponing enforcement of the requirement for six months to ensure that MACs have sufficient time to process provider enrollment applications and opt-out affidavits, and consequently to avoid a lot of prescription drug claims denials by beneficiaries’ Part D plans.
Prescribers may submit their enrollment application electronically using the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) or by completing the paper CMS-855I (Medicare enrollment) or CMS-8550 (Part D-only enrollment) application. Opt-out affidavits are submitted to the MAC within the prescriber’s jurisdiction. Note that opt-out affidavits must be submitted every two years, and a National Provider Identifier (NPI) is required.

Renee Dustman
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Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.

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