LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2012-03 855-O Medicare Enrollment Application Ordering and Referring Physicians

Jurisdiction 11 Part B

855-O Medicare Enrollment Application Ordering and Referring Physicians or Other Eligible Professionals

MLN Matters® Number: SE1208 Related Change Request (CR) #: N/A Related CR Release Date: N/A Effective Date: N/A Related CR Transmittal #: N/A Implementation Date: N/A

  • Provider Types Affected
    This MLN Matters® Special Edition article is intended for physicians and eligible professionals who may need to enroll/register in the Medicare Program for the sole purpose of ordering or referring Medicare-covered items and services to Medicare beneficiaries.
  • What You Need to Know
    The Affordable Care Act, Section 6405, ‘Physicians Who Order Items or Services Required to be Medicare Enrolled Physicians or Eligible Professionals,’ requires physicians or other eligible professionals to be enrolled in the Medicare Program in order to order or refer items or services for Medicare beneficiaries. Some physicians or other eligible professionals do not and will not send claims to a Medicare Contractor for the services they furnish and therefore may not be enrolled in the Medicare program. The Centers for Medicare & Medicaid Services (CMS) permits such physicians or other eligible professionals to enroll in the Medicare program for the sole purpose of ordering or referring items or services for Medicare beneficiaries. The submission and approval of a completed CMS-855O form or its Internet-based Provider Enrollment, Chain and Ownership System (PECOS) equivalent will register/enroll the physician or other eligible professional in the Medicare Program for the sole purpose of ordering and referring specific services for Medicare beneficiaries.
  • Background
    Most physicians or other eligible professionals enroll in the Medicare program to be reimbursed for the covered services they furnish to Medicare beneficiaries. However, with the implementation of Section 6405 of the Affordable Care Act, CMS permits certain physicians or other eligible professionals to enroll in the Medicare program for the sole purpose of ordering or referring items or services for Medicare beneficiaries. These physicians or other eligible professionals do not and will not send claims to a Medicare contractor for the services they furnish. The physicians or other eligible professionals who may wish to enroll in Medicare solely for the purpose of ordering and referring include, but are not limited to, those who are:
    Employed by the Department of Veterans Affairs (DVA)
    Employed by Federally Qualified Health Affairs Centers (FQHCs), Rural Health Clinics (RHCs)
    Employed by the Public Health Service (PHS) or Critical Access Hospitals (CAHs)
    Employed by the Department of Defense DOD) TRICARE
    Licensed residents and physicians in a fellowship
    Dentists, including oral surgeons
    Employed by IHS or tribal organizations
    Pediatricians
  • Physicians or other eligible professionals can apply for enrollment for the sole purpose of ordering and referring items and/or services to Medicare beneficiaries using either:
    The Internet-based PECOS
    The paper enrollment application process (CMS-855O). The CMS-855O is available at www.cms.gov/cmsforms/downloads/CMS855O.pdf on the CMS Web site.
    For additional information regarding the Medicare enrollment process, including Internet-based PECOS, go to www.cms.gov/MedicareProviderSupEnroll on the CMS Web site.
  • Note: You must obtain a National Provider Identifier (NPI) prior to enrolling in Medicare. Your NPI is a required field on your enrollment application. Applying for the NPI is a separate process from Medicare enrollment. To obtain an NPI, you may apply online at https://NPPES.cms.hhs.gov on the CMS Web site. For more information about NPI enumeration, visit www.cms.gov/NationalProvIdentStand on the CMS Web site.
  • Additional Information
    For additional information about the Medicare enrollment process, including Internet-based PECOS, go to www.cms.gov/MedicareProviderSupEnroll on the CMS Web site.
  • The CMS-855O is available at www.cms.gov/cmsforms/downloads/CMS855O.pdf on the CMS Web site and the next of page of this article contains an image of that form. An updated version of the CMS-855O will be available and implemented in April 2012.
  • The Medicare Learning Network® fact sheet titled ‘Medicare Enrollment Guidelines for Ordering/Referring Providers’ provides information about the requirements for eligible ordering/referring providers and is available at www.cms.gov/MLNProducts/downloads/MedEnroll_OrderReferProv_FactSheet_ICN906223.pdf on the CMS Web site.
  • Disclaimer
    This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2011 American Medical Association.

last updated on 03/09/2012