Provider enrollment is one of the most exasperating trials of a physician or a health care provider's career. Medicare can be a little confusing to many people. A medical provider have the option of participating with Medicare or can be a non-par. A provider can also be a non-par but accept assignment.
What is Medicare Credentialing?
The Medicare credentialing entails the completion of the relevant forms for processing application. Within the credentialing process, Medicare may examine a potential participant's history to evaluate the practice, training, skill level and capacity to administer specific services or carryout specific tasks. Background checks assess the legitimacy of the individual seeking to obtain the credentials. The institution they graduated from, where they conducted their internship residency and fellowship, Broad Certifications and State Medical License(s) are the additional areas that may be explored.
What is Medicare Credentialing?
The Medicare credentialing entails the completion of the relevant forms for processing application. Within the credentialing process, Medicare may examine a potential participant's history to evaluate the practice, training, skill level and capacity to administer specific services or carryout specific tasks. Background checks assess the legitimacy of the individual seeking to obtain the credentials. The institution they graduated from, where they conducted their internship residency and fellowship, Broad Certifications and State Medical License(s) are the additional areas that may be explored.
When a provider(s) enroll to become a Medicare provider they need to understand that they are not only signing up to treat Medicare patients. This Medicare enrollment is also a way to signing up a contract and agreeing to many requirements that they need to be aware of. This is where much unintentional fraud comes in to play. Provider must need to understand of what is this contract that they are agreeing to.
Here are the reasons why a provider needs to complete a new Medicare application:
1. A new provider wants to participate in Medicare and treat Medicare patients.
2. A provider wants to change the following to complete a new Medicare application:
- name
- tax identification (let say provider decides to bill using a tax ID# or EIN instead of using their SS#)
- address [e.g. Provider(s) move their practice to a new location and a new Medicare credentialing application is needed to notify Medicare of the change. If a provider didn't update their new location, Medicare will stop paying because checks cannot be forwarded]
4. A provider decides to use a billing service a new application must be submitted.
Medicare is pretty meticulous with enrollment applications about the required information and attachments. Without this vital attachments the Medicare application will be denied.
Here are the following CMS Forms for Medicare Enrollment Application:
CMS 855I - Physicians and Non-Physician Practitioners. Number of Pages-28 (O.M.B. Exp. Date: 2012-07-31)
CMS 855B - Clinics/Group Practices and Certain Suppliers. Number of Pages-49 (O.M.B. Exp. Date: 2012-07-31)
CMS 855R - Reassignment of Medicare Benefits. Number of Pages-9 (O.M.B. Exp. Date: 2012-07-31)
CMS 460 - Medicare Participating or Supplier Agreement. Number of Pages-3 (OMB Exp. Date: 2013-09-30)
CMS 588 - Electronic Funds Transfer (EFT) Authorization Agreement. Number of Pages-3 (O.M.B. Exp. Date: 2013-04-30)
If a provider files a tax return under EIN number instead of their SS#, Medicare requires that you attach a form from IRS to verify the EIN and legal business name. The form must be preprinted from the IRS on IRS letterhead and it must show the EIN number and legal business name.
Example of acceptable IRS documents are:
- IRS CP-575 - is a computer generated form issued to you by the IRS when you applied for your Employer Identification Number (EIN). Medicare applications require a copy of this form upon submission during the credentialing process. As a reminder W9 is not acceptable form of documentation.
Medicare contractor determines a discrepancy between the provider or supplier's legal business name and EIN provided in the section of the CMS-855 form.
If you do not have the form CP-575: contact IRS on 1-800-829-4933 from 7am to 7pm EST.
Advantages of Internet-based PECOS
Individual Physicians and Non-Physician Practitioners
1. Log onto Internet-based PECOS with your NPPES User ID and password.2. Complete, review, and submit an electronic enrollment application.
Internet-based PECOS will walk you through the application process and supply you with a 2-page Certification Statement for each enrollment application you submit.
Organizational Providers and Suppliers
Who is the Authorized Official (AO)?
What if you cannot find or you lost your CP-575? What should I do?
If you cannot find the original form CP-575 that was issued by the IRS, you can obtain a substitute form. However, the specific CP-575 form is a computer generated and another CP 575 cannot be re-issued. Instead, the IRS will send you a Form 147-C in its place. The 147-C is a proof of EIN and will satisfy the requirements for Medicare.
- IRS substitute 147-C
How to get form 147C from the IRS - CP-575 Form Info
Many merchants have gotten notices from their credit card companies requiring them to validate their Taxpayer Identification (TIN) Numbers. If there is not exact match between the information that the IRS has on file and your processor's records, you can end up experiencing 28% withholding on your credit card terminal. In order to make sure both records line up, Form 147c can be mailed or faxed to you. You may not need this form if you kept CP575 form.
Important Note: Under IRS privacy rules, third parties cannot ask for this form on your behalf. Afetr you get the form, you can share it with your processor or bank.
To get 147c sent you directly, there are few simple steps:
1. Have your TIN or EIN number ready. This will be the same number your business uses when filing taxes.
2. Call the IRS at 1-800-829-4933 between 7AM and 7PM EST on weekdays.
3. Ask to get the form faxed to you. If you do not have a fax machine available, you can ask for it to be mailed.
Once you have the 147c letter, it can be forwarded to your processor, or you can compare the information yourself if you have the documentation from your merchant services company. Some of the most common issues that generate a TIN number matching letter involve the name of the business, since people often leave off "LLC" or "Corporation" when applying for merchant services. They may also use the word "and" when the IRS has an ampersand ("&") listed (or vice versa) and this is enough to trip up an automated TIN matching program. Alternatively, you may have the name of the business correct but the TIN number may be from an older incarnation of the company. This happens frequently when people buy an established firm or merge two business enterprises.
- IRS Form 8109 <<<- - - please click here for more information about 8109
View the free Form 8109 by clicking here
Enrollment using PECOS a web-based Application of Medicare
The Internet-based Provider Enrollment, Chain and Ownership System (Internet-based PECOS) can be used in lieu of the Medicare enrollment application (i.e., paper CMS-855) to:
- Submit an initial Medicare enrollment application
- View or change your enrollment information
- Track your enrollment application through the web submission process
- Add or change a reassignment of benefits
- Submit changes to existing Medicare enrollment information
- Reactivate an existing enrollment record
- Withdraw from the Medicare Program
- Submit a Change of Ownership (CHOW) of the Medicare-enrolled provider
Advantages of Internet-based PECOS
- Faster than paper-based enrollment (45 day processing time in most cases, vs. 60 days for paper)
- Tailored application process means you only supply information relevant to YOUR application
- Gives you more control over your enrollment information, including reassignments
- Easy to check and update your information for accuracy
- Less staff time and administrative costs to complete and submit enrollment to Medicare
Individual Physicians and Non-Physician Practitioners
Physicians and non-physician practitioners may access Internet-based PECOS by using the User IDs and passwords that they established when they applied on-line to the National Plan and Provider Enumeration System (NPPES) for their National Provider Identifiers (NPIs). If they did not establish User IDs and passwords at that time (for example, they may have submitted paper NPI applications to the NPI Enumerator and had no reason to establish User IDs and passwords), they may do so now by going to the NPPES hyperlink listed below and following the directions on the screens. If they have forgotten their User IDs or passwords, or otherwise need assistance in this regard, they may contact the NPI Enumerator at 1-800-465-3203 or customerservice@npienumerator.com.
1. Log onto Internet-based PECOS with your NPPES User ID and password.2. Complete, review, and submit an electronic enrollment application.
Internet-based PECOS will walk you through the application process and supply you with a 2-page Certification Statement for each enrollment application you submit.
3. Mail the original signed Certification Statement from Internet-based PECOS and supporting documents to the Medicare contractor within 15 days of your electronic submission.
The effective date of filing an enrollment application is the date the Medicare contractor receives the signed and dated (blue ink recommended) Certification Statement. Note: A Medicare contractor will not process an Internet enrollment application without the signed and dated Certification Statement.
The effective date of filing an enrollment application is the date the Medicare contractor receives the signed and dated (blue ink recommended) Certification Statement. Note: A Medicare contractor will not process an Internet enrollment application without the signed and dated Certification Statement.
Organizational Providers and Suppliers
Obtaining access to Internet-based PECOS by organizational providers and suppliers (e.g., professional associations, professional corporations, limited liability corporations) involves several steps, and the first step must be taken by the Authorized Official.
Who is the Authorized Official (AO)?
- An individual who will use Internet-based PECOS to submit enrollment applications for the provider or supplier organization will also register in PECOS I&A (Provider Enrollment, Chain and Ownership System Identification and Authentication System).
- This individual may be an employee of the provider or supplier organization or an employee of a separate organization.
- CMS will verify the information provided and the permission of the Authorize Official for that individual to use the Internet-based PECOS on behalf of the provider or supplier organization.
FYI: In July 2000, federal electronic signature legislation was enacted. Physicians who contract with government and/or managed care plans are considered to have valid signature on file.
