Nurse practitioner (NP)

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Home ► Nurse practitioner (NP)

Last Modified: 4/10/2024 Location: FL, PR, USVI Business: Part A, Part B

Nurse practitioner (NP)

Qualification requirements

Nurse practitioners (NP) must meet all of the following criteria to provide services for Medicare beneficiaries:

• Registered professional nurse who is authorized by the state in which he or she practices as a nurse practitioner in accordance with state law and must also meet one of the following sets of criteria:

• Obtained Medicare billing privileges as a nurse practitioner for the first time on or after January 1, 2003, has a master’s degree in nursing or a Doctor of Nursing Practice (DNP) degree, and is certified as a nurse practitioner by a recognized national certifying body that has established standards for nurse practitioners.

• Obtained Medicare billing privileges as a nurse practitioner for the first time before January 1, 2003, and is certified as a nurse practitioner by a recognized national certifying body that has established standards for nurse practitioners.

• Obtained Medicare billing privileges as a nurse practitioner for the first time before January 1, 2001.

Note: The following organizations are recognized national certifying bodies for nurse practitioner at the advanced practice level:

• American Academy of Nurse Practitioners

• American Nurses Credentialing Center

• National Certification Corporation for Obstetric, Gynecologic, and Neonatal Nursing Specialties

• Pediatric Nursing Certification Board (previously named: National Certification Board of Pediatric Nurse Practitioners and Nurses)

• Oncology Nurses Certification Corporation

• American Association of Critical Care Nurses (AACN) Certification Corporation

• National Board on Certification of Hospice and Palliative Nurses

• Nurses Portfolio Credentialing Commission (NPCC)

Documentation requirements and recommendations

• Completed CMS-855I form external pdf file

Note: To expedite the processing of your provider enrollment application, you may use the internet-based PECOS external link

, which will automatically select the appropriate form and allow you to complete the application process online.

• Signed and dated certification statement -- all signatures must be original and signed in ink (blue ink preferred). Stamped, faxed, or copied signatures will not be accepted.

Note: If you submitted your application through internet-based PECOS, you may sign the application electronically or you must submit your paper certification statement within 15 days of your electronic submission.

• Completed Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588) external pdf file

and associated documentation (e.g., copy of a voided check and/or a deposit slip). Please click here for more information.

Note: If a provider/supplier already receives payments electronically and is not making a change to his/her banking information, the CMS-588 is not required. In addition, physicians and non-physician practitioners who are reassigning their benefits to another entity are not required to submit the CMS-588.

• Include copies of the following supporting documents:

• A notarized copy or a certified “true copy” of the practitioner’s state medical license:

• A notarized copy must include the stamp that states “official seal” and the name of the notary public as well as the state, county, and date the notary’s commission expires.

• A certified “true copy” of an original document has a raised seal that identifies the state and county in which it originated or is stored.

Note: A provider/supplier located in Puerto Rico or U.S. Virgin Islands must include a copy of his or her Letter of Good Standing. The letters for Puerto Rico providers/suppliers will be considered valid if it was issued within 12 months of First Coast’s receipt of the enrollment application. The letters for U.S. Virgin Islands providers/suppliers will be considered valid if it was issued within six months of First Coast’s receipt of the enrollment application.

• Certificate of completion, transcript, and/or diploma from accredited educational program(s) required for certification and/or licensure (please refer to Qualification requirements section at the top of the page.)

Additional documentation requirements (when applicable)

Medicare may require additional documentation, when applicable, to validate key information contained within the enrollment application (e.g., name change, tax identification number, proof of citizenship) or to address specific issues that could adversely affect a practitioner’s potential eligibility for enrollment (e.g., adverse legal actions, financial relationships).

• Driver’s license

• Social Security card

• Marriage license

• U.S. passport

• NPI verification from National Plan and Provider Enumeration System (NPPES) -- only durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers are required to submit this type of documentation

• Written confirmation from the IRS verifying provider’s TIN is associated with the provider’s legal business name (e.g., IRS CP 575)

• Final adverse action documentation: Please include copies of legal documents associated with any final adverse action(s) taken against the provider as well as copies of any the legal documents showing its resolution (e.g., notifications, reinstatement letters).

Note: Documents containing a summary of the adverse actions taken or their resolution will not be accepted.

• Completed Medicare Participating Physician or Supplier Agreement (CMS-460) external pdf file

• Statement in writing from the practitioner’s bank (or other financial institution) -- if Medicare payments will be sent to a practitioner’s bank with which he or she has a lending relationship (i.e., any type of loan), then the practitioner must provide a statement in writing from the bank -- which must be specified in the loan agreement -- that the lender has agreed to waive its right of offset for Medicare receivables.

Reimbursement

Nurse practitioners are reimbursed from the Medicare Physician Fee Schedule (MPFS) at 85 percent of the rate allowed when a physician performs the service, subject to a 20 percent coinsurance. See https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf external pdf file

, section 120.

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