Medicare Credentialing Applications

Applying to become a Medicare provider can be a daunting task! First you have to decide which application(s) you need and then work your way through the long application.  Here are a few quick tips that actually apply to any credentialing application you make. I would say they fall into the “essential” category.

  1. If you don’t understand what is being asked for, pick up the phone and call. Medicare, and most other insurance companies are willing to help you.
  2. Dot every single “i” and cross every single “t”.  Any omissions  will prevent your application from moving forward until it’s corrected.
  3. Keep a log of who you have talked to, when and what was said. It will be invaluable later on. (This applies later when you are trying to get paid as well.)
  4. Always…keep a copy of what you have sent in!

I should have started with…get your NPI number first! All applications with all insurance companies now require them.

Comments

  1. says

    Thanks Barb,

    For your weekly wise articles. I agree and every state and specialty is different in what they require. The credentialing process really does need streamlined. It would be great if there was one national software program, that would keep all previous information that applies saved (like from previous employment situations, malpractice for the last 5 years, attestation statements, past employment hx, etc, and if you do change or have a gap or start a new business entity, instead of credentialing yourself, but now you are credentialing for a clinic or corporation, you would only have to add the new information. But until then, it seems we have to start from scratch, if more than a few months have elapsed from previous credentialing. I worked for several months on an hourly wage (the employers consider me an independent contractor, but I was really a non benefitted employee by IRS standards) (that is an other issue), and anyway, those places did not credential me, and since they were temporary, and I knew I wanted to start my own practice, I had to wait, until I got my physical practice location, my practice name, incorporated status, new NPI number and new Tax ID number instead of my ss #, before I could credential. For Oregon, 80% of the insurance carriers require the Oregon Credentialing Application Packet (OCAP), in addition to copies of your license, dea, w9, malpractice. There is also a software program called CAQH, which about 5 companies look at , and then Oregon medicaid and Medicare has their own separate applications. It is quite lengthy. For any state, what ever the form, fill it out, without filling in your signature, initials or date, and then make about 20-30 copies. Then sign and date them, and with a cover letter personalized to each contact person, send out individual packets to each insurance carrier.. Then prepare for waiting, and getting asked for additional information.

    This is a lot of work, but if you start a practice in an area that is affluent, or where most people have insurance, even if you are the ONLY provider in that area, you will need to take insurance or people will drive farther to the next provider. People are paying too much for their insurance these days, to want to pay cash even if the office is nearby. They may come in occly for something that is in the evening or on the weekend and they cannot get anywhere else, but in general, this is what I am learning. So I am still waiting as it has been about a month since I sent in the apps. I did have a recent article come out about my practice opening in the local newspaper, and that at least is letting people know that I am actually in existence. That did generate some calls, so that is good news! Carla

  2. says

    As you know, I am wading through the paperwork right now myself. I’m so glad to be finished with school. Now I can play catch up with my favorite NP bloggers!

  3. bcp says

    Carla,

    Here in WA, we also have a standard application package. I was able to find it in pdf format online where I could just type in my information. Then every time I needed a copy of it, I could put in the specific information for that company, print it out, dot the final “i’s” and sign it before mailing it off. It saved a HUGH amount of time.

    If anyone has that type of form for their state, at the very least, fill out the form for all the standard information and print out copies. Then you can just fill in specific information where required. I started doing this after I filled out a few of these from scratch (though now I have my form on the computer).

    NPs Saves Lives – welcome! You will get through all the paperwork!

    Barbara

  4. says

    Happy Weekend everyone. I finally finished filling out the Medicare papers, (855i)and getting the bank to write on letter head acknowledging that I had an account there. Now my situation is, I was an individual employee before, attached to a group tax id,, now I am considered a “new enrollee” not “re enrollee”, as I am enrolling for the FIRST time as a PC (professional corp) for my clinic Healing Presence. I had to have both my clinic NPI and individual NPI prior to filling out Medicare. In addition, if you want Electronic funds deposit, and you are going to be a participating provider, there are addl 588 and 460 forms to fill out. I asked 6 different people at the Medicare customer service, and was told 6 different answers and that is why it took so long. I wanted to make sure that I did not turn it in, and find glitches. I am still hoping it is right. The Medicare form I tried to type on line but it seemed to be in a hidden excel format, it kept adding and duplicating my words when I clicked on the next line, not working well. So I found a company and just ended up paying 20.00 to a company that was called “EZ Medicare forms” so I could save it, and re type, etc, delete, without error. Medicare customer service said there should not be any scratch outs or errors on the form.. If I were now to go work part time, for an NP or MD owned clinic, then I would need an addl 855R form filled out, and I would get even another Medicare number assigned to that clinic tax id number for billing. As it is, I will end up with 2, one for me as an individual, and one for me as a corporation. I hope to hear more comments from others.

  5. bcp says

    Carla,

    I finally have my paperwork in front of me. It seems like eons ago since I did this. I filled out the following:
    1. CMS 885B
    2. CMS 460 (Participating Agreement)
    3. CMS 588

    You are correct…I had to have one for my LLC and on for myself (group and individual).

    If you want to file electronically directly to CMS, you need a EDI Enrollment Form among other things. Since I am using Office Ally, I didn’t need to do that.

    Something we recently learned, is there is something called Medicare/Medicaid crossover. Medicare will tell you they are sending the bills to Medicaid, but unless you actually sign up for that…it does not happen. I’ve asked her to write more about that for us…so stay tuned.

    Barbara

  6. bcp says

    Hi Eve,

    You can find the standardized forms for WA State in both word and pdf at http://www.wamss.org/02Tools.html.

    Download a copy and add your information. You can print out the entire thing each time you have an application you are sending in. You’ll just need to sign it after filling out the attestation page (which you sign as well). The word doc form is about 13 pages.

    Hope this helps.

    Barbara

  7. says

    Hi Barb,

    For Oregon,

    I filled out an 855i
    460
    588
    and an electronic filing agreement with a letter from the bank. I called 7 customer service agents and got seven different answers about areas on the form, because I was previously credentialed as an employee for someone else before, and now I am filing as a different business entity. But you are right. You have to give your personal npi, your clinic npi, your clinic tax id number, and then eventually I should get a Medicare number for myself, a separate one for the clinic that will attach to my clinic tax id for billing, and then if I work for another provider, which I am doing, I will have to fill out an 855b to have a different Medicare billing number attached to that organization. It does seem as if you should have just one NPI that attaches to the different tax id numbers of all of the different places you work, but they still have it more complicated. I also was able to find a site that I paid 20.00 for, but it allowed the documents to be re saved, and typed on line, instead of printed and hand written. When you try to type on the original Medicare Noridian Website application, things get deleted, and it does not work well at all. With that one you just have to print it off and hand write it.

    I notice you said you filled out an 855b? I was told repeatedly that I had to fill out an 855i as a nurse practitioner, that was starting a “new business entity”, so I had to fill out the “individual form”… I will call Monday now that I am getting a chance to catch up on the insurances, and see what the status is.

  8. Kris Todd says

    Hello ladies!
    I have just found this site and read through your notes on Medicare. I opened an osteoporosis clinic in December 2006. After filling out all forms and receiving 2 NPI numbers I was finally recognized and able to start billing in May. Guess what, there was a glitch in their system(or mine) and all my bills needed to be resubmitted as 2 numbers were in the wrong box. I have finally started to receive reimbursement 10 months after opening.
    I hope that you have a much better response than I did! I am hoping to learn from others as there is only one other NP clinic in my community.
    Thanks for any info!
    Kris

  9. Sherry Kent says

    I have submitted all of my medicare forms a few weeks ago. I was told it may take some time to get a response back from them. Is it any faster if you had a previous Medicare number from working with someone else. OR does that not really make any difference. I was told I could back bill once it all goes through as long as the date I put for opening on the application was before then. Anyone know if this is correct.

  10. says

    Hi Sherry

    Yes, if you see a patient on a certain date that your practice is open, and Medicare makes your contract retroactive to that date, then even if it was 4 months prior, you can submit your claim and they will pay it. Just remember that Medicare does not pay for preventative codes like 99386 etc, unless they are brand new to Medicare and it is part of their “Welcome to Medicare” benefit. I made this mistake, for an “annual exam” for a 72 yr old female who transferred care to me, and I had just opened, and spent an hour with this patient, and Medicare paid zero. I should have charged a 99204 as an office visit, as she did have health concerns. Just look up all of the coding exceptions, for screening as well. Carla

  11. Cecelia says

    Hello,

    What can we do in effort to keep our patients when we accept medicare. In Virginia, medicare patients eventually are changed to a PPO. This poses a problem. The PPO’s here will not credential NP’s. Catch 22 or what? There must be something I can do.

    The only insurance thus far that has agreed to credential me as an NP is Medicare, Medicaid and Tricare.

    Any suggestions. I do plan to offer flat fee. But really need a suggestion on how to get credentialed. Does anyone have a good template for a reconcideration letter?

    Thanks,
    Cecelia
    clrk4@aol.com

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