Medicare Credentialing

Medicare credentialing is a complex process and is a very difficult task for most practices, doing it for the first time. It is very important that practices know the intricacies of Medicare credentialing, if they plan to do the credentialing themselves. For most practices, the majority of their reimbursements are from Medicare, also most insurances follow the same processes as Medicare. A proper understanding of Medicare's credentialing process is crucial to the success of every practice.

For most physician practices, Medicare requires three (3) basic applications which make up the 855 series,

1. 855I – Create or reactivate a physician’s individual number

This Medicare form is used to obtain a physician’s individual Medicare number from each state’s supplier. The physician must submit a copy of the medical school diploma and NPI letter with the individual NPI number with this form. Medicare requires an 855I application if any changes are made to the physician’s file. Also, Medicare will deactivate a Medicare number and require an 855I reactivation if a significant lapse occurs in billing or if no claims are submitted to the number issued.

2. 855B – Create or change a practice's group number

This Medicare application is used to obtain a group number for billing purposes. The physician must submit a copy of the IRS letter with this form. Groups already participating with Medicare use the form to make changes to physician listings, such as practice ownership, phone number, address, NPI group numbers, etc. You will be required to complete an 855B form if you make any changes to your practice, such as add a new physician for billing, change address, change billing, etc.

Ensure that the practice name, bank account details, contact person details are filled in accurately. Errors will delay the acceptance of your application.

3. 855R – Links the physician’s individual number to the group number

This Medicare form is used to reassign the benefits of the physician to the group. The group’s authorized official signs the form in addition to the individual being linked to the group. When reassigning the benefits of a physician to a group you may submit the 855R and 855I together if the provider's Medicare number needs to be reactivated e.t.c.

If the Medicare application is incomplete or incorrect, the Medicare process can take more time and in some cases the process can take about six months for approval.

Some points to note in the Medicare credentialing process,

• When reactivating physician billing privileges, the effective date will now be the later of either the date of filing the Medicare enrollment application (date stamped by Medicare), or the date the physician first began providing services at the new practice location
• When submitting the Medicare forms to a Medicare intermediary, ensure that the practice name is exactly as it appears on the Bank account, the IRS letter and the NPI letter

The Medicare credentialing process though complex can be managed by ensuring that the credentialing information on the 855 forms is accurate and consistent, so that Medicare is able to process the credentialing application without delay.