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Medicare: Basics of Provider Enrollment


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What you need to know about Medicare Provider Enrollment


Medicare enrollment can be daunting, particularly for individuals moving across state lines, providing services in multiple states, or providing telehealth only. While Medicare is a federal program, its administration can vary from state to state, adding layers of complexity to an already intricate system. Here are some basics that you need to know.


  1. Gone are the olden days of submitting paper applications via fax. Now, applications are electronically sent through the PECOS site. All Medicare applications are submitted and viewed in PECOS. Want to know more about the PECOS site? Read more in the article. PECOS has three sites?

  2. You have to connect your group's NPI to your I&A account before you can submit Medicare applications. The owner of the practice must request to be an Authorized Official for the group NPI. Once that request is approved, the NPI will show up in PECOS and the Medicare application can be accessed. If there is someone other than the owner filling out and submitting the application, that person will need to request to be an Access Manager of the NPI. Once that request is approved, the NPI will show up in their PECOS account so they can submit applications on behalf of the practice. Need help connecting to an NPI or requesting to be an Authorized Official? Schedule a call so we can walk you through the process!

  3. One of the fundamental aspects of Medicare enrollment is the application process. Unlike some state-specific healthcare programs, Medicare utilizes a standardized application across all 50 states. This streamlined approach aims to simplify the process for individuals seeking coverage, ensuring consistency and uniformity regardless of where they practice. However, keep in mind that while the application remains the same, the nuances of enrollment can differ based on state regulations and requirements.

  4. A critical aspect that individuals must be aware of is that enrollment in Medicare in one state does not automatically extend coverage to another state. Therefore, if an individual relocates or provides services in another state, they must enroll with Medicare for that particular state. Failure to enroll in Medicare in each state where services are rendered could result in gaps in coverage, leaving individuals vulnerable to unexpected healthcare costs or limited access to essential services. Therefore, understanding the intricacies of Medicare enrollment across state lines is vital for maintaining comprehensive healthcare coverage for patients.

  5. Medicare numbers are linked to tax identification numbers (TINs) or Social Security numbers (SSNs). Each Medicare number is intricately connected to a unique TIN or SSN, reflecting an individual's employment or tax status. Individuals working at several practices will need separate Provider Transaction Access Numbers (PTANs) associated with each workplace. Individuals working in numerous states also have various PTANs to ensure seamless billing and reimbursement processes. One common misconception is that once you have a PTAN, you can use it for each place you provide services. This is incorrect because if you work at Clinic A, that PTAN is attached to Clinic A's Tax ID and group information. If you go to Clinic B and try to bill with the PTAN you got at Clinic A, you will get a denial from Medicare because that PTAN is associated with Clinic A. Remember that provider enrollment is a contract between an individual or clinic and the insurance company. Read more on credentialing and contracting here.

  6. Telehealth providers must enroll with Medicare for every state they render services to. If a provider is based in FL and offering services to GA, VA, and SC states, then they need to enroll with Medicare in FL, GA, VA, and SC states. Medicare applications require a physical address, so the telehealth provider can enter their home address as the physical location if they do not have a brick-and-mortar building. There are other ways to ensure that it's clear you're a telehealth provider when filling out the application. If the provider is a telehealth clinic with multiple individuals across different states the physical address will be the clinic address for each application.

As you can see, even though Medicare applications are on one site for all of the states, there are many nuances that you need to know to ensure you're correctly enrolling with Medicare. Always consult your Medicare rep or a provider enrollment specialist to make sure you are properly and accurately enrolling with Medicare. This will also help the process move along quicker.



Want to know more about Medicare enrollment? Book a free consultation today!




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