Medicare Compliance & Reimbursement

Question: At our rural practice, we have one doctor, and she wants to enroll as a Medicare provider. Does she need to fill out a form? What is the easiest way for her to apply?

Montana Subscriber

Answer: There’s a common belief that medical licensure allows providers to immediately bill Medicare for services rendered, but that’s not the case. There’s actually a process that starts with either getting a national provider identifier (NPI) or confirming one through a query via the National Plan and Provider Enumeration System (NPPES).

Remember: “Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA,” reminds the Centers for Medicare & Medicaid Services (CMS) in online guidance. “The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty,” CMS maintains.

After an NPI has been confirmed, you’ll determine the correct form — which in this situation for a solo practitioner would be a CMS-855I — and submit. The easiest way to get the ball rolling is to complete the application through CMS’ online portal, the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) at https://pecos.cms.hhs.gov/pecos/login.do#headingLv1

If you prefer to send a “completed application with original signatures and all required documentation,” you can do so through your designated Medicare Administrative Contractor (MAC), CMS indicates. “The MAC that services your State is responsible for processing your enrollment application. To locate the mailing address for your designated MAC, go to www.cms.gov/MedicareProviderSupEnroll,” according to the CMS-855I application materials.

Heads up: Though the CMS-855I is the choice for the solo physician at your practice, there are six CMS-855 forms in total. They are:

• CMS-855A — Used by institutional providers (e.g. hospitals).
• CMS-855B — Used by clinics, group practices, and certain other suppliers.
• CMS-855I — Used by physicians and non-physician practitioners.
• CMS-855O — Used for eligible ordering/referring physicians and non-physician practitioners.
• CMS-855R — Used for reassignment of Medicare benefits.
• CMS-855S — Used for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers.

Find more Medicare provider enrollment information at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Enrollment-Applications.