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.
Rebuttal Request When Medicare Enrollment Deactivated
Beginning December 31, 2019 Centers for Medicare and Medicaid Services (CMS) now allows physicians to file a rebuttal if their Medicare enrollment has been deactivated. The Change Request 10978 listed in the Federal Registrar allows for rebuttals for theses specific deactivation reasons:
- Because the physician did not submit Medicare claims for twelve consecutive calendar months.
- Because the physician did not report a change of information within 90 calendar days of when the change occurred or within 30 days of a change in ownership.
- Because the physician did not respond to a revalidation request letter. These include a request for corrections on a revalidation application.
- Because the physician is in an approved status but doesn't have any practice location or active reassignment for 90 calendar days.
Documentation should also include specific reasons and facts to support why the deactivation is incorrect. Physicians have twenty days from the date of the deactivation letter to submit a rebuttal to their Medicare Administrative Contractor (MAC). Any requests received after twenty days will be denied. These requests can be submitted via standard mail, email or fax. Note that some MACs are creating cover letters to submit along with the rebuttal request.
MACS are required to render determination within thirty days of receipt of request. Notification of receipt of the request will be sent to the physician within ten calendar days, however, if a determination is made within those ten days, this letter will be sent in its place. MACs will use mail, email and fax when appropriate.
The final rebuttal determination is not eligible for further review.
Requirements for rebuttal submission are as follows:
- Signature must be the physician whose been deactivated, an authorized or delegated official on file or a legal representative.
- If the physician is using an attorney to submit, the attorney must submit proof they have authority to represent the physician.
- If the correct signature is not provided, the MAC will request this information. Response must be received within thirty days otherwise the request will be dismissed. Missing signature statements or Appointment statements must be received within fifteen days.
Some physicians may choose to submit another application while their rebuttal is pending. The MAC will begin processing this application in conjunction with rebuttal determination.
- If the deactivation is overturned prior to the new application request being approved, the new application request will be returned as no longer needed.
- If the new application is approved prior to the rebuttal request determination with no gap in billing, the MAC will stop processing and submit a letter indicating as such.
Resources from the Academy
Resources from CMS
Resources from Cahaba