Enrollment FAQs

Yes, for initial, revalidation and reactivation applications, a Puerto Rico and/or U.S. Virgin Islands provider is required to submit a letter of good standing with his or her application if there is no online verification source to verify a medical license. The letter of good standing is not required with a change of information application unless it involves a license update/change. 

Puerto Rico: The letter must be dated within 12 months prior to First Coast’s receipt of the application. The letter of good standing can be obtained from the Puerto Rico Department of Health.

USVI: The letter must be dated within six months prior to First Coast’s receipt of the application. The letter of good standing can be obtained from the Virgin Islands Department of Health. USVI providers may alternatively submit a 120-Day Certification Letter from the state/territory licensing authority.

A provider that has opted out of the Medicare program is not required to complete a separate application to order or refer items/services for beneficiaries to other Medicare providers. However, the opt-out provider must meet the following qualifications:

• His or her opt-out information must be current. 

Note: For more information regarding opt-out requirements, please click here.

• He or she must be of a specialty type eligible to order/refer items or services for Medicare beneficiaries.
• Physicians (doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery, doctor of podiatric medicine, doctor of optometry, optometrists may only order and certify DMEPOS products/services and laboratory and X-Ray services payable under Medicare Part B)
• Physician Assistants
• Clinical Nurse Specialists
• Clinical Psychologists
• Interns, Residents, and Fellows
• Certified Nurse Midwives
• Clinical Social Workers
• Marriage and family therapist
• Mental health counselor

References

• CMS MLN Educational Tool – Medicare Provider Enrollment

• SE1305

You can submit a request for a copy of your enrollment certification by sending a request for the information on company letterhead to First Coast’s provider enrollment department. The request needs to be signed by either the authorized official (AO), delegated official (DO) or the practitioner as it is listed on your entity’s enrollment record.

Mail your request to:
First Coast JN Provider Enrollment
P.O. Box 3409
Mechanicsburg, PA 17055-1849

Initial CMS-855A applications and ambulatory surgical centers and portable X-ray suppliers submitting an initial form CMS-855B can be submitted up to 180 days prior to the effective date listed on an application. All other applications can be submitted up to 60 days prior to the effective date you provide on your enrollment form.

References:

• CMS IOM Pub. 100-08, Chapter 10, section 10.4.1.4.2 A 

For providers that enroll solely to order or refer services using the CMS-855O, it is a national enrollment. When you relocate to another state, you are not required to dis-enroll from the current state and re-enroll in the new state. The contractor that maintains your CMS-855O enrollment in PECOS is responsible for processing changes of information, including relocating to a state outside of their jurisdiction. 

Reference: 

• CMS IOM Pub. 100-08, Chapter 10, section 10.3.1.5.3 D 

For practices that operate under the same Tax Identification Number (TIN), you will need to submit only one CMS-855B application; however, you will need to include two Section 4A pages to identify each practice location.

For practices that operate under separate TINs, you will need to submit separate CMS-855B applications for each of the practices. 

If your provider type, supplier type, physician specialty, or non-physician specialty type is not listed in the application, please select other, undefined physician specialty, or undefined non-physician practitioner specialty. Then list your type or specialty in the provided field.

Start by terminating the previous enrollment for the state in which you are no longer residing or working. For the new state, log into your current internet-based PECOS account, select My Enrollments, and then select New Application. The applicant questionnaire will determine that you are enrolling in a new state.

According to the CMS change request (CR) 6417 a provider is eligible to order or refer items or services for a Medicare beneficiary only if he or she meets both of the following criteria:

• The ordering or referring provider must be enrolled in Medicare and have a current enrollment record in the PECOS.
• The ordering or referring provider must be classified as a provider who is eligible to order or refer:
  • Doctor of medicine or osteopathy
  • Dental medicine
  • Dental surgery
  • Podiatric medicine
  • Optometry
  • Physician’s assistant
  • Certified clinical nurse specialist
  • Nurse practitioner
  • Clinical psychologist
  • Certified nurse midwife
  • Clinical social workers

Note: Only Medicare-enrolled physicians and non-physician practitioners that meet the above criteria are eligible to order or refer services for Medicare beneficiaries.

You can verify your eligibility to order or refer beneficiary services by checking the internet-based PECOS to ensure your enrollment record is current and includes your classification as a specialty or type of provider eligible to refer items or services for a Medicare beneficiary.

If you’re the billing provider, you can confirm the ordering or referring provider’s eligibility by accessing CMS’ Ordering and referring data file on the CMS data website.

The effective date is the later of the following two dates:

• The filing date of an enrollment application that was subsequently approved, or
• The date the provider first began furnishing services at a new practice location.

The provider may bill retrospectively for services when:

• The supplier has met all program requirements, including state licensure requirements, and
• The services were provided at the enrolled practice location for up to
  • 30 days prior to their effective date if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries, or
  • 90 days prior to their effective date if a presidentially-declared disaster precluded enrollment in advance of providing services to Medicare beneficiaries. 

Example:

Suppose that a non-Medicare enrolled physician began furnishing services to beneficiaries at her office March 1. She submitted the CMS-855I initial enrollment application May 1, and the application was approved June 1. The physician’s effective date of enrollment would be May 1, which is the later of: (1) the date of filing, and (2) the date she began furnishing services. The retrospective billing date is April 1 (or 30 days prior to the effective date of enrollment). 

Reference 

• CMS IOM Pub. 100-08 Medicare Program Integrity Manual, Chapter 10, section 10.6.2 

A provider’s legal business name is the name that is registered with the IRS and should appear on IRS documents, such as the CP-575, that contains a provider’s EIN or TIN. 

The provider’s legal business name with the IRS should identically match (including any or no punctuation) the business name registered with the National Plan & Provider Enumeration System (NPPES), which issues the NPI. This is the information that will be loaded into the PECOS. PECOS and NPPES must match exactly.

To validate that the legal business name the IRS has for you matches the business name registered with NPPES visit the NPPES website or contact them at 1-800-465-3203 or 1-800-692-2326 for TTY services.

References

• CMS IOM Pub. 100-08 Medicare Program Integrity Manual, Chapter 10

• NPPES

New physicians, practitioners, and suppliers may submit the CMS-460 form at the time of their enrollment. Participants agree to accept assignment for all covered services provided to Medicare patients.

In addition, the CMS-460 may also be used for existing providers during the annual participation open enrollment. The annual physician and supplier participation period begins January 1 of each year and runs through December 31. The annual participation enrollment is scheduled to begin on November 15 of each year. (Note: The dates listed for release of the participation enrollment/fee disclosure material are subject to publication of the annual Final Rule.)

During the annual enrollment period, for First Coast, the MAC for jurisdiction N (JN), which includes Florida, Puerto Rico, and the U.S. Virgin Islands, submit your completed CMS-460 form (or disenrollment request) to:

Provider Enrollment
P.O. Box 3409
Mechanicsburg, PA 17055-1849

Click here to find web addresses for other MACs/carriers. You can locate their mailing addresses for participation enrollment from their websites.

References:
CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 1, section 30.3.12.1

The following shows the information for the various applications:

• CMS-855A and CMS-855B

  For initial enrollment and revalidation, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program. 

  The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted. 

  The provider can have an unlimited number of authorized officials. However, each authorized official must be listed in section 6 of the CMS-855. Anyone listed as a "Contracted Managing Employee" in section 6 of the CMS-855 cannot be an authorized official.

• CMS-855I

  The only person who may sign the CMS-855I is the individual practitioner, including solely-owned entities listed in section 4A. This applies to initial enrollments, changes of information, reactivations, etc. An individual practitioner may not delegate authority to any other person to sign the CMS-855I on his/her behalf.

• All CMS-855 applications

  If the application is not signed and dated appropriately, the application will be rejected. The application will need to be corrected and resubmitted. Any application resubmission must contain a brand new certification statement page containing a signature and date. The provider cannot simply add a signature to the original certification statement submitted.

Access the Provider Enrollment Application Assistance Tool for more help in determining the appropriate enrollment form for submission.

References

• CMS IOM Pub. 100-08 Medicare Program Integrity Manual, Chapter 10