Medicare Provider Enrollment and Claim Submission - Basic information

Provider Enrollment

The provider enrollment process is a critical function that assures only qualified and eligible providers are enrolled in the Medicare program. Physicians and non-physician practitioners (NPPs) who provide services to Medicare beneficiaries must enroll as Medicare providers to receive reimbursement for services.

Providers must choose one of the options below to enroll:

• Complete appropriate CMS-855 enrollment application
• Provider Enrollment, Chain and Ownership System (PECOS)

All providers billing to Medicare must have a National Provider Identifier (NPI). The NPI is a unique, 10-digit identification number for covered health care providers. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) states covered providers must share their NPI with other providers, health plans, clearinghouses, or any other entity that may need it for billing purposes.

You can apply for an NPI through the National Plan and Provider Enumeration System (NPPES). The NPI must be obtained prior to submitting an initial application to Medicare. It is required on all CMS enrollment applications.

PECOS is a national, Internet-based database that supports the provider enrollment function. This database is used to store and verify provider information, add new providers, or make changes to existing Medicare providers during the enrollment process.

PECOS can be used for the following:

• Initial Medicare enrollment
• View, change, or track enrollment
• Add or change a reassignment of benefits
• Revise existing Medicare enrollment information
• Reactivate an existing enrollment record
• Withdraw from Medicare
• Submit a Change of Ownership (CHOW)

Providers must notify Medicare (via the enrollment process) of any enrollment application changes that occur within their practice location. This notification must occur within 30 days of the change. Examples of possible changes are below:

• Mailing, billing, correspondence, or e-mail address
• Medical specialty designation
• Authorized/delegated official

When enrolling to Medicare, it is vital to ensure the application contains complete information. An incomplete application is put on hold until further information is received. If no information is received, the application will be returned to the provider. If an application is denied, information about appeal rights is included in the denial notifications.

Palmetto GBA must complete a new application within 180 days and 120 days to complete changes to an existing application.

The last part of the enrollment process is to indicate how you want to receive payments from Medicare. New providers or providers making changes to existing enrollment information must complete the Electronic Funds Transfer (EFT) Authorization Agreement form (CMS-588). This agreement allows Palmetto GBA to electronically deposit Medicare payments to providers.

Medicare Claim Submission
All participating and non-participating providers are required to submit claims to the Medicare contractor for covered services provided to Medicare beneficiaries. Providers cannot charge beneficiaries for claim submissions. You are responsible for preparing and filing the claim.

Providers are not required, however, to submit claims for non-covered services. If the beneficiary believes a service may be covered or needs a formal Medicare determination for consideration by a supplemental insurance, the provider must submit a claim.

There are two ways to submit a claim: paper or electronic. Select each of the buttons below for more information on each type of claim submission.

PAPER        ELECTRONIC
There is a time limit for filing Medicare claims. The timely filing requirement for Medicare Fee-for-Service (FFS) claims is below.
Date of Service : On or after January 1, 2011
Claim Must be Filed : Within one calendar year after date of service