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This document is a request for information from health care practitioners regarding the Medicare enrollment application process to ensure proper data collection and compliance under the Affordable

How to fill out medicare enrollment application for

How to fill out Medicare Enrollment Application for Physician and Non-Physician Practitioners

1. Obtain the Medicare Enrollment Application for Physician and Non-Physician Practitioners (Form 855I).
2. Read the instructions carefully before filling out the application.
3. Fill out Section 1 with your basic identifying information, including your name, Social Security Number, and business entity details if applicable.
4. Complete Section 2 to indicate your type of practice and the services you provide.
5. Provide information in Section 3 about your education and training, including medical school, residency, and any fellowship, along with relevant dates.
6. In Section 4, disclose any prior Medicare or other healthcare program affiliations, including any disciplinary actions if applicable.
7. Complete Section 5 with information about your practice location and phone number.
8. If applicable, fill out Section 6 regarding your billing agency information.
9. Review all information for accuracy and completeness before submission.
10. Sign and date the application to certify that the information is correct.
11. Submit the application to the appropriate Medicare Administrative Contractor (MAC) for processing.

Who needs Medicare Enrollment Application for Physician and Non-Physician Practitioners?

1. Physicians who wish to bill Medicare for services rendered.
2. Non-physician practitioners such as nurse practitioners, physician assistants, and clinical psychologists seeking Medicare enrollment.
3. Healthcare providers transitioning to or starting a new practice that bills Medicare.
4. Practitioners who have had a change in practice location or ownership requiring re-enrollment.

People Also Ask about

What are the requirements for a referring physician for Medicare?

All physicians, as well as all eligible professionals as defined in section 1848(k)(3)(B) of the Social Security Act must complete this application to enroll in the Medicare program and receive a Medicare billing number.

Does Medicare require a referring physician?

CMS requires Medicare contractors to verify the Medicare claim's ordering/referring provider meets one of the following criteria: The provider has an approved enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS), or. The provider opted out of Medicare and is eligible to order and refer.

How do I enroll in Medicare as a non participating provider?

Requirements The physician or non-physician practitioner must be enrolled in Medicare or Medi-Cal. The ordering, referring or prescribing provider NPI must be for an individual physician or non-physician practitioner (not an organizational NPI).

Who is the CMS form 855I the enrollment application for?

Step 1: Get an NPI. If you already have an NPI, skip this step and proceed to Step 2. Step 2: Complete the Medicare Enrollment Application. Enroll using PECOS,i the online Medicare enrollment system. Step 3: Work With Your MAC.

What are the signature requirements for Medicare physicians?

Signature Log The printed full name of the physician or practitioner. Sufficient information to identify the beneficiary. Date of service. Signature and date by the author of the medical record entry.

What prohibits physicians from referring Medicare patients?

The Physician Self-Referral Law, commonly referred to as the Stark law, prohibits physicians from referring patients to receive "designated health services" payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship, unless an exception applies.

Does Medicare require prior authorization for referrals?

What is prior authorization in original Medicare? Original Medicare rarely requires prior authorization. The government program covers medically necessary services without requiring you or your doctor to submit special forms in advance or even a referral to see a specialist.

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What is Medicare Enrollment Application for Physician and Non-Physician Practitioners?

The Medicare Enrollment Application for Physician and Non-Physician Practitioners is a form that healthcare providers use to enroll in the Medicare program, allowing them to bill for services provided to Medicare beneficiaries.

Who is required to file Medicare Enrollment Application for Physician and Non-Physician Practitioners?

Any healthcare provider, including physicians, nurse practitioners, physician assistants, and other non-physician practitioners, who wish to participate in the Medicare program must file this enrollment application.

How to fill out Medicare Enrollment Application for Physician and Non-Physician Practitioners?

To fill out the application, providers must complete the required sections of the CMS-855 form, provide necessary documentation, and submit it to the designated Medicare administrative contractor for processing.

What is the purpose of Medicare Enrollment Application for Physician and Non-Physician Practitioners?

The purpose of the application is to collect essential information about healthcare providers to verify their eligibility and qualifications to provide services under the Medicare program.

What information must be reported on Medicare Enrollment Application for Physician and Non-Physician Practitioners?

Providers must report personal identification information, practice location details, licensing information, any prior Medicare affiliations, and criminal history, among other relevant details.