Subscribe to eNews Contact us / IVR

Audiologist

Qualification requirements

Audiologists must meet all of the following criteria to provide services for Medicare beneficiaries:

  • Have a master’s degree or a doctorate in audiology and

    • Is licensed as an audiologist by the state in which the individual furnishes such services, or

    • In the case of an individual who furnishes services in a state which does not license audiologists, has:

      • Successfully completed 350 clock hours of supervised clinical practicum (or is in the process of accumulating such supervised clinical experience), and

      • Performed not less than 9 months of supervised full-time audiology services after obtaining a master’s or doctoral degree in audiology or a related field, and

      • Successfully completed a national examination in audiology approved by the Secretary of the Department of Health and Human Services (DHHS).

Documentation requirements and recommendations

Providers must submit an enrollment application by:

  • Completed CMS-855I form
  • Signed and dated certification statement:
    • The signature of the individual practitioner must be a handwritten signature (original signature not required)
    • Digital signatures (DocuSign or other software) are acceptable
    • A copy of the signature is acceptable; however, no stamped signatures can be accepted

or

  • Completed web application using PECOS:
  • Signed and dated certification statement of PECOS web application by:
    • E-signing electronically or
    • Uploading a signed and dated paper certification statement

and

  • Completed Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588) or its equivalent in PECOS:
    • Must include associated documentation (e.g., copy of a voided check or account confirmation letter on bank letterhead)
  • If a provider already receives payments via EFT and is not making a change to banking information, the EFT is not required
  • Physicians and non-physician practitioners who are reassigning their benefits to another entity are not required to submit the CMS-588
  • Read CMS-588 Electronic funds transfer (EFT) for more information

Additional documentation requirements (when applicable):
Medicare may require additional documentation, when applicable, to validate key information submitted on the enrollment application or to address specific issues that could affect a practitioner’s potential eligibility for enrollment unfavorably (e.g., adverse legal actions).

Include copies of the following supporting documents, if applicable:

  • Copy of practitioner’s state medical license if not verifiable online
  • Copy of certification if not verifiable online
  • Certificate of completion, transcript, or diploma from accredited educational program(s) if requested
  • IRS document verifying provider’s TIN is associated with the provider’s legal business name (e.g., IRS CP 575)
    • Applies to clinics, groups, organizations, and institutional providers
  • Final adverse legal action documentation:
    • Include copies of legal documents associated with any final adverse action(s) taken against the provider
    • Include copies of any legal documents showing the resolution (e.g., notifications, reinstatement letters)
  • Completed Medicare Participating Physician or Supplier Agreement (CMS-460), if applicable:
    • A participating provider is one who bills Medicare directly and accepts assignment for covered services as payment in full
    • Physicians and non-physician practitioners who are reassigning their benefits to another entity are not required to submit the CMS-460

Good Standing Letter (GSL) – When there is no online source to verify a provider’s medical license in the U.S. Virgin Islands or Puerto Rico, the provider/supplier must supply a Good Standing Letter (GSL) or 120-Day Certification Letter from the State/Territory licensing authority:

  • A copy of the GSL or 120-Day Certification Letter issued by the State/Territory licensing authority must be submitted with each application received for initial enrollment, reactivations, revalidations, and change of information applications involving a license update/change
  • The GSL may have multiple names listed on the letter to show an active medical license
  • The GSL is valid if it was issued within:
    • 6 months of receiving the application for U.S. Virgin Islands
    • 12 months of receiving the application for Puerto Rico