Want to join Medicare’s network but are confused about the different enrollment forms? Let us be your guide! Medicare is a federal health insurance program with over 68.9 million enrollments. This makes it the second largest source of health coverage in the U.S., right behind Medicaid.
So, naturally, every provider wants to be a part of its network. Unfortunately, Medicare’s credentialing process is designed to test your patience, involving multiple steps and documentation. However, we can help you solve this puzzle.
Read on to learn the ins and outs of Medicare provider credentialing. But before that, let’s discuss the different types of enrollment forms.
Quick Overview of CMS Enrollment Forms
So, which form do you need to get started? The Centers for Medicare and Medicaid Services (CMS) oversees the entire process and categorizes each supplier and provider differently. That’s why providers often get confused between different CMS-855 forms. Here is a quick overview of each form, so you know exactly where to begin:
| CMS Form | Description |
|---|---|
| CMS-855A | Institutional providers, such as hospitals, SNFs, hospices, and more, should use this. |
| CMS-855B | This form is for clinics, group practices, and certain suppliers. |
| CMS-855I | It is suitable for individual physicians or non-practitioners. |
| CMS-855O | Appropriate for physicians and non-physician practitioners who only order and certify services. |
| CMS-855S | Applicable to DMEPOS suppliers. |
| CMS-20134 | It is for MDDP suppliers. |
We know anyone can feel overwhelmed with these many options. The good news is that Medicare has a faster and more efficient online enrollment system than paper applications.
How to Get Credentialed with Medicare?
CMS has clearly outlined the process for becoming a Medicare provider or supplier on its website. But if you don’t have the time to go through it, here is a clear step-by-step method you can use for credentialing with Medicare:
Step 1: Verify Eligibility
The first step, verification, sets the foundation for others. Make sure you are eligible to apply for Medicare’s network. In simple terms, you meet all CMS requirements and have a valid medical license in your state.
Step 2: Obtain an NPI Number
The next step is to obtain a National Provider Identifier (NPI) number. This permanent 10-digit number is issued to all healthcare organizations and providers through the National Plan & Provider Enumeration System (NPPES). Hence, you can also apply for it through their website.
Keep one thing in mind! If you are a part of a group practice, both you and your organization should have separate NPIs. Unsure about having this number? Check the NPI Registry for confirmation. If you already have it, then skip this step and proceed to the next.
Step 3: Gather Required Documentation
After obtaining an NPI, make sure you have all the necessary documents, including personal, educational, and medical information, in your hand.
Step 4: Submit the Medicare Credentialing Application
CMS offers two options for submitting your application.
Online Submission via PECOS
This is the fastest and recommended method. Provider Enrollment, Chain, and Ownership System (PECOS) is the online system you can use to submit your Medicare credentialing application. But how does it work? You can simply follow these steps to enroll electronically.
- Log in to PECOS or Create an Account
The first step is quite straightforward. Log in to PECOS using the same ID and password you used on the NPPES website. Otherwise, create an account.
- Create A New Enrollment Request
After logging in, click ‘My Associates’ and then select ‘Create Initial Enrollment Application’. PECOS will ask a series of questions on the following topics, so it can take you to the correct application form:
- Personal information
- NPI number
- Type of healthcare services you provide
- Enrollment scenario
- Practicing specialty and state
After answering these questions, review your choices and click ‘Start Application’ to begin the Medicare credentialing process.
- Add Required Details & Upload Documentation
After clicking ‘Start Application’, you will see a form with three navigation tabs. Begin by entering your personal information, and then add your educational details by clicking the ‘Add Information’ button. Move through the form by using the ‘Next Topic’ button. At this point, complete all required fields and upload any necessary supporting documentation in PDF format.
- Select Signature Method
After completing all fields, proceed to the ‘Signature Method’ page. Our advice? Select the ‘Electronic Signature’ option for quick processing. Remember, if you are filling out the form on someone’s behalf, be sure to enter their email address. Otherwise, simply click ‘Sign Now’. Then, review and accept the terms and conditions and click on ‘Submit’.
- Choose an Appropriate MAC
The next step is to select the appropriate Medicare Administrative Contractor (MAC). PECOS will display options based on your location and the type of services you render. Review all the options and select the most appropriate MAC from the dropdown menu.
- Submit the Application
Finally, click ‘Complete Submission’ to send your application to the MAC you chose for processing. A pop-up will appear at the end indicating that you have successfully submitted your Medicare credentialing request. Click ‘Okay’ and do one more thing. Save and print the confirmation page for tracking and monitoring your Medicare credentialing application status.
Submitting a Paper Application
The second option is to submit a paper application. However, this process is slower than electronic submission. To become a Medicare provider or supplier, all you have to do is choose the most appropriate CMS enrollment form (CMS-855I in this case), complete the application, and print it.
Next, sign your application and send it to your MAC with supporting documentation and the EFT Authorization Agreement form. You can find your enrollment contractor from this list. An important tip! Don’t forget to keep a copy of the signed Medicare credentialing application for your records.
Step 5: Track Your Application & Respond to Additional Requests
Most providers overlook this step and, therefore, face credentialing delays. You should always check your Medicare credentialing application status after submission to stay on track. If you have used PECOS to submit your request online, you can monitor your application status from the ‘My Enrollments’ page.
Medicare’s credentialing process usually takes 60 to 90 days. However, it can take longer depending on your submission method and additional requests from your MAC. What if Medicare returns your application for corrections? In that case, you have 30 days to make all the necessary corrections.
Medicare Provider Credentialing Requirements
The following documents must be submitted as part of Medicare credentialing requirements.
| Key Requirements | Description |
|---|---|
| NPI Number | You must obtain a unique, 10-digit National Provider Identifier (NPI) number from NPPES. |
| Professional License | You must hold a valid and unrestricted professional license in your state. |
| Tax ID Number or Social Security Number (SSN) | You must provide your Tax Identification Number (TIN) or Social Security Number (SSN). |
| DEA Registration | You must also have a valid and unrestricted Drug Enforcement Administration (DEA) certificate. |
| Educational Documents | Upload your diplomas, residency certificates, post-graduate training, and other relevant documents. |
| Malpractice Insurance Coverage | You should provide proof of your professional liability insurance coverage. |
| Updated CV | Must include your work history. |
| Practice Address | You must also provide your current practice address. |
| Signed Application Form | CMS requires your signature, regardless of your application submission method. |
Challenges in Getting Credentialed with Medicare
So, which hurdles do providers face when getting credentialed with Medicare? You must understand the following common challenges so you can avoid the same mistakes.
Incorrect Form Selection
This is perhaps the biggest Medicare credentialing hurdle. Many healthcare providers get overwhelmed by the number of available CMS-855 forms, each collecting specific information depending on the provider type. Hence, they frequently face credentialing delays and denials due to wrong selection.
PECOS Login & Access Issues
PECOS may have made the Medicare credentialing process easier and time-effective for many providers, but it has its own issues. Providers can use NPPES credentials to log in to this system. The problem? They often forget their NPPES user IDs and passwords, which further extends their credentialing timeline.
Inaccurate or Incomplete Information
Want to know the leading cause of Medicare provider credentialing rejections? It is inaccurate or incomplete data. Healthcare providers often miss important details or upload outdated documents in the system. This halts the verification process and can have serious consequences for providers, including delays or interruptions in their ability to see patients.
Choosing an Appropriate MAC
CMS relies on a network of administrator contractors to process a large volume of applications. However, this creates another challenge for healthcare providers, especially for those who apply through paper applications. The reason? They find it difficult to select an appropriate MAC or navigate through their requirements.
Best Practices for Medicare Insurance Credentialing
So, what are the best ways to avoid Medicare credentialing rejections or delays? We have some suggestions:
Collect and Verify All Your Documents
As mentioned in the credentialing process, you must collect and verify all information before starting Medicare credentialing. This includes making sure your NPI number, name, tax ID, education, and training history are consistent across every document.
Choose the Correct Form
Review all the available forms to understand them thoroughly. We highlighted their details earlier. So refer to that information to identify which form matches your provider type (individual, group, or institutional). Select the correct CMS-855 form before starting the application.
Opt for Online Submission
To avoid selecting the wrong form, submit your Medicare credentialing application electronically through PECOS. This system will guide you to the correct form after a few basic questions. It also processes applications faster than paper submissions.
Use a Password Manager
Too many passwords and accounts to keep track of? Use a password manager to store and manage your NPPES login credentials. This will help you avoid access issues with the PECOS.
Verify Medicare Credentialing Requirements
CMS frequently updates its credentialing requirements. Therefore, don’t rely solely on this blog. Visit the official CMS website to confirm the latest details.
Choose MediBillMD for Exceptional Medicare Credentialing Support
Too many forms and too many details to fill? As we said earlier, Medicare’s credentialing process can test your patience even if you are an expert in paperwork. That’s why it is better to consult someone who knows their way around credentialing. For a smoother process and exceptional support, you can always count on our insurance credentialing services.
At MediBillMD, we help countless providers enroll in Medicare’s network. Hence, our credentialing experts efficiently manage CMS’s changing requirements. For more options, you can refer to our top 10 medical credentialing companies guide.
