Physicians may enroll or make a change in their Medicare Part B enrollment information through the web-based Provider Enrollment, Chain and Ownership System (PECOS).
The Affordable Care Act established a requirement for all enrolled providers and suppliers to revalidate their enrollment information under new enrollment screening criteria. Every three or five years, CMS Medicare Administrative Contractors will ask providers to submit a complete and up-to-date enrollment application. Physicians currently and actively enrolled can use the Medicare Revalidation Lookup Tool in order to determine if they are up for revalidation. If the tool displays “TBD” this means the provider is not up for revalidation at this time, continuing to periodically monitor this tool is highly encouraged.
If a provider’s due date is listed, submit revalidation within six months of that date. You will be able to submit your application via paper (CMS-855i form) or electronically through the internet-based PECOS (Provider Enrollment, Chain, and Ownership System). CMS urges you to use internet-based PECOS for responding to the request for revalidation – and for most other updates that may need to be made to your provider enrollment records.
Prescriber Enrollment – Feb. 1, 2017 New Requirement
Any physician or other eligible professional who prescribes Part D drugs must either enroll in the Medicare program or officially opt out in order to prescribe drugs to their patients with Part D prescription drug benefit plans. Medicare Part D may no longer cover drugs that are prescribed by physicians who are neither validly enrolled, nor officially opted out of Medicare. Solely to order and refer means the provider can prescribe Part D drugs but cannot bill Medicare for services. Full enforcement of the Part D prescriber enrollment requirement will begin on Jan. 1, 2019. All prescribers must be enrolled by Jan. 1, 2019 to ensure enrollees get their prescriptions. The Academy encourages physicians to submit completed enrollment applications as soon as possible to allow adequate time for processing.
How to Report Changes
You can submit a change of information, including a change of address, using PECOS or the appropriate paper enrollment application. You must report a change of ownership or control, a change in practice location, and any final adverse legal actions such as revocation or suspension of a Federal or State license, within 30 days or the reportable event. Submit all other changes within 90 days of the reportable event.
Additional CMS Resources:
PECOS FAQs from CMS
Whether enrolling or re-enrolling, this new CMS document answers frequently asked questions about PECOS (pdf).
Enrollment and Change of Ownership Denials Due to Overpayments
Medicare contractors may now deny a Form CMS-855 enrollment application if the current owner of the enrolling provider or supplier or the enrolling physician or non-physician practitioner has an existing or delinquent overpayment that has not been repaid in full at the time an application for new enrollment or Change of Ownership is filed.
Provider Enrollment and Certification Tips
When submitting on paper, either by fax or mail, Medicare has 60 days to process your application. Be sure to choose one method of submitting. If duplicate applications are submitted (one by fax and one by mail), this can slow the process down and take longer than 60 days to process.
If you choose to submit via Internet-based PECOS, the application should be approved in 45 days. With that, CMS encourages providers to choose the Internet-based PECOS system to enroll.
You can start to see patients on the date you enter on your application as the “effective date.” Most practices will hold claims until the application is approved and then submit.
Verifying Enrollment and Validation
You can go to Ordering and Referring Report to verify if your name and NPI is present. This file is updated every two weeks. If you are not enrolled, visit the CMS website to learn how. All enrollment applications, including those submitted over the Internet, require verification of the information reported. Sometimes, Medicare enrollment contractors may request additional information in order to process the enrollment application. Waiting too long to begin this process could mean that your enrollment application may not be processed prior to the implementation date of the ordering/referring Phase 2 provider edits
Is Your PECOS Data Accurate?
Physicians must check their PECOS data to assure accuracy for CMS claims payment and PQRS reporting. To delay could result in lack of payment. Information such as address, NPI and name of practice must be confirmed. Check by physician or practice.
Resources from the Academy
Resources from CMS
Resources from Cahaba