Medicare Application Processing Essentials

Before we get into the process of enrolling in Medicare using PECOS, we want to provide with you a few tips and answer some frequently asked questions.

Improve the processing time of your application by ensuring the application is complete and accurate prior to submitting.  Seems easy enough but there’s this idea out there that you should just get your application in the pipeline even if you’re not sure about some things or if your application is inaccurate or subject to change.  Submitting erroneous information to speed up the processing can lead to severe delays and even fraud claims.

One item that is often overlooked or disregarded is the verification process CMS uses for your company.  The name on your IRS form CP575 or 147C must be identical to the name on your organization’s NPI application, business banking account and state’s secretary of state website.  This is critical and your application will be rejected if there is an error here.

Frequently Asked Questions

Do I need malpractice insurance to apply?

No.  You are not required to have malpractice insurance in place prior to submitting an individual enrollment.

Are hospital privileges required?

Hospital privileges are not required for submitting a Medicare application but are required for most commercial insurance companies.

How long does it take?

Depending on the type of enrollment record, you can expect it to take anywhere from 60-90 days for individual and new practice enrollment records(submitted through PECOS) and approximately 120 days for DMEPOS or part A (855s and 855a) enrollment applications.

Can I retroactively bill?

Yes, as a rule you can bill for services rendered while your application is in process.  We wrote an article on this linked below which we encourage you to read.

Do I need general liability insurance?

For individual and new practice enrollments, you are not required to have established general liability insurance.  For DMEPOS enrollment or reactivation applications (855s), you are required to have general and comprehensive liability insurance in place which must be submitted along with the application.

If I'm participating in one state will it transfer over to new state?

If you’re currently enrolled in one state and want to practice in another, you will see your current enrollment record listed in PECOS but you WILL need to create a new one for the state you’re entering.  Enrollment applications are administered by different MACs which means your enrollment status does not follow you across state lines.

Do I need a group (type II) NPI in order to apply?

Unless you’re enrolling as a sole proprietor or joining an established group, you WILL need a type II NPI for your organization in order to apply.

Contact Us for Medicare Enrollment Assistance

Step 1: Identity & Access Management

The first step in setting up your enrollment record is to set up an account in Identity & Access Management System.  You will need an NPI in order to do this.  Your I&A account is what you will use to access PECOS.  If you do not have an NPI, start with NPPES and obtain an NPI.  Most providers in residency will already have an NPI so if you’re not sure, do a search on the NPI Registry to see if you’re listed.  If you are, you simply need to reset your login info using your personal info.

See if you have an NPI with NPI Registry

Identity & Access Management System

Step 2: Login to PECOS

  1. Next you will want to login to PECOS using your new information.  If you are setting up a new company, perhaps as the sole owner of a new LLC, you will need obtain a type 2 NPI otherwise known as an Organizational Provider NPI.  You can apply for a type 2 NPI here: NPPES
  2. Upon logging in, you will see a button to apply for an NPI.  You will want to apply for a type 2 NPI if you already have your persona NPI. 
  3. Before you can apply for a type 2 NPI, you will need your company registered in your state and will need to have obtained your TAX ID from the IRS.  You can do that here: IRS Online EIN Request

Sole Proprietorships (even those with a tax id) should not apply for a type 2 NPI.  Type 2 NPIs are reserved for corporations and organizations registered in their state.

Step 3: Submit Your application

There are primarily four ways that you will be enrolling in PECOS which are as follows: 

  • Enrolling as an employee/contractor of an established Medicare Provider/Supplier
  • Enrolling as a provider and owner of a new Medicare supplier
  • Enrolling as an owner/managing investor of a new Medicare supplier
  • Enrolling as an individual of a sole proprietorship

All of these applications can and should be submitted using PECOS.  You can submit paper applications which are linked below but you can expect the paper enrollment process to take 90-120 days longer than an online PECOS application.

Video Tutorials for PECOS Enrollment

  1. Individual Provider – starting sole proprietorship or joining an established group
  2. Organizational Provider- setting up new company that plans to bill Medicare
  3. Change of Information for Individual- Updating current enrollment record with Medicare
  4. Change of Information for Organization
  5. Creating a new DMEPOS Supplier Number

What You'll Need for each application

The basics of your individual or new practice enrollment application are as follows:

  • Business location
  • Mailing Address(can be the same)
  • Billing Company info(if outsourcing)
  • State License
  • Board Certification(or eligibility for Physicians, it’s required for NPs)
  • DEA 
  • Company Info if registering a new business.  You will need tax id and company must be registered in the appropriate state
  • Company Phone/Fax
  • Company Type II NPI
  • Medicare Bank Letter or Voided Business Check (See example or download Medicare bank letter template here)
  • IRS Form 575 or 147C verifying your TAX ID

You can download a full checklist from Medicare here although there are some things mentioned that will not apply to every application: Checklist for Provider/Supplier Enrollment Applications

Medicare Paper Application Downloads

  • CMS-855A for Institutional Providers such as hospitals and rural health facilities
  • CMS-855B for Clinics, Group Practices, and Certain Other Suppliers such as Labs
  • CMS-855I for Physicians and Non-Physician Practitioners
  • CMS-855R for Reassignment of Medicare Benefits
  • CMS-855O for Ordering and Certifying Physicians and Non-Physician Practitioners.  This is used for providers who do not want to participate with Medicare but do refer Medicare patients as a nonpar provider.
  • CMS-855S for DMEPOS Suppliers