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Practice Management & Allied Staff News & Materials

Medicare Enrollment Rule for Providers Eligible to Render/Order/Refer Items or Services for Medicare Beneficiaries

November 23rd, 2011

The Centers for Medicare and Medicaid Services (CMS) now requires all physicians and non-physician practitioners who are eligible to render and/or order items or services, or refer Medicare beneficiaries to other Medicare providers or suppliers for services, to have current enrollment records in Medicare. A current enrollment record is one that is in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and also contains the physician/non-physician practitioner's National Provider Identifier (NPI). A physician or non-physician practitioner who renders, orders, or refers and who does not have a current enrollment record that contains the NPI will cause the claim submitted by the Part B provider/supplier who furnished the ordered or referred item or service to be rejected.

CMS-8550-For Eligible Ordering and Referring Physicians and Non-Physician Practitioners

With the implementation of Section 6405 of the Affordable Care Act, CMS requires OMSs and general dentists to enroll in Medicare and be registered in PECOS in order to refer and / or order services, when those services are of the kind requiring ordering / referring provider information. These OMSs and general dentists do not and will not send claims to a Medicare contractor for the services they furnish. AAOMS is encouraging all members (including those that have opted out of Medicare) to verify their enrollment information in the Internet-based PECOS system, regardless as to when enrolled in Medicare.

CMS-855I- For Physicians and Non-Physician Practitioners

Physicians and non-physician practitioners, including OMSs who are enrolled in the Medicare program as participating or non-participating providers, but have not submitted the CMS 855I since 2003, are required to submit a new Medicare enrollment application via the PECOS system.

CMS-855B- For Clinics/Group Practices and Certain Other Supplies

Complete and submit this application if you are an organization/group that plans to bill Medicare and you are:

  • A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, portable x-ray suppliers.)
  • A hospital or other medical practice or clinic that may bill for Medicare Part A services but will also bill for Medicare Part B practitioner services or provide purchased laboratory tests to other entities that bill Medicare Part B.
  • Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor's jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another Medicare fee-for-service contractor).
  • Currently enrolled in Medicare and need to make changes to your enrollment data (e.g., you have added or changed a practice location). Changes must be reported in accordance with the timeframes established in 42 C.F.R. § 424.516(d). (IDTF changes of information must be reported in accordance with42 C.F.R. § 410.33.)

CMS has made available a downloadable PDF file of National Provider Identifiers (NPIs) and names (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is legally eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS). It is a PDF file containing approximately 800,000 records and will be updated periodically to include changes in enrollment records. Providers are encouraged to check this list to see if those from whom referrals for services are received, are in fact listed.

A recent CMS document titled Medicare Enrollment Guidance for Physicians that Infrequently Receive Reimbursement from the Medicare Program provides guidance to dentists, including oral surgeons, as well as to physicians in fellowships, federal employment or employed by qualified health centers, rural health clinics or critical access hospitals. Since enrollment for these types of physicians or practitioners are unique, CMS has modified the process of enrollment to accommodate their special circumstances. For specific details on which sections of the enrollment application need to be completed by providers enrolling solely to order and refer, also review page 3 of Medicare Learning Network Article.

The last known enforcement date released by CMS was July 5th, 2011, but claims are not officially being rejected if the referring or ordering physician is not enrolled in PECOS. Instead, explanation of benefits (EOBs) for claims submitted with the name of an ordering or referring physician not enrolled in the PECOS system, will reflect as such in preparation for the day that CMS does begin to enforce this rule. A new enforcement date can be assigned at anytime so AAOMS does encourage all OMSs to enroll in PECOS. For additional information visit the Medicare Enrollment section of the Practice Management pages at aaoms.org, and the Medicare Provider-Supplier Enrollment pages of the CMS web site