Medicare providers serve Medicare beneficiaries and are paid for their services by Medicare instead of by the individuals. Medicare approves a variety of individual practitioners, agencies and facilities to provide high-quality care to Medicare recipients. Medicare credentialing standards vary depending on the type of services you are providing.
TL;DR (Too Long; Didn't Read)
Credentialing is the process of approving a physician, agency or other medical provider as part of the Medicare supply chain.
Becoming a Medicare Provider
If you want to serve patients with Medicare, it is not as simple as opening your doors to them. You must meet Medicare credentialing standards and go through the enrollment application process. The general steps for being considered in-network for Medicare patients are as follows:
- Obtain a National Provider Identifier (NPI) by applying on the National Plan and Provider Enumeration System Website.
- Complete a Medicare enrollment application CMS-855I through the Provider Enrollment, Chain and Ownership System (PCOS).
- Select a specialty, when applicable. For instance, psychologists select either "clinical psychologist" or "independently practicing psychologist" as their specialty.
Once you submit all of your paperwork, expect it to take two to three months for your application to be reviewed and either accepted or denied. Once you are an approved Medicare provider, you will be able to bill retroactively for all services provided during the waiting period.
Medicare Credentialing Requirements
Medicare will require you to meet all of the credentialing and licensing requirements of your field. As such, be prepared to provide the following documentation as part of the application process:
- Tax records
- Proof of malpractice insurance
- Practitioner licenses
- Board certifications
- Federal and state CDS certificates
- Current CV using a month and year format
- Proof of identification
Your specific credentialing requirements will depend upon your field of practice, but will be in line with state and federal requirements for your profession.
Maintaining Medicare Credentials
Once you meet Medicare credentialing standards and have been approved as a provider, you need to keep up your credentials. Every three years, you will need to resubmit the Medicare enrollment application CMS-855I.
You can also complete the revalidation online by using the PECOS system, which can be more convenient and speed up the process. If you are a group practice, the process is very similar, but you will utilize form CMS-855B.
Physician and Non-Physician Medicare Providers
You do not have to be a physician in order to be approved as a Medicare provider. Both physicians and non-physician practitioners are included in the Medicare system. If you are part of an unlicensed profession, you will simply check a box on the application that indicates a license is not required.
The same applies for certifications. If you are a board-certified physician or a professional certified by an organization, you can include that information in your application. If certifications are not available, simply check the box indicating this is the case.
Non-physician practitioners supported in the Medicare system include these professions and more:
- Anesthesiology assistants
- Certified nurse midwives
- Certified registered nurse anesthetists
- Certified clinical nurse specialists
- Clinical social workers
- Nurse practitioners
- Occupational therapists
- Speech-language pathologists
- Registered dietitians
- Physical therapists
Billing Through Medicare
Once you are credentialed through Medicare, you must ensure that you bill accurately for every Medicare patient you serve. Electronic claims are simple to file from your computer and are delivered directly to the Medicare Administrative Contractor. If claims do not meet HIPAA standards, they might be rejected and need to be resubmitted. After three levels of edits, Medicare claims are either accepted or rejected.
Medicare claims can involve a lot of time and effort, including time required to resubmit claims, and finding the right claims procedures for your specialty can involve trial and error. Some people hire outside services to help simplify this process, as they already have a wealth of experience about the fastest way to have claims approved without rejections.
- Centers for Medicare and Medicaid Services:Medicare Enrollment Application - Physicians and Non-Physician Practitioners
- American Psychological Association: Applying to Become a Medicare Provider
- Medicare.gov: Chiropractic Services
- National Plan and Provider Enumeration System: Identity and Access Management System
- National Credentialing: About Credentialing and Enrollment
- CMS.gov: Electronic Health Care Claims
- IRS. "Topic No. 751 Social Security and Medicare Withholding Rates." Accessed July 17, 2020.
- Medicare.gov. "Medicare Costs at a Glance." Accessed July 17, 2020.
- Medicare.gov. "Get Started With Medicare." Accessed July 17, 2020.
- Medicare.gov. "Medicare Advantage Plans." Accessed July 17, 2020.
- Medicare.gov. "Drug Coverage (Part D)." Accessed July 17, 2020.
- AARP. "Medicare Eligibility: Do You Qualify?" Accessed July 17, 2020.
- Medicare.gov. "What's Medicare Supplement Insurance (Medigap)?" Accessed July 17, 2020.
- U.S. Department of Health and Human Services. "What Is the Difference Between Medicare and Medicaid?" Accessed July 17, 2020.
- Medicare.gov. "Medicare and Medicaid," Pages 3–4. Accessed July 17, 2020.
Anne Kinsey is an entrepreneur and business pioneer, who has ranked in the top 1% of the direct sales industry, growing a large team and earning the title of Senior Team Manager during her time with Jamberry. She is the nonprofit founder and executive director of Love Powered Life, as well as a Certified Trauma Recovery Coach, certified HRV biofeedback practitioner and freelance writer who has written for publications like Working Mother, the San Francisco Chronicle, the Houston Chronicle and Our Everyday Life. Anne works from her home office in rural North Carolina, where she resides with her husband and three children.