How to Get a Medicare Provider Number: A Step-by-Step Guide

There is great diversity and complexity in the healthcare landscape. Most healthcare providers have to face multiple challenges in serving patients linked to Medicare. They obtain the Medicare Provider number to bill Medicare for services provided to those eligible beneficiaries. However, if you want to know more about how to get a Medicare Provider number then here you can get the complete step-by-step guide. So if you want to know more then read this article thoroughly and get answers to all your related questions. 

What is Medicare?

Medicare is a federal health insurance program for US individuals who are younger or have the age of 65 or more and obtain disability benefits. This program covers a broad range of services that play a vital role in making you healthy as your age progresses. 

There are four different parts of Medicare which offer different types of health coverage. Moreover, there is also a diversity in their cost. 

Part A:  Hospital insurance

This type pays for hospital care, skilled nursing facilities and related services. The funding process of part A is controlled by the payroll tax (FICA) which is then deposited into the Hospital Insurance Trust Fund.

Part A comprises the healthcare at home and hospice care for those individuals who are terminally ill. 

Part B: Medical Insurance

This part pays for those things that are not covered by part A such as outpatient hospital care, home health and doctor visits. Part B also covers the following:

• Mental health care
• Ambulance services
• Medical equipment
• Diagnostic, screening or lab tests 

The funding of Part B is done by the Part B premiums. 

Part C: Medicare Advantage plans

This is offered by private insurers and cover the same benefits of both part A and B. If you have enrollment in part C, then you will receive your healthcare services through the private plan. 

Part D: Prescription drug coverage

This part pays for the prescription drugs. Private drug plans which are approved by Medicare are offered by part D. Moreover, this is funded by the state payments, general revenues from the federal government and premiums you pay. 

Who is eligible for Medicare?

The eligibility for Medicare is based on the following factors:

• US citizenship
• Age of 65 or more
• Younger age with having a disability

However, those individuals who obtain the Social Security Disability Insurance (SSDI) acquire the eligibility after waiting for two years. 

What is Original Medicare and how it works?

Original Medicare is also referred to as traditional Medicare. This includes both hospital insurance and medical insurance. It employs based on a fee-for-service. Without the referral, beneficiaries can select any healthcare provider or doctor who accepts the Medicare program. 

What is the Medicare provider number?

Medicare provider number is a specific identification code that is issued to those healthcare providers who have participated in Medicare. Centre for Medicare & Medicaid Services (CMS) assigns the provider number. 

Medicare provider number exhibits great significance as it assists the providers in billing and then obtaining the payments for the services provided to the Medicare beneficiaries. 

Medicare number is also utilized for the eligibility verification and the tracking of healthcare claims. Moreover, this is also useful to deal with abuse and fraud in the system.

How Providers can obtain the Medicare Provider number?

Providers can only obtain the Medicare provider number if they meet certain standards or qualifications such as certificates and licenses linked with a speciality.

After getting the provider number, providers keep them throughout their whole career. However, if any changes occur in the location of practice or employment, then this must be immediately reported to the CMS. 

Why do healthcare providers need a Medicare provider number?

Healthcare providers require the Medicare provider number for multiple aspects which include billing, patient care as well as compliance. 

Direct billing to Medicare:

By using the Medicare provider number, healthcare providers can directly bill Medicare for the services provided to those eligible beneficiaries. With this benefit, healthcare providers can obtain their payments on time without any delay.

Enhanced revenue:

The Medicare provider number gives healthcare providers access to Medicare’s reimbursement process which is robust and ensures feasibility and accuracy. Their better efficiency as compared to other payment methods results in an improved stream of revenue. 

Patient care

Most of the patients have a strong association with Medicare for their healthcare coverage. These healthcare providers who have Medicare provider numbers can gain the attention of more patients for their services.

Exceptional patient outcomes 

Although healthcare providers are professional and skilled, they can also learn and develop more improved strategies by communicating with each other. They can develop personalized plans regarding the diagnosis, medication management and treatment. This ultimately results in enhanced outcomes for patients. 

Compliance: 

Eligibility verification

Compliance with federal rules and regulations is extremely significant for various reasons. The Medicare provider number is involved in the verification of healthcare providers regarding their certification with Medicare. This verification results the compliance. 

Prevention of fraud

The Medicare provider number can also prevent fraud within the Medicare system by:

• Tracking the healthcare claims
• Eligibility verification of providers

Reduced administrative burden

Healthcare providers can also streamline their billing process and make it more efficient with the help of Medicare numbers. This not only results in a reduction in errors but also elevates the rate of reimbursements.

Who can apply for a Medicare provider number?

Different healthcare providers exhibit eligibility to get Medicare provider which includes:

Individual Healthcare Practitioners

• Physicians
• Clinical Psychologists
• Nurse Practitioners
• Physician Assistants 
• Clinical Social Workers

Organizations

• Hospitals 
• Clinics 
• Group practices 
• Skilled nursing facilities
• Home Health agencies 

What is a National Provider Identifier?

A national provider identifier is a unique identification number that healthcare providers obtain to apply for the Medicare provider number. 

Step-by-Step Process to Obtain a Medicare Provider Number

The process of getting the Medicare provider number comprises the following steps:

Get a National Provider Identifier (NPI)

The first step to obtain the medicare provider number involves getting the NPI. With the help of the National Plan & Provider Enumeration System (NPPES), you can apply to get the NPI number. Another way to apply for the NPI is by completing the NPI application or update form and sending it via email. If you already have the NPI number then there is no need for application.

Complete the Medicare enrollment application

PECOCS, the Medicare enrollment system is used to complete the application form. This enrollment system is typically online and does not involve any paperwork. PECOS also have multiple videos and print tutorials that provide a guide on how you can complete the application step.

Online PECOS Application

All the supporting documents are submitted with PECOS. However, the following instructions must be considered:

• First log in to PECOS online system. 
• If you have already an account then continue with it. Otherwise, you can also create a new account for your application.
• PECOS will determine the complete scenario of your enrollment. Then, you will get the topics for your application submission. 
• After you submit the entire information, PECOS will confirm whether your data process is complete or not. Other responsibilities of PECOS are as follows:
• Providing the option to electronically sign & certify
• Listing of MAC documents to submit and then review
• Displays your mailing address and MAC’s name
• Allows you to print your application to keep the records
• Sending of application to your MAC electronically
• Sending the emails for confirmation that MAC got your application

Respond to your Medicare Administrative Contractor (MAC) requests

If you want to process your application then show your response by providing the additional information requested by the MAC. The duration of response should be around 30 days.  

Keep your information updated

The enrollment information should be updated to prevent any errors or issues. By the use of PECOS, you can report the following changes to your enrollment:

• A change in practice location
• A change in ownership
• A severe legal action

The reporting time for all the above changes is 30 days. However, other changes should be reported within 90 days. 

Check the status of the application

After applying, you can also check the status of your application. Moreover, you can also get answers to your queries. 

What are the common challenges and solutions in getting the Medicare Provider number?

Obtaining the Medicare provider number is an essential but complex process. Many healthcare providers encounter multiple challenges in getting the Medicare provider number. Fortunately, certain solutions are useful in preventing them:

Challenge: Incomplete applications

If there is navigation difficulty in provider enrollment, PECOCS and chain then it can result in the processing difficulty in the application and can result in multiple errors. 

Solution:

To prevent this complexity, you should have a complete awareness of the PECOS interface. You can get complete guidance with the help of videos and tutorials or answers to queries present on the CMS website. 

Challenge: Issues in Eligibility verification

Healthcare providers also have to struggle with their eligibility verification for Medicare enrollment. They get into more difficulty when they do not have the National Provider Identifier (NPI).

Solution: 

The best way to deal with this challenge is to make sure that you have the NPI before starting the enrollment process. Other ways include:

• Use of the NPPES website for the NPI application
• Double checking with MAC for eligibility status

Challenge: Claim denials

The inaccurate linking of the provider number with provided services can result the denials or rejection of claims.

Solution:

The provided information should be accurate and records should be maintained in an appropriate manner. The updating of information should also be performed on a regular basis to prevent denials.

Challenge: Incomplete applications

The enrollment process can also get delayed due to the submission of incomplete information or any other error.

Solution:

The best solution to prevent delays is to make a complete and accurate review process. Moreover, the number of documents should be complete.

How to update or change your Medicare provider number?

If you want to make changes to your Medicare provider number, you can use the online system of PECOS or CMS-855A.

PECOS

For information updates and review, first log in to the online Medicare enrollment system. PECOS is also used for the following purposes:

• Reassignment
• Withdraw from Medicare

CMS-855A form

First, download the form and complete the section 1A. Then in section 1B, check all the boxes. If there is any supporting document is required then you can also add them. 

NPPES Login

You can also update your record of NPI by logging into the NPPES. 

Concluding thoughts

There is a great requirement and significance of obtaining the Medicare provider number by healthcare providers who want to bill Medicare for their healthcare services. Obtaining the Medicare provider number is important in different ways. It is not only beneficial for billing but also helps in generating a significant amount of revenue with improved attention of patients towards the services. However, if you want to prevent the rejections and denials then you have to make sure that each step is accurate to prevent the denials and rejections. 

Furthermore, if you want to upgrade your healthcare practice then you can reach out to Medstar billing services. Outsource medical billing, behavioural billing and dental billing services to us and streamline your billing process to generate significant revenue. 

Frequently asked questions

What is the cost to obtain a Medicare provider number?

The cost for getting the Medicare provider number is  $709. 

How long does it take to receive a Medicare provider number?

Medicare typically completes enrollment applications in 60–90 days, but the turnaround time can vary by state and intermediary. 

Can I apply for a Medicare provider number online?

You can apply for a Medicare provider number online via PECOS, Chain and Provider Enrollment.

What should I do if I lose my Medicare provider number?

If you lose your Medicare provider number then don’t worry as you can retrieve it. Simply contact the Medicare & Medicaid Services (CMS) for replacements or other changes. 

Are the Medication provider number and NPI the same?

Yes. NPI is required for doing business with Medicare and can be obtained online via the NPPES website.  However, NPI is not a Medicare provider number. 

How many numbers are present in the Medicare provider number?

Six digits are present in the Medicare provider number.