In order to legally treat Medicare eligible patients, a doctor must apply and be accepted as a provider in the program. Doctors that are not enrolled cannot legally treat any Medicare eligible patients … not even one!
Enrolling in the Medicare program involves completing and submitting various CMS-855 forms. The forms can be submitted by completing and mailing in the required forms or online using the Medicare Provider Enrollment, Chain, and Ownership System (PECOS)
The Medicare program also uses a re-validation process that requires that the forms be resubmitted from time to time.
National Provider Identifier (NPI)
Before a doctor can apply to be a provider in the Medicare program he must have an NPI number. The NPI is the standard Unique Health Identifier for health care providers issued and maintained by the National Plan and Provider Enumeration System (NPPES)
All Chiropractors must complete an 855i application to enroll in the Medicare program.
Your Medicare Administrative Contractor (MAC) will issue an approval/notification letter, including your Provider Transaction Access Number (PTAN), when an enrollment is approved. Your enrollment must be approved before you can submit claims.
The PTAN number is a Medicare only number used to identify the doctor. It does not appear on either the paper or electronic claim form.
A clinic / group practice is established when individuals are employed/contracted and reassign Medicare benefits allowing the clinic / group practice to submit claims and receive payment for their Medicare Part B services. Clinic / group practices have more than one owner.
Group practices should submit an 855b Application
Reassignment Of Medicare Benefits
If you reassign your benefits to another entity, such as a group practice that receives payment for your services, you must also complete the CMS 855r form
Electronic Funds Transfer (EFT)
All providers are required to receive electronic funds transfer (EFT).
This includes non-participating providers that do not accept assignment.
At the time of enrollment, revalidation, change of Medicare contractors or submission of an enrollment change request you must complete the CMS-588 form and include a copy of a voided check.
Just be aware that you will not only be allowing deposits into your bank account but you are also allowing the withdrawal of funds. Some doctors choose to establish a separate bank account specifically for EFT transfers.
Upon application, if the doctor decides to be a participating provider he should complete the CMS 460 form otherwise he will be enrolled as a non-participating provider (Non-Par).
To get an understanding on how your participation status affects payment take a look at our Medicare Payments course.
See also Changing Your Medicare Participation Status blog post.
Note: All physicians in a group practice must be the same participation status.
Note: Providers who opt out cannot be employed by or work with other groups who have members who have not also chosen to opt out of the Medicare program. Chiropractors cannot opt out of the Medicare program but they could be in a group with medical doctors that have opted out.
Ballpark Time for Application Approval (Palmetto)
Paper Application — Accurate Submission — 55 days
Paper Application — Incomplete at Submission — 65 days
Internet PECOS Submitted Application — Accurate at Submission — 43 days
Log into PECOS the Medicare Provider Enrollment, Chain, and Ownership System.
More information about Identification Numbers for a Practice blog post
See Also Reporting Changes in Ownership or Location to Medicare blog post
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