07/31/13 Provider Enrollment Teleconference - WPS Medicare

Provider Enrollment
Reducing Application Delays
The purpose of this teleconference is to assist the provider community in understanding the
process, the documents needed for enrollment and completion of an application and the
reasons for development that delay applications.
National Provider Identifier (NPI)
• The NPI is a 10 digit number to identify a individual provider or supplier
• Any Health Insurance Portability and Accountability Act (HIPAA) covered entity must
obtain an NPI
• Obtaining the NPI DOES NOT enroll a provider with a payer
The National Plan and Provider Enumeration System (NPPES)
• NPPES collect required information and uniquely identifies individual and organization
health providers
• Maintains and updates information
• Disseminates information
o For an individual provider or an organization – designate an authorized
individual. This could be the physician or a member of the management staff of
the organization.
o The user ID and the secret questions cannot be changed. If your physician has
set these up prior to joining your organization, you will need to get this
information from him/her.
o When completing the form, print off the pages as you complete them. Don’t use
your browser arrow keys to move around the form – use the next and previous
buttons on the form itself.
• You will need the following information to request an NPI
o Provider Name
o Social Security Number (SSN) or Individual Tax Identification Number (ITIN) if
not eligible for a SSN
o Date, County, and State (if in US) of birth
o Gender
o Mailing address
o Practice Location
o Taxonomy Code
o State License Information
o Contact Person and Contact Information
Created 07/08/2013 1
http://www.wpsmedicare.com/

Appropriate 855 Form
http://www.wpsmedicare.com
• 855A – Medicare Enrollment Application – Institutional Providers
• 855B – Medicare Enrollment Application – Clinics/Group Practices and Certain Other
Suppliers
• 855I – Medicare Enrollment Application – Physicians and Non-Physician Practitioners
• 855O – Medicare Enrollment Application – Registration for Eligible Ordering and
Referring Physicians and Non-Physician Practitioners
• 855R – Medicare Enrollment Application – Reassignment of Medicare Benefits
• 855S – Medicare Enrollment Application – Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) Suppliers
Provider Enrollment, Chain and Ownership System (PECOS)
• We encourage all applicants to use the electronic PECOS.
• In order to use PECOS you will need the following information
o Used ID and password from NPPES
o Active NPI
o Personal identifying information
o Professional license and certification information
o All practice locations
o Information on any adverse legal actions
• Providers can track the status of the application. There are four possible choices
o Received by Medicare Contractor – We have the application
o Reviewed by Medicare Contractor – The application is in process
o Returned for Additional Information – We need additional information and the
process has stopped. Respond as quickly as possible. If we have not received
information within 30 days, we may deny or reject the application.
o Approved or Rejected – The application is complete.
• Providers will determine whether they will become a participating provider (agreeing to
accept assignment on all Medicare claims) or a non-participating provider (not agreeing
to accept assignment on all Medicare claims).
o If choosing participating, you will need to submit a Centers for Medicare &
Medicaid Services (CMS) 460 form.
o Send this with the signature and other documents.
Supporting Documentation
• The signature document.
• When submitting signatures, we need both pages of the certification statement. 855I
page 30 and 31, 855R pages 25 and 26.
• Do not submit a paper copy of an application submitted electronically.
• Diplomas, certifications, etc., to establish the validity of the person enrolling
• Internal Revenue Service (IRS) form CP 575 to show the legal business name and
Employer Identification Number (EIN.)
• The CMS form 588 to allow for electronic funds transfer
• Any documents showing adverse legal actions.
• Other documents
• Physician offices do not have an application fee at this time.
• Some provider specialties need a site visit prior to accepting and completing the
application.
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• There are new screening requirements for all applications. These are detailed in the
CMS Internet Only Manual http://www.wpsmedicare.com
(IOM) Publication 100-08, Chapter 15, Section 15.7.1.1.
• The above can include telephone calls to verify phone numbers, addresses, and new
patients. Remind staff answering the phone of the possibility.
Effective Billing Date Determination
• For some specialties it is the later of the filing date or the date the practitioner began
furnishing services at the practice location.
Examples:
• Dr. A established a practice and began seeing patients on 2/15/13. Her
application was dated 2/1/13. Effective date is 2/15/13. We cannot go
back further than when she started seeing patients.
• Dr. B established practice and began seeing patients on 2/1/13.
Application was dated 2/15/13. Effective date is 2/1/13. We can go back
30 days.
• Dr. C established practice and began seeing patients on 12/1/12.
Application is dated 2/15/13. Retrospective billing date is 1/16/13. We can
only go back 30 days.
• For Independent Diagnostic Testing Facilities (IDTF) it is the later of the filing date or the
date ITDF started furnishing services.
Example:
• IDTF began seeing patients on 1/15/13. Filing date is 2/1/13. Effective
date is 2/1/13.
• For all other providers the effective date is the later of the date the provider began
furnishing services or the date when all eligibility requirements are met.
Example:
• An ambulance who indicates that they want an effective date of 1/1/2013
and we received their application on 6/1/2013 however their license was
not effective until 3/1/2013. We would only be able to grant the 3/1/2013
effective date.
Reasons for Return and Development
• Application sent to wrong contractor
• Filing date is more than 60 days prior to the requested effective date.
• Filing date is more than 180 days prior to the requested effective date for Ambulatory
Surgical Centers (ASC) or portable x-ray suppliers.
• Missing signatures.
• Missing effective date of addition, change, or deletion.
• Missing supporting documents.
• Missing legal business name.
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• The correspondence address must be the applicant’s address. This can be a billing agency.
• The correspondence telephone http://www.wpsmedicare.com
number is where to reach the provider if there are
questions concerning the application.
• Missing answers concerning adverse legal actions.
• Missing a definitive “yes” or “no”.
• Missing complete dates. When a date is requested use the date, month and year, not
just the month and year. An example is 855I Section 2C.
• Missing Electronic Funds Transfer (EFT) information.
• The information is missing the NPI for the enrolling provider. In the 855B form, see
Section 1, Section 2C, Section 2G, Section 4A, Section 5A, Section 6A, Attachment 2
Section C, and Attachment 2 Section E. In the 855I, see Section 1, Section 2E-2G,
Section 4A-4C, and Section 6. In the 855R, see Section 2-3.
• Missing Birth State or a response to the question “Are you accepting new Medicare
patients”. Section 2A of the 855I.
• We need a copy of a signed passport or a driver’s license.
• Screening such as calling offices.
• Additional information or denial Letters.
• The authorized or delegated official is not listed or does not match the PECOS record or
previous 855 forms.
• Practice Address/Phone number need to match.
Appeals
• Corrective Action Plans (CAP)
o A provider may submit a CAP to show how they plan to correct any deficiencies.
We must receive this within 30 days and it must be signed and dated by the
physician or an authorized or delegated official.
• Reconsideration of Denial or Revocation
o This is an independent review with a contractor hearing officer.
o Submit any additional information along with your request.
o We will send a letter giving the provider a reference number for the appeal.
o There can be a couple of responses
• Providers are notified of a favorable decision. We then send the
information to the Provider Enrollment staff for processing. We will send
a notification letter when the enrollment process is complete.
• Providers are notified of an unfavorable decision and provided information
on the next level of appeal.
o A reconsideration of the effective billing dates is only available for certain
specialties. The request should include the reason for the disagreement.
Changes in Information
• Providers are required to keep Medicare updated with any changes in information.
• Change of ownership, change in a practice location, revocation, or suspension of a
Federal or State license is required within 30 days of the change.
• All other changes, (adding a practice location, adding a physician, removing a physician,
etc. are due within 90 days of the change.)
• Failure to comply with the date requirements could result in revocations of billing
privileges.
• Use the form that applies to the situation.
o If a provider is changing the EIN (Employer Identification Number,) this is a new
entity. Use the appropriate form for your type of entity.
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Revalidation
http://www.wpsmedicare.com
• This applies to all providers enrolled prior to March 25, 2011 and is required by Section
6401 of the Affordable Care Act.
• Applications are due within 60 days of the date of the letter.
• Check the box 1A to show this is a revalidation.
• One 855I and 855R can be used to revalidate all the PTANs for reassignment to a single
legal entity (this is under one tax ID.)
• Enclose the revalidation letter with your documents.
Reactivation After Deactivation From Failure to Revalidate
• If approved application for reactivation is received with 120 days of a deactivation, then
there is no gap in coverage and the original PTAN is reinstated with the original effective
date.
Resources
CMS
National Plan and Provider Enumeration System (NPPES)
http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-
Simolipication/NationalProvStand/sownloads/EFIUserManual.pdf
Access to Provider Enrollment, Chain and Ownership System (PECOS)
https://pecos.cms.hhs.gov/pecos/login.do
CMS Internet based PECOS information
http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/MedicareProviderSupEnroll/InternetbasedPECOS.html
CMS Forms
http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html
Medicare Provider – Supplier Enrollment
http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/MedicareProviderSupEnroll/index.html
CMS IOM Publication 100-08, Chapter 15
http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/pim83c15.pdf
CMS Publication – Medicare Provider/Supplier National Education Products
http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/MedicareProviderSupEnroll/downloads/Medicare_Provider-
Supplier_Enrollment_National_Education_Products.pdf
WPS
J5 - Provider Enrollment Department
http://www.wpsmedicare.com/j5macpartb/departments/enrollment/
J8 - Provider Enrollment Department
http://www.wpsmedicare.com/j8macpartb/departments/enrollment/
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On Demand Training
J5 - http://www.wpsmedicare.com/j5macpartb/training/on_demand/prov-enroll.shtml
J8 - http://www.wpsmedicare.com/j8macpartb/training/on_demand/prov-enroll.shtml
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