Two different way of Medicare enrollment process

Medicare Enrollment Application Submission Options All eligible provider and supplier organizations can apply for enrollment in the Medicare program, make a change in their enrollment information, or voluntarily withdraw from Medicare
by using either:

• Internet-based Provider Enrollment, Chain and Ownership System (PECOS)

or

• The paper enrollment forms (i.e., the CMS-855A or the CMS-855B forms).



Notes:

• Suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)    do not, at this time, have the option of using Internet-based PECOS. The availability of   Internet-based PECOS to DMEPOS suppliers will be announced at a future date.

• Some enrollment scenarios cannot be accommodated by Internet-based PECOS at this    time. These scenarios are listed in the document entitled, “Overview of Internet-based  Provider Enrollment, Chain and Ownership System (PECOS) – Information for Provider and Supplier Organizations,” available from the Downloads Section of this web page.



What Are Provider and Supplier Organizations?

Provider and supplier organizations are entities that meet the Medicare definitions of “provider” and “supplier” and have business structures of corporations, partnerships, professional associations, or limited liability companies. Provider and supplier organizations do not include business structures that are sole proprietorships or “disregarded entities” as defined by the Internal Revenue Service (IRS).

The Employer Identification Number (EIN) issued by the IRS is the Taxpayer Identification Number (TIN) of an organization provider or supplier. Examples of providers and suppliers that are usually organizations as defined in this document include hospitals, medical group practices and clinics, portable X-ray suppliers, ambulatory surgical centers, hospices, skilled nursing facilities, and others. Provider and supplier organizations must enroll in Medicare and keep their enrollment information up to date in order to be eligible to receive Medicare payments for covered services furnished to Medicare beneficiaries.

How to enroll in PECOS, Check list you need

Checklist for Sole Proprietor or Solely Owned Organizations (eg. LLC, PC)

Below is a checklist of information that will be needed to complete enrollments via Internet-based PECOS:

• An active National Provider Identifier (NPI).
  • Sole Proprietors only need a type 1 (individual) NPI
  • Solely Owned Organizations need both a type 1 (Individual) NPI and type 2 (Organization) NPI
• National Plan and Provider Enumeration System (NPPES) User ID and password. Internet-based PECOS can be accessed with the same User ID and password that a physician or non-physician practitioner uses for NPPES.
  • For help in establishing an NPPES User ID and password or assistance in changing an NPPES password, contact the NPI Enumerator at 1-800-465-3203 or send an e-mail to customerservice@npienumerator.com.
• Personal identifying information. This includes:
  • Legal name on file with the Social Security Administration
  • Date of birth
  • Social Security Number
• Schooling information. This includes:
  • Name of School
  • Graduation year
• Professional license information. This includes:
  • Medical license number
  • Original effective date
  • Renewal date
  • State where issued
• Certification information. This includes:
  • Certification number
  • Original effective date
  • Renewal Date
  • State where issued
• Specialty/secondary specialty information
• Drug Enforcement Agency (DEA) number
• If applicable, information regarding any final adverse actions. A final adverse action includes:
  • a Medicare-imposed revocation of any Medicare billing privileges;
  • suspension or revocation of a license to provide health care by any State licensing authority;
  • revocation or suspension by an accreditation organization;
  • 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 or revalidation;
  • or an exclusion or debarment from participation in a Federal or State health care program.
• Practice location information. This information includes:
  • Practitioner's medical practice location
  • 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
  • Special Payment Information
  • Medical Record Storage Information
  • Billing Agency Information (if applicable)
  • Any Federal, State, and/or local (city/county) business licenses, certifications and/or registrations specifically required to operate as a health care facility.
• Electronic Funds Transfer documentation - mechanism by which providers and suppliers receive Medicare Part A and Part B payments directly into a designated bank account.

what is Medigap and when to buy or purchase

Now let’s talk about Medigap. Original Medicare pays for many health care services and supplies, but it doesn’t pay all of a person’s health care costs. A Medigap policy is a health insurance policy sold by private insurance companies to fill the “gaps” in coverage under Original Medicare, like
deductibles, coinsurance, and copayments.

Some Medigap policies also cover benefits that Medicare doesn’t cover, like emergency
health care while traveling outside the U.S.

The insurance companies that sell these policies must follow Federal and state laws that
protect people with Medicare. The Medigap policy must be clearly identified as “Medicare
Supplement Insurance.”

A Medigap policy only works with Original Medicare. If you join a Medicare Advantage
Plan or other Medicare plan, your Medigap policy can’t pay any deductibles, copayments,
or other cost-sharing under your Medicare plan.

In all states except Massachusetts, Minnesota, and Wisconsin, a Medigap policy must be
one of 12 standardized plans (A - L) so people can compare them easily. Each plan has a
different set of benefits. The benefits in any Medigap plan A – L are the same for any
insurance company. It’s important to compare Medigap policies, because costs can vary.



The best time for a person to buy a Medigap policy is during his or her Medigap open enrollment period (OEP) which lasts for 6 months starting on the first day of the month a person is enrolled in Medicare Part B and age 65 or older. During the Medigap OEP, a person has the right to buy any
Medigap policy sold in his or her state. (Some states have additional enrollment guarantees for people under age 65.)

People may also buy some Medigap policies if through no fault of their own, their employer
group health plan coverage ends, if they move out of the service area, or under certain
circumstances, if they leave their Medicare Advantage Plan. People may also buy a Medigap
policy any time an insurance company will sell them one, but their health history may be
used to decide if they can buy one and how much they have to pay.

NOTE: People can no longer buy Medigap policies covering prescription drugs because Medicare now offers prescription drug coverage.

However, people with an existing policy that covers prescription drugs can keep it.
People pay the insurance company a monthly premium for their Medigap policy and also
pay their monthly Part B premium ($96.40 in 2009). After they get a health care service,
they will get a Medicare Summary Notice showing what Medicare paid, and their Medigap
insurance company will send them information on what it paid.