Credentialing Corner

# Medicare Provider Enrollment Eligibility Verification

- September 19, 2024
- Posted by Brian Bertrand

11 Jul

Medicare is a federal health insurance program in the US that covers healthcare services for aged people, disabled young people, and patients with chronic end-stage diseases. Healthcare organizations who provide these services get the bills covered by Medicare and for that reason, they have to be enrolled in this program. These providers need to follow some protocols and medicare requirements to be verified and get reimbursement for the services on time.

The Center for Medicare Services oversees the enrollment process. CMS evaluates providers’ credentials and only allows qualified providers to register. In this article, we will discuss the eligibility criteria for provider enrollment and verification.

## Medicare Enrollment Types

Before delving deep into the enrollment and verification criteria, it is very necessary to understand the Medicare program and its different types.

### Part A

Part A concerns inpatient services, including hospital visits, hospital stays, nursing facility care, and hospice facilities. A few home care services are also included in this section. Hospitals or healthcare organizations that want these services should meet the eligibility criteria and have all the necessary infrastructure and staff.

### Part B

This part deals with outpatient services, including doctors’ services, medical supplies, and laboratory services. Providers who provide such services should be enrolled in this part. They should meet the compliance and requirements protocols to be verified and reimbursed.

### Part C

Part C is also referred to as Medicare Advantage plans, which are dealt with by private companies. Medicare has approved some private companies that cover vision, hearing, and dental services in addition to all services in other parts. Providers enroll and verify with these private companies to get paid.

### Part D

This part covers drug prescription services. Pharmacies and other healthcare organizations that only prescribe drugs for the treatment of disease should enroll in this part. They must meet the drug utilization review standards and compliance policies.

## Eligibility Criteria For Medicare Providers

Before submitting the application for enrollment in the Medicare plan, it is important to have the checklist for the enrollment and verification process. Eligibility criteria are different for individual and institutional providers.

### Individual providers

Providers such as physicians, nurse practitioners, private clinic providers, and social workers have different requirements to become eligible for registration. They should have the following credentials:

- Valid medical license
- National Provider Identifier (NPI)
- Compliance documents with federal or state regulations

### Institutional providers

Institutional providers are those who have hospital setups along with different physicians of different scopes and nurse practitioners. Home care agencies also come under the institutional providers. They should have the following credentials:

- State licensure and certifications
- Accreditation by an accrediting body
- Medicare participation compliance documents

## Steps For The Medicare Credentialing Requirements in 2024

### 1. Obtaining NPI number

All health coverage, including Medicare, is billed using the provider’s NPI (National Provider Identifier) number. The first step is to get the NPI number by applying through the National Plan and Provider Enumeration System (NPPES). The application involves basic information about the provider, including name, address, tax details, credentialing or accreditation documents, and contact information.

### 2. Completing CMS-855 form

Medicare enrollment steps involve the CMS form submission. It should be completed with full attention and care to make the process smooth and efficient. Different types of forms are available depending upon the type of providers.

- CMS-855A: For institutional providers such as hospitals, home health agencies, and skilled nursing facilities.
- CMS-855B: For clinics and group practices.
- CMS-855I: For individual practitioners.
- CMS-855R: This is for reassigning benefits. Providers who want to change their service from one to another entity i.e. group practice can use this form in this regard.
- CMS-855O: For ordering and referring physicians and non-physician practitioners.

### 3. Application submission and revalidation

PECOS (Provider Enrollment, Chain, and Ownership System) is an online system for managing the enrollment process. Providers fill out the application form and submit it on PECOS. They can also make changes to the form, provide additional details to Medicare, and track the application status using this online system.

The application should correctly contain all data and information, and all the necessary verified documents should be attached. Medicare has also required revalidation to check that providers have maintained the protocols throughout. Revalidation is made every five years. Three-year revalidation is recommended for prosthetics, orthotics, and medical equipment providers.

## 4. Verification Of Medicare Eligibility Verification

Verification steps are made to confirm that the medical providers are highly skilled and well-educated to give the best patient care. Medicare performs the following steps to ensure this:

### 5. Site visits and inspection

CMS visits the providers’ operational area to check the patient care protocols. These visits review the existence of operational space, working conditions, hygiene, and environment. CMS agents check whether providers are complying with regulatory policies and rules. A detailed inspection is made as it is concerned with the safety of patients.

### 6. Background Checks

Background checks are made to save people from fraudulent and ill-practiced providers. Criminal record, malpractice histories, financing records for malpractice claim history, and providers’ licenses is evaluated to check the professionalism and legitimacy of the medical providers. The integrity of the Medicare plan is maintained by only enrolling professional, ethical, and legitimate providers.

## Compliance with Medicare Conditions of Participation

These are federal regulations that help ensure quality care and patient safety. They specifically deal with quality assessment, patient rights, infection control, and doctor-patient relationships. One should comply with all the above regulations to enjoy the benefits of the Medicare program.

In case of any violations, providers’ membership is canceled, and they are also charged with penalties. The CMS conducts regular audits to ensure that all compliance policies are followed. Medical providers should also conduct internal audits to check their service and address any problems at once.

## Conclusion for Medicare Credentialing Requirements

Provider enrollment verification in the Medicare program is crucial if you want to get reimbursed for the services you provide to the people part of the Medicare program. The Medicare program covers the inpatient, outpatient, and prescription services. The steps to be registered with this program are obtaining an NPI number, filling out the CMS-855 form, and submitting the application using the PECOS platform. CMS verifies the information and pays visits to providers’ sites for confirmation. Medical providers should have all necessary credentials and comply with policies to get verified.

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