Provider Enrollment handout

Provider Enrollment
Palmetto GBA J1 A/B MAC
Provider Outreach and Education
Agenda
Overview of Provider Enrollment
 Applications overview
 Internet-based PECOS
 Application timelines
 Revalidation
 Current CMS Initiatives
 Enrollment Tips
 Resources
 Q & A chat session

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Role of Provider Enrollment
 Review,
validate and process J1 CMS
enrollment applications, including
supporting documentation, to ensure
applicants are qualified and eligible to
participate in the Medicare Program
Role of Provider Enrollment
 Maintain
provider enrollment records
in Internet-based PECOS and MCS/FISS
 Adhere to CMS processing timeliness
standards based on application types
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When Should You Submit An
Application?
 Joining
Medicare Program for the first
time
 Joining a group
 Anytime something changes with your
practice
 If you wish to enroll for the purpose of
ordering and/or referring services
 Revalidation
Application Lifecycle
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CMS Provider Enrollment Forms
 CMS
855I
 CMS 855B
 CMS 855R
 CMS 460 - Participation Agreement
 CMS 588 - Electronic Funds Transfer
(EFT) Agreement
Speaker Note: These forms can be found in the Provider Enrollment section of the CMS
and Palmetto GBA Web sites. Downloading directly from the Web ensures you are using
the most current form available.
PTANs and NPIs
 Provider
Transaction Access Number
(PTAN)
 Minimum number of PTANs will be
assigned
 Exceptions are made for hospital
departments under certain
circumstances
 National Provider Identifier (NPI)
Speaker Note: To obtain an NPI providers should use the Web based National Plan and Provider
Enumeration System also known as NPPES. To access this site, go to the CMS web page.
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What is Your Business Structure?
□ One Owner
□ Sole owner, not incorporated
□ Submit 855I
□ Sole owner, incorporated
□ Must have both Type I (Individual) and Type II (
Organizational) NPI and submit 855I
□ Multiple Owners
□ Must have Type I and Type II NPI
□ Must be signed by A/O or D/O as required
□ Submit 855B
Solely Owned Organization
vs. Sole Proprietor
Solely Owned Organization
Sole Proprietor

Providers who are the sole
owners of their
incorporated business (Inc.,
LLC, PC, etc.)

Physician operates an
unincorporated business
and the business name is
the same as his/her name

Be sure to include all
business information in
section 4A of CMS 855I


In most cases, a Type 2
Organizational NPI is
needed for the business
Be sure to include the
individual tax
identification information
in section 4F of CMS 855I
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How do I enroll in Medicare?
 Submit
the latest version of a CMS 855
enrollment application
 Complete online enrollment via
Internet-based PECOS
Application Overview: CMS 855I
 Initial
enrolling Individual practitioner
 Providing
setting
services in group or private
 Enrolled
practitioner making changes
to enrollment data
 Enrolled practitioner forming a sole
owned business entity
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Application Overview: CMS 855I
The CMS 855I application must be completed by the following nonphysician practitioners to initiate the enrollment process:
□ Anesthesiology
Assistant
□ Mass immunization
roster biller
□ Psychologist, Clinical
□ Audiologist
□ Nurse practitioner
□ Psychologist billing
□ Certified nurse midwife
□ Occupational therapist
in private practice
□ Certified registered
nurse anesthetist
□ Registered Dietitian or
Nutrition Professional
□ Physical therapist in
private practice
□ Clinical nurse specialist
□ Speech Language
Pathologist
□ Clinical social worker
□ Physician assistant
Application Overview: CMS 855B
 Providers
planning to bill Medicare for
Part B services
 Currently enrolled providers making
changes to enrollment data
 Currently enrolled providers changing
Medicare jurisdiction
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Application Overview: CMS 855B
The following suppliers must complete the 855B application to
initiate the enrollment process:
□
□
□
□
□
□
□
□
□
Ambulance Service Supplier
Ambulatory Surgical Center
Clinic/Group Practice
Competitive Acquisition Program (CAP) Part B
Drug Vendor
Independent Clinical Laboratory
Independent Diagnostic Testing Facility (IDTF)
Mammography Center Mass Immunization
(Roster Biller Only)
Portable X-ray Supplier
Radiation Therapy Center
Application Overview: CMS 855R
 Completed
by individuals
 Initial
Reassignment
 Terminating a reassignment
 Reassigning
benefits
 Allows
eligible Provider/Supplier to submit
claims and receive payment for Medicare
Part B services provided by individual
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What is PECOS?
 Provider
Enrollment Chain and
Ownership System
 CMS
Database of all medical
providers/suppliers
 System
of record for all enrollment
related information
Are You In PECOS?
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Are You In PECOS?
Accessing Internet-based PECOS

You must have:
 Internet
access
 Current NPPES User ID and password
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CMS PECOS Webpage
 PECOS
example
 Enrollment products
 Webinars
 Sole
Proprietor or Owner
 Change of Information
 Reassignment
 Two directors
Internet-based PECOS
Capabilities
 New
provider enrollment
 Change established enrollments
 View current enrollment information
 Check status of PECOS application
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Internet-based PECOS Limitations
 May
not change name or SSN
 May not change existing business
structure
 May not change TIN or LBN
 May complete reassignment of
benefits if both are enrolled in PECOS
 CMS EUS Help Desk at 1-866-484-8049
Important Reminders about
Internet-based PECOS
 Mail
Certification Statement with
documentation
 Submit within 15 days
 Mail original signature pages
 Use Blue Ink
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Reminder: Hit The “Submit” Button
Reminder: Print, Complete and
Mail Certification Statement
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Reminder: Provide Application
Contact Person
Enrollment Outcomes
Decision
Action/Recourse
Approved
If disagree with decision, follow
instructions in approval letter for
reconsideration
Denied
If disagree with decision, follow
instructions in denial letter for
reconsideration
Denied/Rejected
If disagree, follow instructions for
CAP submission
Return
Review letter, application not
needed
Rejected
Review letter and follow
instructions for resubmission
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CAP vs. Reconsideration
□ CAP = Corrective Action Plan
□ Allows provider to correct deficiencies with original
submission
□ Must submit all missing information with CAP form within 30
days
□ Application will be reopened and effective date preserved
□ Reconsideration = Appeal of Enrollment decision
□ Allows provider to dispute decision
□ Details provided in approval/denial letter
□ Provider must submit letter detailing why decision was not
correct within 60 days
□ Both can be submitted concurrently
Revalidation Activities
 CMS
initiatives or Contractor discretion
 Provider must submit a complete
enrollment package
 Ensures all information is up to date in
the enrollment system
 Effective Date will not change
Speaker Note: When should you revalidate? Every 5 years if no changes to practice.
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Current CMS Initiatives
Current Initiatives
 CR-6417:
Expansion of the Current
Scope of Editing for
Ordering/Referring Providers
 CR-7350: Implementation of Provider
Enrollment Provisions
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CR 6417: Expansion of the Current
Scope of Editing for
Ordering/Referring Providers
Ordering and Referring Providers
 All
providers ordering and referring
services for Medicare beneficiaries
must have an Internet-based PECOS
enrollment record
 Validate your PECOS status on CMS
Ordering Referring Report
 Must be of the type/specialty who are
eligible to order/refer services for
Medicare beneficiaries
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Eligible to Order/Refer
Doctor of Medicine
or Osteopathy
 Dental Medicine
 Dental Surgery
 Podiatric Medicine
 Optometry
 Chiropractic
Medicine

Physician Assistant
 Certified Clinical
Nurse Specialist
 Nurse Practitioner
 Clinical Psychologist
 Certified Nurse
Midwife
 Clinical Social
Worker

During Phase 1 (October 5, 2009until further notice):
□ If the ordering/referring provider is not
on the PECOS file or is not of the
specialty eligible to order or refer:
□ The claim will continue to process but a
message will be included on the
remittance advice notifying the billing
provider that the claims may not be paid
in the future
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During Phase 2 (Start Date to Be
Announced):
□ If the billed service requires an
ordering/referring provider and the
ordering/referring provider is not on
the claim, the claim will not be paid
□ If the ordering/referring provider is not
PECOS or if they are not of the
specialty eligible to order or refer, the
claim will not be paid
CR 7350: Implementation of
Provider Enrollment Provisions
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PE Provisions: Beginning
March 25, 2011
□ Establishes provider enrollment screening
categories
□ Submission of application fees as part of the
provider enrollment process
□ Suspensions of payment based on credible
allegations of fraud
□ Authority to impose a temporary moratorium
on the enrollment of new Medicare
providers and suppliers of a particular type
(or the establishment of new practice
locations of a particular type) in a
geographic area
Screening Process
□ Medicare will place newly-enrolling
and existing providers and suppliers in
one of three levels of categorical
screening:
□ Limited
□ Moderate
□ High
Speaker Note : Chapter 15, Section 19.2.1 of the “Program Integrity Manual” (PIM) provides the
complete list of these three screening categories, the provider types assigned to each category, and a
description of the screening processes applicable to the three categories, and procedures to be used
for each category.
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Application Fees
Does not apply to physicians, nonphysician practitioners, physician group
practices and non-physician group
practices
 Providers and suppliers that are:
 Initially enrolling in Medicare
 Adding a practice location or
 Revalidating their enrollment
information

Must submit an application fee of $505
Enrollment Tips
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Top Development Reasons
 Application
is incomplete – Missing
information
 Signature issues
 Missing CP-575 tax document
 Missing CMS 588 EFT application
 Wrong type of NPI - Type 2 needed
 NPPES mismatch
Add/Change /Delete
□ Add = new enrollment for first time,
new additional location or revalidation
□ Change = submit change to existing
information
□ Delete = Removal of information
□ Section 4 can be copied and
submitted multiple times to complete
multiple actions or locations
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Signature Requirements
□ Signature verification required for:
□ Change of practice location
□ Change of Corr/Special Payment address
□ Change EFT
□ Revalidation or Reactivation
□ Establishment of sole owner or sole
proprietor when provider currently
reassigning all benefits
Participation vs. Opt Out
□ Participating: Accepts Medicare
assignment
□ Non – Participating: Option to accept
or not accept Medicare assignment
□ Opt Out: Not enrolled/ does not
participate in Medicare program
□ Opt Out period runs for two years
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Supporting Documents
□ IRS
□ CP 575 preferred to validate Legal
Business Name
□ Must be on pre-printed form from IRS
□ I-9 Verification
□ Foreign born providers must prove
residency or ability to work in United
States
□ Requirements consistent with SSA
Specialty Codes
□ Must designate a primary specialty (P)
and a secondary specialty (S)
□ Avoid “other” if at all possible –
example a provider designated D.D.S
is viewed as a “Dentist”
□ Consider carefully and view ranges –
Pediatric Neurology would be
considered “Neurology”
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Minimizing Risks

Ensure information is accurate and
submitted timely
All changes, no matter how small must be
submitted
 All service locations must be on file
 Be proactive – Failure to do so could impact
your ability to receive reimbursement
 Use the most current enrollment forms
located on the CMS Web site

Minimizing Risks

Stay informed of changes
Subscribe to ListServ messages/Email Updates
 Review materials and information on the CMS
and Palmetto GBA Web sites
 Participate in Outreach and Education
opportunities in your area


Ensure EFT and EDI information is current
CMS 588 form is required and must be accurate
 EDI enrollment/submitter linkage is completed
through EDI team and not Provider Enrollment

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Resources
Resources
 CMS
Web site Resources:
 Provider Enrollment
Internet-based
PECOS
Ordering/Referring Report
Medicare Program Integrity Manual
(IOM 100-8, Chapters 10 &15)
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Resources
 Palmetto
GBA Web site Resources:
 Provider Enrollment
 Self-Service Tools
Provider
Enrollment Application Help
Provider Enrollment Application
Lookup
 MLN
Matters Articles
CR6417
CR7350
J1 Provider Enrollment
Application Help Tool
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J1 Provider Enrollment
Application Lookup
Q/A Chat Session
This concludes the audio portion of today’s
webinar. We will remain online for the next 30
minutes to conduct the Q & A session via the Chat
feature in WebEx.
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