Last Modified: 6/17/2024
Location: FL, PR, USVI
Business: Part A, Part B
There are many scenarios to consider when determining your Medicare effective date. Use this guide to determine your Medicare effective date for initial enrollment, change of information resulting in a new PTAN, and reactivations not related to revalidation. Your specialty may determine which guidelines to follow.
The providers/suppliers are separated into five groups.
If you are trying to determine a Medicare effective date for a reactivation due to a deactivation from revalidation, please use the last section of the chart, regardless of specialty.
Supplier type |
Rule |
• Physicians (MD, DO, DC, DMD, DDS, DPM, OD) • Physician assistant • Nurse practitioner • Anesthesiologist assistant • Clinical nurse specialist • Certified registered nurse anesthetist • Certified nurse midwife • Clinical social worker • Clinical psychologist • Registered dietitians or nutrition professional • Physical therapist • Occupational therapist • Audiologist • Independent psychologist • Speech language pathologist • Marriage and family therapist • Mental health counselor • Group practices consisting of any of the category of individuals listed above • Ambulance service supplier • Part B hospital departments • CLIA labs • Opioid treatment program • Mammography centers • Mass immunizers/pharmacies • Radiation therapy centers • Home infusion therapy service suppliers |
The Medicare effective date will be the later of the receipt date or the date they began furnishing services. If the receipt date is the later date, you may apply the retrospective billing date. |
• Intensive cardiac rehabilitation facilities |
The Medicare effective date will be the date provided on the application. |
• Independent diagnostic testing facility • Medicare diabetes prevention program |
The Medicare effective date will be the receipt date or requested future date. |
CMS certified providers/suppliers: • All Part A suppliers • Ambulatory surgical center • Portable X-ray supplier |
The Medicare effective date will be determined by CMS/state agency. |
Reactivations from revalidation non-response deactivations: • Revalidations starting March 2016 |
The provider/supplier will have a gap in coverage from the date of deactivation to the receipt date of a full, new revalidation application (this is not applicable for CMS certified providers/suppliers). |
The dates are provided in the applications/sections listed below:
• Medicare Enrollment Application - Medicare Diabetes Prevention Program (MDPP) Suppliers (CMS-20134), section 4A
• Medicare Enrollment Application - Institutional Providers (CMS-855A), section 4A
• Medicare Enrollment Application - Clinics/Group Practices and Other Suppliers (CMS-855B), section 4A
• Medicare Enrollment Application - Physician and Non-Physician Practitioners (CMS-855I):
• Individuals in private practice, sole owners, sole proprietor/disregarded entity: Section 4B
• Individuals who are reassigning (including physician assistants): Section 4F
The date we receive the enrollment application.
The date the contractor approved the application.
The later of the date of filing or the date (the supplier) first began furnishing services at a new practice location.
This date can be up to 30 days prior to receiving the Medicare enrollment package.
If the date requested is not more than 30 days prior to the receipt, the requested date will be the Medicare effective date.
A date provided on the application that is after the receipt date.
The effective date of the reassignment is 60 days before the Physicians and Non-Physician Practitioners (CMS-855I) application is submitted if all applicable requirements during that period were otherwise met.
• Physicians and Non-Physician Practitioners (CMS-855I) application submitted with Clinics/Group Practices and Other Suppliers (CMS-855B) application either simultaneously or as part of development:
• The contractor shall apply the Clinics/Group Practices and Other Suppliers (CMS-855B) effective date to the Physicians and Non-Physician Practitioners (CMS-855I) application. When one or both of these forms requires the contractor to develop for information, and for purpose of establishing the §§ 424.520(d)/424.521(d) effective date, the contractor may apply the receipt date of the first application.
The following situations are considered a true reactivation:
• An individual returns to the same group/group PTAN he/she was previously deactivated from.
• A previously deactivated individual, group, or organization is enrolling into Medicare with the same practice location/PF locality as it had before.
The effective date of a reactivation of billing privileges is the date on which the contractor received the provider's or supplier's reactivation submission that the contractor processed to approval.
• The Medicare effective date can’t be before provider/supplier’s license/certification effective date.
• A reassignment Medicare effective date can’t be before the reassigning group’s Medicare effective date.
• During a Presidentially declared disaster, the retrospective billing date for reassigners can be back dated up to 120 days from the receipt date; all others can be back dated up to 90 days from the receipt date.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
