How to become a Medicare Provider?

  • Posted On: November 23, 2021

How to become a Medicare Provider?

To bill Medicare for the items and services you give to patients, whether you are a practitioner and own a medical service such as a nursing home, home health agency, hospice, or durable equipment supply firm, you must go through a multi-step process. Become a Medicare provider also allows for new patients who rely on the benefits to offset their healthcare expenses. Accepting Medicare becomes an increasingly crucial strategy to continue offering services to your patients as the baby boomer cohort ages.

How to Get Your NPI

To begin, you must receive a one-of-a-kind National Provider Identifier, or NPI. This 10-digit NPI number is necessary in all administrative and billing activities to identify the provider anonymously without looking at other information, such as their medical specialty. The numbering system was created in accordance with HIPAA standards. Fill out an NPI Application online to request your number.

Who Should Apply?

Only entities that match the federal regulations’ definition of a healthcare provider are eligible to apply for an NPI. Healthcare providers provide healthcare and are subject to HIPAA requirements. Doctors, dentists, pharmacists, physical therapists, and nurses are examples of individual healthcare professionals. Hospitals, clinics, nursing homes, ambulance services, home health agencies, health maintenance organisations, and group practices are examples of organizational health providers. Billing services, healthcare clearinghouses, value-added networks, non-emergency medical transportation services, and other companies that do not satisfy the definition of the healthcare provider are not eligible for an NPI. Despite the fact that non-eligible companies are not granted an NPI, they are subject to HIPAA requirements and must utilize the identifiers in HIPAA transactions, including electronic transmissions.

Form of Application

The CMS website contains Form CMS-10114, NPI Application/Update Form, which healthcare providers can obtain. The form comes with step-by-step instructions. Applicants can fill out and print the form, but it cannot be saved with the data. By phone at 800-465-3203, healthcare providers can also request a hardcopy form from the NPI Enumerator. The CMS advises using the web-based application to apply for an NPI because it is the quickest and most efficient method. An Electronic File Interchange organisation, or EFIO, may apply on behalf of a healthcare provider with the provider’s permission.

Application Form Online

The web-based application can be found on the NPPES website. To enter the system and access the programme, providers will generate a log-in. Users should gather all necessary information before commencing the application procedure, which does not allow users to save and resume data entry. Name, date of birth, gender, Social Security number, state licensing information, and contact information are all provided by individual providers. Provider information for an organisation comprises the provider’s name, employer identification number, provider type, contact person, and location. Applicants can get help from the NPI Enumerator via phone or email. Before proceeding, candidates must read and agree to particular terms on the application page before clicking “Begin Application Form.”

Determine Your Eligibility to Serve as a Medicare Provider

The next stage is to determine your eligibility as a Medicare provider. You may need to be certified with the Conditions of Participation in order to be eligible. Most providers’ eligibility is determined by state bodies, not by the Centers for Medicare and Medicaid Services. For further information on eligibility requirements, contact your state survey agency.

Fill out the Enrollment Application

The next step toward becoming a provider is to fill out an enrollment application. CMS 855A, commonly known as the Medicare Enrollment Application for Institutional Providers, is required for institutional providers such as home health organisations, hospices, and outpatient physical therapy programmes. Fill out CMS 855S, also known as the Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers, if you sell medical equipment or supplies.

Prepare to Submit Electronic Data

Medicare payments and claims are all processed electronically. To submit claims, you must complete the CMS EDI Registration Form and the EDI Enrollment Form. Enroll in Electronic Funds Transfer to get the amounts owed to you by Medicare. The forms are available online at the CMS website or through your Medicare FFS Contractor.

Pursue Annual Renewal

When you are approved to become a Medicare provider, you are automatically enrolled in Medicare Part A unless you opt-out. According to the American Medical Association, you must choose whether to participate in Medicare Part B or Part D on an annual basis. By signing up to take Medicare Parts B and D, you agree to accept payments directly from Medicare as full payment and do not bill your patients.

You can also opt-out and be a non-participating provider. In this situation, you bill Medicare for a portion of the payment and the patient for the remainder, based on Medicare-agreed-upon amounts.

Employ Your MAC

Your Medicare Administrative Contractor (MAC) is specific to the region in where you practice and may have extra information demands when processing your application. You can also inquire with your MAC about your enrollment status.

Keep Your Information Up to Date

It is critical to keep your enrollment information current. If you want to keep your Medicare billing credentials, you must disclose the following changes within 30 days:

  • A change in ownership
  • A judicial action that is unfavorable
  • A shift in the site of the practice

All other modifications must be reported within 90 days. If you applied online, you can keep your information in PECOS up to date. If you applied on paper, you must resubmit your form to change your details.

Medicare Advantage

Plans, also known as Medicare Part C, Medicare Choice Plans, or MA Plans, are health insurance plans provided by commercial insurance firms or managed care organisation that have a contract with Medicare to provide Medicare Part A and B services to Medicare beneficiaries.

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