Medicare Enrollment For Providers Who Solely Order, Certify, Or Prescribe 64MB Med Enroll Order Refer Prov Fact Sheet ICN906223

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MEDICARE ENROLLMENT FOR PROVIDERS WHO

SOLELY ORDER, CERTIFY, OR PRESCRIBE

ICN 906223 December 2017

PRINT-FRIENDLY VERSION

Target Audience: Medicare Fee-For-Service Program (also known as Original Medicare)

and Medicare Part D drug, the Prescription Drug Benet

The Hyperlink Table, at the end of this document, provides the complete URL for each hyperlink.

MLN BookletMedicare Enrollment for Providers Who Solely Order, Certify, or Prescribe

ICN 906223 December 2017

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NPI

Updated

Provide more

information

QUICK START

GUIDE

STEP1Get an NPI

• Check to see if you have one

• If not, apply online, via paper

application, or through an EFI

STEP2Enroll

• Online in PECOS

• Via paper application

(CMS-855O)

STEP3Respond to requests from

your MAC for more information

STEP4Keep enrollment information

up to date (use PECOS or paper

enrollment form)

MLN BookletMedicare Enrollment for Providers Who Solely Order, Certify, or Prescribe

ICN 906223 December 2017

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TABLE OF CONTENTS

Who Are Eligible Ordering/Certifying/Prescribing Providers? 5

Requirement 1: You Must Have an Individual NPI 6

Requirement 2: You Must Be Enrolled in Medicare in an “Approved” or “Opt-Out” Status 6

Requirement 3: You Must Be Eligible to Order/Certify/Prescribe 7

How Do I Enroll in Medicare as an Eligible Provider? 8

Step 1: Obtain an Individual NPI 8

Step 2: Complete the Proper Medicare Enrollment Application 9

A. Online PECOS Application 9

B. Paper Medicare Enrollment Application (Form CMS-855O) 9

Application Fee 10

Step 3: Respond to Requests From Your MAC for More Information 10

Step 4: Use PECOS to Keep Enrollment Information Up to Date 10

Resources 11

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Recent legislation requires physicians and other eligible professionals to enroll in the Medicare Program

or have a valid opt-out afdavit on le to solely order or certify items or services, or to prescribe Part D

drugs for Medicare beneciaries.

Those physicians and other eligible professionals enrolled solely as ordering, certifying, and prescribing

providers do not and will not send claims to a Medicare Administrative Contractor (MAC) for their

services. Explore these booklets for information on Medicare enrollment for health care professionals

that will submit claims for reimbursement:

●PECOS for DMEPOS Suppliers

●Medicare Enrollment for Institutional Providers

●Medicare Enrollment for Physicians, NPPs, and Other Part B Suppliers

NOTE: We use “you” and “eligible provider” to refer to physicians and other professionals eligible to

solely order items, certify services, and prescribe Part D drugs.

This booklet outlines the requirements for providers who solely order, certify, or prescribe to enroll in

Medicare. First, we describe who qualies as eligible providers. Then, we explain how to enroll in

Medicare as one of these eligible providers.

ORDERING AND CERTIFYING TERMS

Medicare Part B claims use the term “ordering/certifying provider” (formerly “ordering/referring

provider”) to identify the person who orders, prescribes, or certies an item, drug, or service

reported in a claim. The following are technically correct terms:

●A provider orders non-physician items or services for the beneciary, such as Durable

Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); clinical laboratory

services; or imaging services.

●A provider certies home health services for a beneciary.

The health care industry uses the terms “ordered,” “referred,” and “certied” interchangeably. To

view comments about this terminology, read the Changes in Provider and Supplier Enrollment,

Ordering and Referring [Certifying], and Documentation Requirements Final Rule.

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WHO ARE ELIGIBLE ORDERING/CERTIFYING/PRESCRIBING

PROVIDERS?

This booklet focuses on Part D prescribers and any other physicians or eligible professionals who order

or certify Part A or Part B services but do not want to submit claims to Medicare.

Any individual already enrolled as a Medicare Part B provider, DMEPOS supplier, or Part A Home

Health Agency (HHA) provider may submit claims with ordering, certifying, or prescribing information,

and receive payment without re-enrolling using Form CMS-855O. Those who enroll as eligible

providers using Form CMS-855O may not seek or receive reimbursement from Medicare for

services they furnish. They do not have billing privileges to submit claims to Medicare for services to

Medicare beneciaries.

Eligible providers must meet these three basic requirements:

1. Have an individual National Provider Identier (NPI)

NOTE: Organizational NPIs do not qualify and cannot order, certify, or prescribe

2. Be enrolled in Medicare in either an “approved” or an “opt-out” status

3. Be of a specialty type that is eligible to order, certify, or prescribe

DENIAL OF ORDERING, CERTIFYING, OR PRESCRIBING CLAIMS

MACs deny the following claims if they lack a valid individual NPI:

●Claims from clinical laboratories for ordered tests

●Claims from imaging centers for ordered imaging procedures

●Claims from suppliers of DMEPOS for ordered DMEPOS

●Claims from Part A or Part B HHAs (services may only be ordered or certied by a Doctor of

Medicine [M.D.], Doctor of Osteopathy [D.O.], or Doctor of Podiatric Medicine [DPM])

Part D plans will deny claims for Part D covered drugs if they lack a valid individual NPI.

If a billed service requires an eligible provider and one is not present on the claim, the MAC will

deny the claim. Along with a valid individual NPI, the claim must contain the eligible provider’s

name as it appears in the Provider Enrollment, Chain, and Ownership System (PECOS).

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Requirement 1: You Must Have an Individual NPI

There are two types of NPIs: Type 1 (individual) and Type 2

(organizational). Medicare allows only Type 1 NPIs for solely

ordering items, certifying services, or prescribing Part D drugs.

You can apply for an NPI in one of three ways:

1. Online Application: If you have not done so, register for an

Identity & Access Management (I&A) System user account.

Then apply for your NPI through the National Plan and Provider

Enumeration System (NPPES).

2. Paper Application: Complete, sign, and submit the NPI Application/Update Form (Form CMS-10114)

paper application to the NPI Enumerator address on the form. To request a hard copy application,

call 1-800-465-3203 or TTY 1-800-692-2326, or email customerservice@npienumerator.com.

3. Bulk Enumeration: Apply for Electronic File Interchange (EFI) access and upload your own

comma-separated values (CSV) les.

NOT SURE IF YOU

HAVE AN NPI?

Search for your NPI

on the NPPES NPI

Registry.

ONE ACCOUNT, MULTIPLE SYSTEMS

The I&A System allows you to:

●Apply for and manage your NPIs in the NPPES

●Use PECOS to enroll in Medicare or update your current enrollment information

Requirement 2: You Must Be Enrolled in Medicare in an “Approved” or

“Opt-Out” Status

Once you have an NPI, use PECOS to verify you have a current Medicare enrollment record that

includes your NPI and that you are in an “approved” or “opt-out” status. Table 1 explains options to

verify whether your current enrollment record exists in PECOS.

Table 1. Options to Verify Your Current Enrollment Record Exists in PECOS

Verication Option Enrollment Record

Is Current If:

Refer to the Medicare Ordering and Referring les for physicians/non-

physician practitioners (NPPs) and for power mobility device (PMD)

suppliers.*

You are identied on

one of these reports.

Visit PECOS to locate your enrollment record. Your enrollment record

displays a status of

“approved” or “opt-out.”

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Table 1. Options to Verify Your Current Enrollment Record Exists in PECOS (cont.)

Verication Option Enrollment Record

Is Current If:

If you submitted an enrollment application as one of the eligible provider

types on paper (Form CMS-855O) or via PECOS and want to check the

status, refer to the Initial Physician Applications Pending Contractor Review

and Initial Non-Physician Applications Pending Contractor Review datasets.

Remember that these applications are not fully processed and are awaiting

contractor review.

Your enrollment

application is pending

contractor review if

you are on one of

these reports.

* Certain claims for PMDs will be denied if the ordering provider is not on Medicare’s list of providers eligible to order

them. Read Denial for Power Mobility Device (PMD) Claim from a Supplier of Durable Medical, Orthotics, Prosthetics,

and Supplies (DMEPOS) When Ordered By a Non-Authorized Provider for more information.

If you do not have an enrollment record in PECOS, refer to the “How Do I Enroll in Medicare as an

Eligible Provider?” section of this booklet.

Requirement 3: You Must Be Eligible to Order/Certify/Prescribe

The physicians and eligible professionals who may enroll in Medicare solely for the purpose of

ordering/certifying/prescribing Part D drugs include, but are not limited to, those physicians and

eligible professionals who are:

●Employed by the Department of Veterans Affairs (DVA)

●Employed by the Public Health Service (PHS)

●Employed by the Department of Defense (DOD)/TRICARE

●Employed by the Indian Health Service (IHS) or a Tribal Organization

●Employed by Federally Qualied Health Centers (FQHCs), Rural Health Clinics (RHCs), or Critical

Access Hospitals (CAHs)

●Licensed Residents (as dened in 42 Code of Federal Regulations [C.F.R.] Section 413.75(b)) in

an approved medical residency program

●Dentists, including oral surgeons

●Pediatricians

●Retired physicians who are licensed

If you are not sure your specic provider specialty qualies to enroll as an ordering or certifying

provider, refer to Section 4 of Form CMS-855O or contact your MAC before submitting a Medicare

enrollment application. Refer to the Medicare Fee-For-Service Provider Enrollment Contact List for

MAC contact information for each State.

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INTERNS AND RESIDENTS

Claims for items or services ordered or certied, or for covered Part D drugs prescribed by interns

and residents, whether licensed or unlicensed, must specify the name and NPI of a teaching

physician. State-licensed residents may enroll to order, certify, or prescribe, and claims may

list them. However, if States provide provisional licenses or otherwise permit residents to order,

certify, or prescribe, the Centers for Medicare & Medicaid Services (CMS) allows interns and

residents to enroll to do so, consistent with State law.

HOW DO I ENROLL IN MEDICARE AS AN ELIGIBLE PROVIDER?

CMS allows certain physicians and other eligible professionals to enroll in Medicare for the

sole purpose of ordering or certifying specic items or services, or prescribing Part D drugs for

Medicare beneciaries.

STEP 1: OBTAIN AN INDIVIDUAL NPI

Providers must obtain an NPI before enrolling in the Medicare Program. See the earlier section,

“Requirement 1: You Must Have an Individual NPI,” for instructions on obtaining an individual NPI.

PROTECT YOUR INFORMATION

Your NPI and Tax ID are publicly available information. Use extra caution to monitor and protect

your professional and personal information to help prevent fraud and abuse. You must also ensure

your patients’ personal health information is secure. CMS provides the following resources to help:

●Medicare Fraud & Abuse: Prevention, Detection, and Reporting

●Ofce of Inspector General

●Help Fight Medicare Fraud for patients

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STEP 2: COMPLETE THE PROPER MEDICARE ENROLLMENT

APPLICATION

Once you have an NPI, you can apply to enroll in the Medicare Program, revalidate your enrollment,

or change your enrollment information. Make sure you have the information you need to enroll before

starting. Complete these actions using either PECOS or the paper enrollment form.

A. Online PECOS Application

This is CMS’ preferred method for Medicare enrollment. You must log in to PECOS with your I&A System

credentials to initiate and complete the application process.

PECOS is a scenario-driven application—it presents a series of questions to retrieve only the

information needed to process your specic enrollment scenario. You can submit all supporting

documentation through PECOS.

PECOS IS EASY!

We encourage you to use PECOS instead of the paper Medicare enrollment application.

Advantages of using PECOS include:

●Completely paperless process, including electronic signature and digital document feature

●Faster than paper-based enrollment

●Tailored application process means you only supply information relevant to your application

and specialty

●More control over your enrollment information, including reassignments

●Easy to update and check your information for accuracy

●Less staff time and administrative costs to complete and submit enrollment to Medicare

B. Paper Medicare Enrollment Application (Form CMS-855O)

The paper Medicare Enrollment Application: Eligible Ordering, Certifying, and Prescribing Physicians

and Other Eligible Professionals (Form CMS-855O) is the application for enrolling solely to order,

certify, or prescribe Part D drugs. Carefully complete and submit the paper enrollment application.

Even if you submit your application on a paper form, a record is still created in PECOS.

NOTE: If you submitted an abbreviated Form CMS-855I to enroll solely to order/certify prior to the

implementation of Form CMS-855O, your enrollment is still valid and you are not required

to reapply.

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Application Fee

Physicians, NPPs, physician organizations, and non-physician organizations do not have an

application fee. For more information about the provider types subject to an application fee, refer to

the Application Fee Requirements Matrix.

STEP 3: RESPOND TO REQUESTS FROM YOUR MAC

FOR MORE INFORMATION

Your MAC pre-screens and veries all information on the enrollment application. During processing,

you may need to submit additional information. Respond to any requests from your MAC as soon

as possible, but within 30 days of the request. Failure to do so may delay enrollment or result in the

rejection of the submitted application (deactivation). Once your MAC approves the application, it will

switch the PECOS record to an “approved” status and send you an approval letter.

STEP 4: USE PECOS TO KEEP ENROLLMENT INFORMATION

UP TO DATE

You can report a change in your Medicare enrollment information using PECOS. You must report a

change of ownership or control, a change in practice location, and any nal adverse legal actions

(such as revocation or suspension of a Federal or State license) within 30 days of a reportable event

(see the PECOS FAQs section on reportable events for a denition). Submit all other changes within

90 days of a reportable event.

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RESOURCES

For more information about the Medicare enrollment process, visit the Medicare Provider-Supplier

Enrollment webpage, which provides information about:

●PECOS, including how to update your records using PECOS

●Paper Medicare enrollment application forms

●Frequently asked questions

●Contact information for all MACs

●CMS updates on provider enrollment

Table 2. Resources

For More Information About… Resource

CMS External User Services (EUS) Help Desk To report PECOS navigation, access, or printing

problems, contact the CMS EUS Help Desk.

Find contact information at EUS.custhelp.com.

I&A System Account Registration NPPES.CMS.HHS.gov/IAWeb/register/start

Registration.do

Initial Non-Physician Applications Pending

Contractor Review

Data.CMS.gov/Medicare-Enrollment/Pending-

Initial-L-and-Ts-Non-Physicians/n86y-dqck

Initial Physician Applications Pending Contractor

Review

Data.CMS.gov/Medicare-Enrollment/Pending-

Initial-L-and-Ts-Physicians/ip7y-ztn9

MACs Provider Enrollment Contact List

CMS.gov/Medicare/Provider-Enrollment-and-

Certication/MedicareProviderSupEnroll/

Downloads/contact_list.pdf

Review Contractor Directory – Interactive Map

CMS.gov/Research-Statistics-Data-and-

Systems/Monitoring-Programs/Medicare-FFS-

Compliance-Programs/Review-Contractor-

Directory-Interactive-Map

MLN Matters® Article, Eligible Physicians and

Non-Physician Practitioners who need to Enroll

in the Medicare Program for the Sole Purpose of

Ordering and Referring Items and Services for

Medicare Beneciaries

CMS.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNMattersArticles/

Downloads/MM7097.pdf

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Table 2. Resources (cont.)

For More Information About… Resource

MLN Matters Article, Instructions for Processing

Form CMS-855O Submissions

CMS.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNMattersArticles/

Downloads/MM7723.pdf

MLN Matters Article, Denial for Power Mobility

Device (PMD) Claim from a Supplier of Durable

Medical, Orthotics, Prosthetics, and Supplies

(DMEPOS) When Ordered By a Non-Authorized

Provider

CMS.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNMattersArticles/

Downloads/MM8239.pdf

MLN Matters Special Edition Article, Full

Implementation of Edits on the Ordering/Referring

Providers in Medicare Part B, DME, and Part A

Home Health Agency (HHA) Claims

CMS.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNMattersArticles/

Downloads/SE1305.pdf

MLN Matters Special Edition Article, Opting out

of Medicare and/or Electing to Order and Certify

Items and Services to Medicare Beneciaries

CMS.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNMattersArticles/

Downloads/SE1311.pdf

NPI CMS.gov/Regulations-and-Guidance/

Administrative-Simplication/NationalProvIdent

Stand

Order and Referring Data Files, Eligible

Physicians/NPPs

Data.CMS.gov/Medicare-Enrollment/Order-and-

Referring/qcn7-gc3g

Order and Referring PMD Data Files, Eligible

Physicians/NPPs

Data.CMS.gov/Medicare-Durable-Medical-

Equipment-DME-/Order-and-Referring-PMD/

g6jg-y93m

PECOS PECOS System

PECOS.CMS.HHS.gov

About PECOS

CMS.gov/Medicare/Provider-Enrollment-and-

Certication/MedicareProviderSupEnroll/Internet

basedPECOS.html

PECOS Technical Assistance Contact

Information

CMS.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNProducts/MLN-

Publications-Items/CMS1243418.html

Video Resources YouTube.com/playlist?list=PLaV7m2-zFKpia1Mc

B1WKKkw2esAdiZRem

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Table 3. Hyperlink Table

Embedded Hyperlink Complete URL

Application Fee Requirements Matrix https://www.cms.gov/Medicare/Provider-

Enrollment-and-Certication/MedicareProvider

SupEnroll/Downloads/ApplicationFee

RequirementMatrix.pdf

Change of Ownership or Control https://www.cms.gov/Outreach-and-Education/

Outreach/FFSProvPartProg/Provider-

Partnership-Email-Archive-Items/2017-05-18-

eNews.html#_Toc482773810

Changes in Provider and Supplier Enrollment,

Ordering and Referring [Certifying], and

Documentation Requirements Final Rule

https://www.gpo.gov/fdsys/pkg/FR-2012-04-27/

pdf/2012-9994.pdf

Check https://npiregistry.cms.hhs.gov

Denial for Power Mobility Device (PMD) Claim

from a Supplier of Durable Medical, Orthotics,

Prosthetics, and Supplies (DMEPOS) When

Ordered By a Non-Authorized Provider

https://www.cms.gov/Outreach-and-Education/

Medicare-Learning-Network-MLN/MLNMatters

Articles/downloads/MM8239.pdf

Electronic File Interchange (EFI)

EFI

https://nppes.cms.hhs.gov/webhelp/nppeshelp/

EFI%20HELP%20PAGE.html

For Physicians/Non-Physician Practitioners

(NPPs)

https://data.cms.gov/Medicare-Enrollment/Order-

and-Referring/qcn7-gc3g

For Power Mobility Device (PMD) Suppliers https://data.cms.gov/Medicare-Durable-Medical-

Equipment-DME-/Order-and-Referring-PMD/

g6jg-y93m

Help Fight Medicare Fraud https://www.medicare.gov/forms-help-and-

resources/report-fraud-and-abuse/fraud-and-

abuse.html

Identity & Access Management (I&A) System

I&A System

https://nppes.cms.hhs.gov/IAWeb

Information You Need to Enroll https://pecos.cms.hhs.gov/pecos/help-main/

checklists.jsp

Initial Non-Physician Applications Pending

Contractor Review

https://data.cms.gov/Medicare-Enrollment/

Pending-Initial-L-and-Ts-Non-Physicians/n86y-

dqck

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Table 3. Hyperlink Table (cont.)

Embedded Hyperlink Complete URL

Initial Physician Applications Pending Contractor

Review

https://data.cms.gov/Medicare-Enrollment/

Pending-Initial-L-and-Ts-Physicians/ip7y-ztn9

Medicare Enrollment Application: Eligible

Ordering, Certifying, and Prescribing Physicians

and Other Eligible Professionals (CMS-855O)

CMS-855O

https://www.cms.gov/Medicare/CMS-Forms/

CMS-Forms/Downloads/cms855O.pdf

Medicare Enrollment for Institutional Providers https://www.cms.gov/Outreach-and-Education/

Medicare-Learning-Network-MLN/MLNProducts/

MLN-Publications-Items/CMS1243482.html

Medicare Enrollment for Physicians, NPPs, and

Other Part B Suppliers

https://www.cms.gov/Outreach-and-Education/

Medicare-Learning-Network-MLN/MLNProducts/

MLN-Publications-Items/CMS1243432.html

Medicare Fee-For-Service Provider Enrollment

Contact List

https://www.cms.gov/Medicare/Provider-

Enrollment-and-Certication/MedicareProvider

SupEnroll/Downloads/contact_list.pdf

Medicare Fraud & Abuse: Prevention, Detection,

and Reporting

https://www.cms.gov/Outreach-and-Education/

Medicare-Learning-Network-MLN/MLNProducts/

MLN-Publications-Items/CMS1243333.html

Medicare Provider-Supplier Enrollment https://www.cms.gov/Medicare/Provider-

Enrollment-and-Certication/MedicareProvider

SupEnroll

National Plan and Provider Enumeration System

(NPPES)

NPPES

https://nppes.cms.hhs.gov

NPI Application/Update Form (Form CMS-10114) https://www.cms.gov/Medicare/CMS-Forms/

CMS-Forms/Downloads/CMS10114.pdf

NPPES NPI Registry https://npiregistry.cms.hhs.gov

Ofce of Inspector General https://oig.hhs.gov

Online https://nppes.cms.hhs.gov/IAWeb

Paper Application https://www.cms.gov/Medicare/CMS-Forms/

CMS-Forms/Downloads/CMS10114.pdf

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Table 3. Hyperlink Table (cont.)

Embedded Hyperlink Complete URL

PECOS FAQs https://www.cms.gov/Outreach-and-Education/

Medicare-Learning-Network-MLN/MLNProducts/

MLN-Publications-Items/ICN909015.html

PECOS for DMEPOS Suppliers https://www.cms.gov/Outreach-and-Education/

Medicare-Learning-Network-MLN/MLNProducts/

MLN-Publications-Items/CMS1243483.html

PECOS https://pecos.cms.hhs.gov

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