MLN9658742 – Medicare Provider Enrollment (2024)

What’s Changed?

Substantive content changes are in dark red.

Application Fee

Physicians, non-physician practitioners, physician organizations, non-physician organizations, and Medicare Diabetes Prevention Program suppliers don’t pay a Medicare enrollment application fee.

Generally, institutional providers and suppliers like DMEPOS suppliers and opioid treatment programs pay an application fee when enrolling, re-enrolling, revalidating, or adding a new practice location.

Enrollment

Providers must enroll in the Medicare Program to get paid for providing covered services to Medicare patients. Determine if you’re eligible to enroll and how to complete enrollment.

Step 1: Get an NPI

To enroll in the Medicare Program, get an NPI through:

• Online Application: Get an Identity & Access Management (I&A) System user account. Then apply for an NPI in NPPES.
• Paper Application: Complete, sign, and mail the NPI Application/Update Form (CMS-10114) paper application to the address on the NPI Enumerator form. To request a hard copy application:
  • Call 1-800-465-3203 (TTY 1-800-692-2326)
  • Email customerservice@npienumerator.com
• Bulk Enumeration: Apply for Electronic File Interchange access and upload your own CSV or XML files.

CMS Provider Enrollment Systems:

• I&A System
• NPPES
• PECOS
• Electronic Health Record (EHR) Incentive Payments

Step 2: Complete Proper Medicare Enrollment Application

After you get an NPI, you can complete Medicare Program enrollment, revalidate your enrollment, or change your enrollment information. Before applying, get the necessary enrollment information, and complete the actions using PECOS or the paper enrollment form.

A. Online PECOS Application

After we approve your I&A System registration, submit your PECOS application.

PECOS offers a scenario-driven application, asking questions to recover the information for your specific enrollment scenario. You can use PECOS to submit all supporting documentation. Follow these instructions:

1. Log in to PECOS.
2. Continue with an existing enrollment or create a new application.
3. When PECOS determines your enrollment scenario and you confirm it’s correct, you’ll see the topics for submitting your application. To complete each topic, enter the necessary information.
4. At the end of your data entry process, PECOS:
   • Confirms you entered all necessary data
   • Lists MAC documents to submit for review
   • Gives the option to electronically sign and certify
   • Shows your MAC’s name and mailing address
   • Lets you print your enrollment application for your records (don’t submit a paper copy to your MAC)
   • Sends the application electronically to your MAC
   • Emails you to confirm your MAC got the application

B. Paper Medicare Enrollment Applications

Submit the appropriate paper enrollment application if you’re unable to use PECOS. Carefully review the paper application instructions to decide which form is right for your practice. The paper enrollment application collects your information, including documentation verifying your Medicare Program enrollment eligibility.

If you submit a paper application, your MAC processes your application and creates a Medicare enrollment record by entering the data into PECOS.

Step 3: Respond to Requests for More Information

MACs pre-screen and verify enrollment applications for completeness. If the MAC needs more information, respond to information requests within 30 days. If you don’t, the MAC may reject your enrollment.

Your MAC won’t fully process your PECOS enrollment application without your electronic or uploaded signature, application fee (if applicable), and necessary supporting documentation. The enrollment application filing date is when the MAC gets your enrollment application.

You can check your PECOS enrollment application status 2 ways:

• Log in to PECOS and select the View Enrollments link. In the Existing Enrollments section, find the application. The system shows the application status.
• To see your enrollment status without logging in, go to PECOS and, under Helpful Links, select Application Status.

When your MAC approves your application, it switches the PECOS record to an approved status and sends you an approval letter.

Step 4: Use PECOS to Keep Enrollment Information Current

Report a Medicare enrollment change using PECOS. Physicians, NPPs, and physician and NPP organizations must report a change of ownership or control (including a change in authorized or delegated official), a change in practice location, and any final adverse legal actions (like a felony or suspension of a federal or state license) within 30 days of the change and report all other changes within 90 days of the change.

DMEPOS suppliers must report changes in their enrollment application information within 30 days of the change.

Independent diagnostic testing facilities must report changes in ownership, location, general supervision, and adverse legal actions within 30 days of the change and report all other changes within 90 days of the change.

Medicare Diabetes Prevention Program suppliers must report changes in ownership, including AO or Access Manager; location; coach roster; and adverse legal actions within 30 days of the change and report all other changes within 90 days of the change.

PECOS Users

We allow various organizations and users to work in our systems. The type of user depends on their relationship with you and the duties they perform in your practice.

You may choose other users to act for your organization to manage connections and staff, including appointing and approving other system-authorized users. Depending on your professional relationships with other providers, the CMS External User Services Help Desk may ask you for additional validation information.

One Account, Multiple Systems

We use several provider enrollment systems. Organizational providers and suppliers must use the Identity & Access Management (I&A) System to name an AO to work in CMS systems. The I&A System allows you to:

• Use NPPES to apply for and manage NPIs
• Use PECOS to enroll in Medicare or update or revalidate your current enrollment information
• Register to get electronic health record (EHR) incentive payments for eligible professionals and hospitals that adopt, use and upgrade, or show meaningful use of EHR technology

Authorized Officials, Access Managers, Staff End Users, & Surrogates

Organizational providers or suppliers must appoint and authenticate an Authorized Official (AO) through the I&A System to work in PECOS for them. That person must meet the AO regulatory definition. For example, an AO is a chief executive officer, chief financial officer, general partner, chair of the board, or direct owner who can legally enroll in the Medicare Program.

Respond to your employer’s AO invitation or initiate the request yourself. After you’re the confirmed AO, use PECOS for your provider or supplier organization. As an AO, you’re responsible for approving PECOS user system requests to work on behalf of the provider or supplier organization. Regularly check your email and take the requested actions.

AOs may delegate their responsibilities to an Access Manager who can also initiate or accept connections and manage staff for their organizations.

AOs or Access Managers may invite a Staff End User (SEU) or Surrogate to access PECOS for their organization. Once registered, an SEU or Surrogate may log in to access, view, and modify CMS system information, but they can’t represent the practice, manage staff, sign enrollment applications, or initiate or accept connections.

PECOS Technical Help

Using PECOS may require technical support. The first step toward a solution is knowing which CMS contractor to contact.

Common Problems & Who to Contact

PECOS FAQs

Organizational providers and suppliers must designate a provider enrollment AO to work in CMS systems, including the I&A System, NPPES, and PECOS. The AO may also authorize Access Managers, Surrogates, and SEUs to use PECOS. Individual providers and suppliers don’t require an AO but can authorize Surrogates and SEUs to work in PECOS. Refer to the I&A System Quick Reference Guide and I&A FAQs for more information on registering for an I&A System account or enrolling as an AO.

An application is the paper or electronic form you submit for Medicare Program enrollment approval. After the MAC processes the application, PECOS keeps the enrollment record, which includes all your enrollment application data.

No. All Fee-for-Service (FFS) providers can apply in PECOS.

PECOS is available 24 hours a day, Monday–Saturday, with scheduled downtime on Sunday. We offer technical support daily, 5 am–8 pm CT.

Application Fee & Supporting Documentation

Generally, institutional providers and suppliers, like DMEPOS suppliers and opioid treatment programs, pay an application fee when enrolling, re-enrolling, revalidating, or adding a new practice location.

No. When you electronically submit the Medicare enrollment application, a page appears that lists the supporting documentation to complete the enrollment. You can submit all this documentation electronically through PECOS.

Yes, either is acceptable. You must send this information electronically (as supporting documentation uploaded into PECOS).

During the PECOS application process, the Penalties for Falsifying Information page has the same text as the paper Medicare enrollment application and lists the consequences for providing false information. These consequences include criminal and civil penalties, fines, civil monetary penalties, exclusion from federal health care programs, and imprisonment, among others. You must acknowledge this page by selecting the Next Page button before continuing the PECOS submission process.

Enrollment Application Issues

First, make sure you entered your correct SSN, legal name, and date of birth. If you believe you entered the correct information but PECOS doesn’t accept this information, contact the Social Security Administration.

You must report an SSN to enroll in Medicare. If you don’t want to report your SSN over the web, use the appropriate paper Medicare enrollment application.

An Invalid Address error indicates the address entered doesn’t comply with the U.S. Postal Service address standards. This page lets you continue by either saving the address you entered or selecting the address PECOS displays.

As a security feature, PECOS will time out if you’re inactive (you don’t hit any keys on your computer keyboard) for 15 minutes. The system warns you of inactivity after 10 minutes. If it gets no response after 5 additional minutes, the system automatically times you out. Save your work if you anticipate inactivity while applying in PECOS. If you don’t save your work and the system times out, you must start from the beginning.

Submitting Reportable Events

No. If you report a change to existing information, check Change, include the effective date of change, and complete the appropriate fields in the impacted sections.

Yes. Following your initial enrollment, report certain changes (reportable events) to your MAC within 30 calendar days of the change. Report all other changes to your MAC within 90 days.

Since Medicare pays claims by EFT, the Special Payments address should indicate where all other payment information must go (for example, paper remittance notices or special payments).

No. If you have a new business location, complete a new PECOS or paper application. Each DMEPOS enrollment record can only have 1 current business location.

Revalidations

Revalidation means resubmitting and recertifying your enrollment information.

DMEPOS suppliers must revalidate every 3 years, while all other providers and suppliers generally revalidate every 5 years. We can also conduct off-cycle revalidations. You can revalidate using PECOS or by submitting the appropriate paper Medicare enrollment application.

Yes. Your MAC will send a revalidation notice 90–120 days before your revalidation due date.

Yes. PECOS lets you review information on file and update and electronically submit your revalidation. If you use PECOS, you need to update only changed information.

If you submit your revalidation after its due date, your MAC may place a hold on your Medicare payments or deactivate your Medicare billing privileges. If the MAC requests additional documentation, respond within 30 days. If you don’t, they may deactivate your Medicare billing privileges.

Protect Your Identity & Privacy

You can help protect your professional medical identifiers from identity thieves attempting to defraud the Medicare Program.

Keep PECOS Enrollment Information Current

Log in to PECOS and review your Medicare enrollment information several times a year to ensure no unauthorized changes were made.

PECOS Provides Security

Only you, authorized surrogates, authorized CMS officials, and MACs may enter and view your Medicare PECOS enrollment information. CMS officials and MACs get security standards training and must protect your information. We don’t disclose your Medicare enrollment information to anyone, except when authorized or required by law.

Review & Protect Enrollment Information

Review your Medicare enrollment information in PECOS frequently to ensure it’s accurate, current, and unaltered.

Use your I&A System user ID and password to access PECOS. Keep your ID and password secure.

Take these steps to verify your Medicare enrollment information:

If you suspect your PECOS profile is incorrect due to unauthorized account access, contact your MAC, law enforcement authorities, and your bank. Your MAC and bank can flag your respective accounts for possible fraudulent activity, and law enforcement can begin investigating if and how your accounts were compromised.

Additional Privacy Tips

Take these additional actions to protect your Medicare enrollment information:

• Change your password in the I&A System before accessing PECOS the first time. You can’t change your user ID, but you must change your password every 60 days.
• Review your Medicare enrollment information several times a year to ensure no one changed information without your knowledge. Immediately report changes you didn’t submit.
• Maintain your Medicare enrollment record. Report Medicare enrollment changes known as reportable events, including change of ownership or control, change in practice location, banking arrangements, and any final adverse legal actions.
• Store PECOS copies or paper enrollment applications in a secure location. Don’t allow others access to this information as it contains your personal information, including your date of birth and SSN. Don’t leave copies in a public workspace.
• Enroll in electronic Medicare payments, and ensure they deposit directly into your bank account. We require all providers to use electronic funds transfer (EFT) when enrolling in Medicare, revalidating, or making changes to their enrollment. The most efficient way to enroll in EFT is to complete the EFT information section in PECOS and provide the required supporting documentation. Using EFT allows us to send payments directly to your bank account.

DMEPOS Supplier Requirements

DMEPOS Supplier Standards, Accreditation, & Surety Bond

To enroll or keep your Medicare billing privileges, all DMEPOS suppliers (except certain exempted professionals) must meet supplier and DMEPOS Quality Standards to become accredited. Certain DMEPOS suppliers must also submit a surety bond.

DMEPOS suppliers (except those exempted eligible professionals and other persons) must be accredited by a CMS-approved accrediting organization before submitting a Medicare enrollment application to the National Provider Enrollment (NPE) DMEPOS contractors.

Each enrolled DMEPOS supplier covered under the Health Insurance Portability and Accountability Act (HIPAA) must name each practice location (if it has more than 1) as a sub-part and make sure each sub-part gets its own NPI.

Individual DMEPOS Suppliers (for example, sole proprietorships)

Physicians, NPPs, and DMEPOS suppliers may use their I&A System user ID and password to access PECOS. If you don’t already have an I&A System account, refer to the I&A System User Registration page and enter the information to open an account. For help, refer to the How to Setup Your Account if you are a Sole Owner section in the I&A System Quick Reference Guide.

As an individual DMEPOS supplier, you don’t need an AO or another authorized user.

Organizational DMEPOS Suppliers System Users

A DMEPOS supplier organization must appoint an AO to manage connections and staff, including appointing and approving other authorized PECOS users. The organization must identify the AO in the enrollment application. The AO must have ownership or managing control in the DMEPOS supplier organization.

Providers Who Solely Order or Certify

Physicians and other eligible professionals must enroll in the Medicare Program or have a valid opt-out affidavit on file to solely order or certify Medicare patient items or services.

Those physicians and other eligible professionals enrolled solely as ordering/certifying providers don’t send billed service claims to a MAC.

Who Are Eligible Ordering/Certifying Providers?

Physicians or eligible professionals who order or certify Part A or Part B services but don’t want to submit Medicare claims are eligible ordering/certifying providers.

A person already enrolled as a Part B provider may submit claims listing themselves as the ordering/certifying provider without re-enrolling using Medicare Enrollment Application: Enrollment for Eligible Ordering/Certifying Physicians and Other Eligible Professionals (CMS-855O).

Note: Those who enroll as eligible providers using CMS-855O can’t bill Medicare, and we can’t pay for their services because they have no Medicare billing privileges.

Organizational NPIs don’t qualify, and you can’t use them to order or certify.

Eligible providers must meet these basic conditions:

• Have an individual NPI
• Be enrolled in Medicare in either an approved or opt-out status
• Be an eligible specialty type to order or certify

Requirement 1: Get an Individual NPI

The 2 types of NPIs are: Type 1 (individual) and Type 2 (organizational). Medicare allows only Type 1 NPIs to solely order items or certify services. Apply for an NPI through:

• Online Application: Get an I&A System user account. Then apply for an NPI in NPPES.
• Paper Application: Complete, sign, and mail the NPI Application/Update Form (CMS-10114) paper application to the address on the NPI Enumerator form. To request a hard copy application:
  • Call 1-800-465-3203 (TTY 1-800-692-2326)
  • Email customerservice@npienumerator.com
• Bulk Enumeration: Apply for Electronic File Interchange access and upload your own CSV or XML files.

Requirement 2: Enroll in Medicare in an Approved or Opt-Out Status

Once you have an NPI, use PECOS to verify current Medicare enrollment record information, including your NPI and that you’re approved, or go to the Opt Out Affidavits list to check your status. To opt out of Medicare, submit an affidavit expressing your decision to opt out of the program.

Part C and Part D providers don’t have to enroll in Medicare in an approved or opt-out status.

*We deny certain power mobility device claims if the ordering provider isn’t on our eligible providers list.

Requirement 3: Be Eligible to Order or Certify

The physicians and eligible professionals who may enroll in Medicare solely for ordering or certifying include, but aren’t limited to, physicians and eligible professionals who are:

• Department of Veterans Affairs employees
• Public Health Service employees
• Department of Defense or TRICARE employees
• Indian Health Service or Tribal Organization employees
• Federally Qualified Health Center, Rural Health Clinic, or Critical Access Hospital employees
• Licensed Residents in an approved medical residency program defined in 42 CFR 413.75(b)
• Dentists, including oral surgeons
• Pediatricians
• Retired, licensed physicians

If you’re unsure whether your specific provider specialty qualifies to enroll as an ordering/certifying provider, refer to Section 4 of CMS-855O or find your MAC’s website before submitting a Medicare enrollment application.

Beginning January 1, 2024, we established new provider specialty codes for dentists.

Requirement 4: Respond to Requests for More Information

MACs pre-screen and verify enrollment applications for completeness. If the MAC needs more information, respond to information requests within 30 days. If you don’t, the MAC may reject your enrollment.

Your MAC won’t fully process your PECOS enrollment application without your electronic or uploaded signature, application fee (if applicable), and necessary supporting documentation. The enrollment application filing date is when the MAC gets your enrollment application.

You can check your PECOS enrollment application status 2 ways:

• Log in to PECOS and select the View Enrollments link. In the Existing Enrollments section, find the application. The system shows the application status.
• To see your enrollment status without logging in, go to PECOS and, under Helpful Links, select Application Status.

When your MAC approves your application, it switches the PECOS record to an approved status and sends you an approval letter.

Requirement 5: Use PECOS to Keep Enrollment Information Current

Report a Medicare enrollment change using PECOS. Providers and suppliers must report a change of ownership or control (including a change in authorized or delegated official), a change in practice location, and any final adverse legal actions (like revocation or suspension of a federal or state license) within 30 days of the change and must report all other changes within 90 days of the change.

DMEPOS suppliers must report changes in their enrollment application information within 30 days of the change.

Independent diagnostic testing facilities must report changes in ownership, location, general supervision, and adverse legal actions within 30 days of the change and report all other changes within 90 days of the change.

Medicare Diabetes Prevention Program suppliers must report changes in ownership, including AO or Access Manager; location; coach roster; and adverse legal actions within 30 days of the change and report all other changes within 90 days of the change.

Revalidation

Revalidation, or re-submitting and recertifying your enrollment information accuracy, is an important anti-fraud tool. All Medicare-enrolled providers and suppliers must periodically revalidate their enrollment information.

Generally, physicians, including physician organizations, opioid treatment programs, Medicare Diabetes Prevention Program suppliers, and institutional providers, revalidate enrollment every 5 years or when we request it. DMEPOS suppliers must revalidate their enrollment information every 3 years.

PECOS is the most efficient way to revalidate information.

If you’re actively enrolled, go to the Medicare Revalidation List to find your revalidation due date. If you see a due date, submit your revalidation before that date. Your MAC notifies you when it’s time to revalidate. If you submit your revalidation application after the due date, your MAC may hold your Medicare payments or deactivate your billing privileges.

Get more information:

• 42 CFR 424.515
• Provider Enrollment Revalidation Cycle 2 FAQs
• Revalidations (Renewing Your Enrollment)

Resources

Use these resources to learn how to enroll in the Medicare Program, revalidate your enrollment, or change your enrollment information. Enroll in the Medicare Program to get paid for providing covered patient services. Enroll if you solely order items or certify services.

You can enroll online by using PECOS or the appropriate paper enrollment application you submit to your MAC.

• Get an I&A System user account
• Apply for your NPI in the NPPES
• Enroll in PECOS

Enrollment Forms

If you enroll using a paper application instead of PECOS, search the CMS Forms List to find the form you need and read on page 1, Who Should Submit This Application.

Commonly Used Terms

CMS

CMS is the federal agency that administers the Medicare, Medicaid, Children’s Health Insurance Program (CHIP), HIPAA, Clinical Laboratory Improvement Amendments (CLIA), and several other health-related programs.

CMS-460

The Medicare Participating Physician or Supplier Agreement describes your willingness to accept assignment for all covered services you provide to patients. If you participate, we pay 5% more, and participating providers get timely, direct payment.

CMS-588

The Electronic Funds Transfer (EFT) Authorization Agreement tells you how to get electronic payments or update existing banking information.

CMS-855A

The Medicare enrollment application institutional providers use to enroll, revalidate enrollment, or change enrollment information.

CMS-855B

The Medicare enrollment application clinics or group practices and other suppliers (except DMEPOS suppliers) use to enroll, revalidate enrollment, or change enrollment information.

CMS-855I

The Medicare enrollment application physicians and non-physician practitioners (NPPs) (individual physicians or NPPs) use to enroll, revalidate enrollment, or change enrollment information. Physicians and NPPs can also reassign their right to bill the Medicare Program, terminate a current reassignment of Medicare benefits, or make a change in their reassignment of Medicare benefit information using the CMS-855I.

CMS-855O

The Medicare enrollment application eligible ordering, certifying, and prescribing physicians and other eligible professionals (physicians, including dentists and other eligible NPPs) use to enroll to order items or certify patient services. This includes those physicians and other eligible NPPs who don’t and won’t send patient service claims to a MAC.

CMS-855S

The Medicare enrollment application DMEPOS suppliers use to enroll, revalidate enrollment, or change enrollment information.

CMS-1561

The Health Insurance Benefit Agreement is an agreement between a provider and CMS to get Medicare payments.

CMS-10114

This form tells you how to apply or submit NPI updates.

CMS-20134

The Medicare enrollment application Medicare Diabetes Prevention Program suppliers use to enroll, revalidate enrollment, or change enrollment information.

Director

A director of a corporation, even when the provider or supplier is a non-profit entity. This includes any member of the corporation’s governing body regardless of the board’s or member’s specific title. The body could be a board of directors, board of trustees, or something similar.

DMEPOS Suppliers

Entities or persons, including physicians or Part A providers, who sell or rent Medicare Part B covered items to patients and meet the DMEPOS supplier standards.

Electronic File Interchange (EFI)

The EFI process lets CMS-approved EFI Organizations electronically submit provider NPI applications and update NPPES information with minimal manual intervention.

Electronic Funds Transfer (EFT)

We directly pay EFT providers by sending payments to the provider’s financial institution whether they file claims electronically or on paper. All our providers must apply for EFT.

Electronic Health Record (EHR)

An EHR is an electronic version of a patient’s medical history.

External User Services (EUS) Help Desk

EUS is a dedicated CMS online support site offering help, including, but not limited to, the Identity & Access Management (I&A) System, PECOS, and NPPES.

Identity & Access Management (I&A) System

Users register for usernames and passwords to access PECOS, NPPES, and the EHR Incentive Program.

Institutional Provider

These are providers or suppliers that submit a CMS-855A, CMS-855B (except physician and NPP organizations), or CMS-855S form. See page 1 of the respective provider-type forms about who should use them.

Managing Organization

An entity that exercises operational or managerial control over, or directly or indirectly conducts, the day-to-day operations of the provider or supplier, either under contract or through some other arrangement.

Medicare Administrative Contractor (MAC)

A private company that contracts with us to process and pay Fee-for-Service patient Part A and Part B medical or DME claims.

Medicare Application Fee

Institutional providers and suppliers must pay an application fee when they initially enroll in Medicare, add a practice location, or revalidate their enrollment information. We define an institutional provider as any provider or supplier that submits a CMS-855A, CMS-855B (except physician and NPP organizations), or CMS-855S form.

NPPES

NPPES assigns unique NPIs to Medicare providers and health plans to improve the efficiency and effectiveness of electronically submitting health information.

National Site Visit Contractor (NSVC)

The NSVC performs a site visit to screen and stop questionable providers and suppliers from enrolling or maintaining enrollment.

NPI Enumerator

The NPI Enumerator helps Medicare providers apply for NPIs and update their information in NPPES.

NPI Registry

The NPI Registry is a directory of all active NPI records that displays relevant public portions of the record, including the provider’s name, specialty, and practice address.

Officer

An officer of a corporation, regardless of whether the provider or supplier is a non-profit entity.

Participating Physician or Supplier

Participating physicians or suppliers agree to accept patient assignment on Medicare service claims. They agree to accept allowed amounts as payment in full and to collect only the deductible and coinsurance or copayment. See CMS-460.

PECOS

PECOS is CMS’s online provider enrollment system allowing registered users to securely and electronically submit and manage enrollment information. You can use PECOS instead of paper enrollment forms.

Reassignment of Medicare Benefits

Reassigning your Medicare benefits lets an eligible organization or group submit claims and get payment for Part B services you provide as a member of an organization or group. See CMS-855I.

Revalidation

A provider and supplier mandatory resubmission and recertification process to maintain enrollment information accuracy and Medicare billing privileges. The process ensures enrollment information on file remains complete and current and helps fight health care fraud.

State Survey Agency

They perform initial surveys and periodic resurveys of all institutional providers (including labs) and certain kinds of suppliers. These surveys determine if a provider or supplier meets the conditions to participate in the Medicare Program and evaluates their performance and quality of care.

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