Last Modified: 4/3/2018 Location: FL, PR, USVI Business: Part A, Part B
Part D prescriber enrollment – Effective date is January 1, 2019
In May 2014, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS 4159-F) that revised the Medicare Advantage (MA) and Part D prescription drug benefit programs regulations. This regulation, authorized under Section 6405 of the Affordable Care Act, requires that all physicians and other eligible professionals who write prescriptions for covered Part D drugs are accurately enrolled in the Medicare program. This requirement will help CMS ensure that Part D drugs are only prescribed by qualified individuals.
To meet these requirements, any physician or other eligible professional (e.g., general dentists) who prescribes Part D drugs must either enroll in or opt-out of the Medicare program. Effective January 1, 2019, if prescribing physicians and non-physician practitioners have not enrolled or opted out of the Medicare Program, Medicare Part D plans will deny pharmacy claims at the point of sale. To allow time for application processing and ensure all requirements are met before the January 1, 2019, enforcement date, all prescribers should submit enrollment applications or opt-out affidavits now.
Prescribers enrolling to bill the Medicare program
If you wish to enroll in the Medicare program to be reimbursed for covered services furnished to Medicare beneficiaries, in addition to prescribing Part D covered drugs, you must complete the CMS-855I application. You may also use internet-based PECOS to submit your enrollment information as an online alternative for enrolling in the Medicare program.
Prescribers enrolling that will not bill the Medicare program
The CMS-855O , which is a shorter, abbreviated form, should be completed if you are seeking to enroll solely to prescribe Part D drugs. This will allow prescribers to verify their personal information and credentials for the sole purpose of prescribing; however, prescribers that complete the CMS-855O will not have billing capabilities in the Medicare program. You may also use internet-based PECOS to submit your enrollment information as an online alternative for enrolling in the Medicare program. For guidance on using Internet-based PECOS to submit your CMS-855O enrollment, please view the CMS’ how-to guide, Enrolling Solely to Order and Certify Items and Services and/or Prescribe Part D Drugs via the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) .
Note: If you do not see your specialty listed on the CMS-855O application, select the Undefined Physician Type option and identify your specialty in the space provided (e.g., general dentistry).
Prescribers opting out of the Medicare program
If you elect to opt-out of Medicare, you must submit an opt-out affidavit. Your opt-out information must be current and a National Provider Identifier (NPI) is required to be submitted on the affidavit. A provider with an opt-out status may still order/refer and prescribe for Medicare beneficiaries, but may not bill the Medicare program. Providers with opt-out statuses enter into private contracts with beneficiaries. Prescribers wanting more information about opting out may refer to SE1311 and the CMS’ internet-only manual (IOM) 100-02, Chapter 15, Section 40.1 .
Provider enrollment address
If you decide to complete one of the paper CMS forms or submit the opt-out affidavit, the information should be mailed to First Coast Service Options at the following address:
P.O. Box 44021
Jacksonville, FL 32231-4021
For more contact information regarding provider enrollment inquiries, please review Provider enrollment: Contact information – Florida, Part B.
CMS has designed a website with a comprehensive list of resources needed to navigate Part D Prescriber Enrollment. The Medicare Learning Network (MLN) MattersŪ article special edition (SE) 1434 also advises that questions or issues may be submitted directly to CMS at firstname.lastname@example.org.
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.