Information required for PECOS enrollment submission

What information will I need before I begin to complete my enrollment via Internet-based PECOS?

below is a list of the types of information needed to complete an initial enrollment action using Internet-based PECOS. This information is similar to the information needed to complete a paper Medicare enrollment application.

    *       An active National Provider Identifier (NPI).
    *       National Plan and Provider Enumeration System (NPPES) User ID and password.
    *       Personal identifying information. This includes legal name on file with the Social Security Administration, date of birth, Social Security Number
    *       Professional license and certification information. This includes information regarding the physician's or non-physician practitioner's professional license, professional school degrees or certificates.
    *       Practice location information. This information includes information regarding the practitioner's medical practice location, the legal business name of a solely-owned Professional Association, Professional Corporation, or Limited Liability Company (LLC) on file with the Internal Revenue Service and appearing on the IRS CP575, and any Federal, State, and/or local (city/county) business licenses, certifications and/or registrations specifically required to operate as a health care facility.
    *       If applicable, information regarding any final adverse actions. A final adverse action includes: (1) a Medicare-imposed revocation of any Medicare billing privileges; (2) suspension or revocation of a license to provide health care by any State licensing authority; (3) revocation or suspension by an accreditation organization; (4) a conviction of a Federal or State felony offense (as defined in 42 CFR 424.535(a)(3)(A)(i)) within the last ten years preceding enrollment, revalidation, or re-enrollment; or (5) an exclusion or debarment from participation in a Federal or State health care program.

Note: Some physicians and non-physician practitioners may find it useful to print and review the CMS-855I paper enrollment application before initiating an Internet-based PECOS enrollment action.