Medicare (Novitas Solutions)

Core Requirements and Processes:

1. National Provider Identifier (NPI): You must have a valid NPI. You can apply for one through the National Plan and Provider Enumeration System (NPPES) website.  
2. Medicare Enrollment Application: You need to complete the appropriate Medicare enrollment application form https://www.cms.gov/medicare/forms-notices/cms-forms-list. The most common forms are:  
   • CMS-855I: For physicians and non-physician practitioners.  
   • CMS-855B: For clinics, group practices, and other suppliers (e.g., ambulance companies, Independent Diagnostic Testing Facilities – IDTFs).  
   • CMS-855A: For institutional providers (e.g., hospitals, Skilled Nursing Facilities – SNFs).  
   • CMS-855O: For ordering and certifying physicians and other eligible professionals who do not bill Medicare for their services.  

You can complete these applications either:

1. • Online via PECOS (Provider Enrollment, Chain and Ownership System): This is the preferred and generally faster method. You’ll need an Identity & Access Management (I&A) System user account to access PECOS.  

https://pecos.cms.hhs.gov/pecos/login.do#headingLv1

• • Paper Application: Download the relevant CMS-855 form from the CMS website or the Novitas Solutions website, complete it, and submit it with all required supporting documentation. You can upload the completed paper application and supporting documents through the Provider Enrollment Gateway on the Novitas Solutions website or mail them directly to Novitas Solutions.  

3. Supporting Documentation: You must submit various documents along with your enrollment application, which may include:

• • Texas State License: A copy of your current and unrestricted Texas professional license.
  • DEA and Texas CDS Certificates (if applicable): Copies of your valid Drug Enforcement Administration (DEA) and Texas Controlled Dangerous Substances (CDS) certificates if you prescribe controlled substances.
  • Professional Liability Insurance: Proof of current coverage meeting Medicare requirements.
  • Board Certifications: Copies of relevant board certifications.
  • Education and Training: Documentation of your medical or professional education and training (e.g., diplomas, residency certificates).  
  • Tax Identification Number (TIN) and Legal Business Name Verification: IRS documentation (e.g., CP575) confirming your TIN and legal business name.  
  • Electronic Funds Transfer (EFT) Information: Completed CMS-588 form with a voided check or bank letter.  
  • Medicare Participation Agreement (CMS-460): Required for initial enrollment or reactivation if you want to be a participating provider.  
  • Adverse Legal Action Documentation (if applicable): Copies of any final adverse legal action documentation and resolutions.  
  • Business Licenses: Federal, state, and/or local business licenses, certifications, or registrations required to operate your healthcare facility.
  • For Organizations: Corporate documents, ownership information, etc.

4. Practice Location Information: You must provide the physical address(es) where you render services to Medicare beneficiaries. P.O. boxes, commercial mailboxes, or drop boxes are not acceptable as practice locations.  

5. Reassignment of Benefits (if applicable): If you plan to reassign your Medicare benefits to a group or organization, you must complete the relevant sections of the CMS-855I or CMS-855B form and provide information about the entity receiving the reassignment.

6. Attestation and Signature: You must sign and date the application (handwritten or eligible digital signature). The individual practitioner cannot delegate the authority to sign their own enrollment application.

7. Payment of Application Fee (if applicable): Certain provider and supplier types may be required to pay an application fee. You can pay this fee online through PECOS or the CMS Paper Application portal.  

Key Considerations:

• PECOS is Encouraged: CMS and Novitas Solutions strongly encourage using PECOS for enrollment as it can expedite the process.  
• Accuracy is Crucial: Ensure all information provided is accurate and complete to avoid delays or denials.
• Timeliness of Updates: You must report any changes to your enrollment information (e.g., change of address, ownership, adverse legal actions) to Novitas Solutions within specific timeframes (typically 30-90 days). This can be done through PECOS if you enrolled online or by submitting a new application or relevant updates if you used a paper application.  
• Revalidation: Medicare providers must revalidate their enrollment periodically (usually every five years, but potentially more frequently based on risk). Novitas Solutions will notify you when it’s time to revalidate.  
• State Licensure: Maintaining a current and valid Texas license is an ongoing requirement for Medicare participation.
• Provider Enrollment Gateway: This tool on the Novitas Solutions website allows you to upload paper applications, submit responses to development requests, and check the status of applications submitted through the gateway.  
• Medicare Learning Network (MLN): CMS offers various educational resources through the MLN to help providers understand Medicare enrollment requirements.

Summary Table: Medicare (Novitas Solutions) Credentialing Steps in Texas