Jogaza Credentialing

Medicare enrollment for nurse practitioners: PECOS, the 855I and your group

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Short answer

  • Nurse practitioners enroll on the CMS-855I, and a group practice on the CMS-855B, usually online in PECOS. Neither pays a Medicare application fee.
  • The CMS-855R has been discontinued. Reassigning your Medicare payments to your group is now done on the 855I itself.
  • Billing can start from the date you file an application that gets approved, and up to 30 days before that if circumstances kept you from enrolling earlier. Apply before you see Medicare patients.

Which forms you need

  • CMS-855I: for physicians and non-physician practitioners, including NPs. It enrolls you, and it now also handles reassigning your benefits to a group.
  • CMS-855B: for clinics, group practices and certain other suppliers. Your LLC enrolls on this under its Type 2 NPI and EIN.
  • CMS-855O: only for clinicians who want to order and certify (labs, imaging, equipment) without billing Medicare. Most NPs in practice need the 855I instead.

If you've read older advice about filing a CMS-855R for reassignment: the current 855I says "All reassignment actions should now be reported via the CMS-855I. The CMS-855R (Reassignment of Medicare Benefits) form has been discontinued."

If you bill through your own LLC

Most NPs who own a practice want Medicare to pay the LLC, not them personally. That takes three things, which can go in together:

  1. The group enrolls on the 855B (Type 2 NPI, EIN, practice location).
  2. You enroll on the 855I (Type 1 NPI, license, practice location).
  3. You reassign your benefits to the group in the reassignment section of the 855I. You sign Section 15B, and the group's authorized or delegated official signs Section 15C. The group usually submits it.

CMS requires both you and the group to be enrolled, or enrolling at the same time, before the reassignment takes effect. If you reassign all of your benefits to the group, you skip some private-practice sections of the 855I.

Getting into PECOS: I&A access

PECOS uses CMS's Identity & Access Management system (I&A) for logins. Before anyone can file for a group online, someone has to be approved as the organization's Authorized Official in I&A, and anyone helping you (a biller or credentialing company) connects to your record as a surrogate, which you approve in your own I&A account. Never share your login.

  • The Authorized Official request asks for proof of the organization's EIN, such as the IRS CP 575 letter. The legal name must match the IRS record.
  • CMS's External User Services (EUS) team may also verify employment: someone who can vouch for you calls EUS with your ticket number, their name and your job title. For a one-person business, CMS accepts a relative, spouse or friend.
  • Answer EUS emails quickly. They're marked time sensitive, and the approval waits until they hear back.

Fees, dates and renewals

  • No application fee: CMS's fee table lists "No" for physicians, non-physician practitioners and clinic/group practices, for initial enrollment and revalidation.
  • Effective date: the later of the date you filed an application that was approved, or the date you first saw patients at the new location (42 CFR 424.520(d)).
  • Billing back: up to 30 days before the effective date if circumstances kept you from enrolling in advance, or 90 days after a presidentially declared disaster (42 CFR 424.521(a)). Anything earlier isn't payable.
  • Revalidation: every 5 years, when CMS sends notice. Keep your PECOS record current between revalidations: new addresses, tax IDs and reassignments are reported on the same forms.
  • PECOS vs. paper: CMS says online applications tend to process faster than paper ones.

Medicare Advantage comes after

Many Medicare Advantage plans want your Medicare enrollment done first. Humana, for example, takes Medicare Advantage as a separate request after Medicare is approved. See the Humana guide and how long credentialing takes.