Before enrolling as a provider or supplier with the Medicare program, a PT must obtain their National Provider Identifier, or NPI. The NPI is the professional identifier for all categories of healthcare providers and suppliers, including PTs. The application process is free and typically takes 20-30 minutes to complete. The NPI will replace all previous billing numbers, including the Medicare UPIN and private insurer billing numbers.

The National Plan and Provider Enumeration System, or NPPES, was developed by, and is now maintained, by the Centers for Medicare & Medicaid Services. The system is a central repository for managing all issues regarding the application, designation, and use of an NPI.

If you forget your NPI or don't know if you already have one, check existing NPI records on the NPPES NPI Registry. You can search by provider name, taxonomy description, organization name (for institutional NPIs), or their authorized officials; you do not need an NPI to locate a provider, although users are able to search by NPI if they need to.

If you are still unsure, contact NPPES. Currently, the listed phone number is 1-800-465-3203, but NPPES directs that questions can also be emailed to customerservice@npienumerator.com.

The NPI does not change or expire; however, you must update your information in NPPES if your contact or practice information changes. For instance, you must update your information in NPPES when your name, address, taxonomy, or other application information is modified.

More information about the NPI can be found at https://www.apta.org/npi. 

Providers enroll in the Medicare Program in order to receive payment for providing covered services to Medicare patients. The only reason a PT would not enroll in Medicare is if they are not providing covered services to Medicare patients.

If you already have your NPI, you should enroll as an initial applicant in the Medicare program in the following circumstances: (1) you have never been enrolled in the Medicare program before; (2) you are enrolling in a new geographic jurisdiction; or (3) you are seeking to reestablish yourself in the program after a voluntary withdrawal or following termination or revocation of enrollment.

To enroll as an initial applicant, you must identify the appropriate application — this can be accomplished online or via paper enrollment:

• Online Application:
  • Provider Enrollment, Chain and Ownership System, or PECOS; see below for additional information on PECOS. Submitting online through PECOS does require submission of a signed certification statement, described in further detail below.
• Paper Enrollment Application:
• PTs Employed in Private Practice. If you are a PT working in a Physical Therapist Private Practice, or a PTPP, (including as the owner), fill out the CMS-855I- Medicare Enrollment Application for Physicians and Non-Physician Practitioners.
• Group Practices and Clinics. If you are an organization such as a Physical Therapist Private Practice, fill out the CMS-855B-Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers.  
• Note: If you are filling out CMS-855I and CMS-855B at the same time, use "pending" as the business number. 
• PTs Operating as Sole Proprietors. Some PTs operate small, solo private practices as incorporated entities. Sole proprietorships, however, are not required to enroll in Medicare as an organization, meaning they fill out the CMS-855I-Medicare Enrollment Application for Physicians and Non-Physician Practitioners.
• If you are a CORF, Rehab Agency, or other institutional providers, fill out CMS-855A- Medicare Enrollment Application for Institutional Providers.   

Citation(s): Medicare Program Integrity Manual, Chapter 10, Sec. 10.1.4; 10.2.1.1, 10.2.3.10.

Your "location name" is the name of your business. You would use your home address as the practice location address. 

Requests for enrollment packages can be made to the individual Medicare contractors by telephone. CMS also has the forms available online.  

PTs in Private Practice, or PTPPs, are considered suppliers, as are other physicians and group practices/clinics. Comparatively, entities such as rehab agencies, hospitals, CORFs, etc., are termed "providers."

PECOS stands for Provider Enrollment, Chain, and Ownership System. It allows physicians, nonphysician practitioners, and providers to manage their Medicare enrollment online instead of via paper forms. Providers can enroll, make changes to their enrollment status, or view enrollment information on file with Medicare through PECOS.

Additionally, the system allows you to check the status of your pending enrollment application. Physicians and nonphysician practitioners who are DMEPOS suppliers may access PECOS using their login credentials established through the NPPES for NPIs or the PECOS Identity & Access Management, or I&A, System.

If you do not have a user ID and password, visit PECOS and select "Register for a User Account" under the "Become a Registered User" header. This will direct you to the PECOS I&A System registration page. 

For additional information, visit the PECOS Medicare Enrollment for Providers & Suppliers page.

There are two main advantages of completing the application online. First, by completing the application online, you are guided through the application with scenario-driven questions. In other words, certain responses automatically skip inapplicable questions and direct users to the next applicable question. This eliminates the need to weed through the paper form and determine which questions apply to you.

Second, CMS estimates that the online system reduces its application processing time by approximately 50%. CMS officials have stated that once the contractor receives a complete application through PECOS (along with the mailed-in two-page certification statement), it takes, on average, 25 days to approve an application. Visit your Medicare Administrative Contractor's website for average processing timeframes for paper versus online applications.

Yes, applicants must submit a two-page certification statement as part of their application. The Certification Statement can be found in Section 15 of the CMS-855I form. Medicare contractors will not process internet-based enrollment applications without the signed and dated Certification Statement. 

The original Certification Statement must be signed by the provider and mailed to the Medicare contractor within 15 days of electronic submission. The effective date of filing an enrollment application is the date the Medicare contractor receives the signed and dated Certification Statement.

Citation: Medicare Program Integrity Manual, Chapter 10, Sec. 10.2.3.10

The answer is setting dependent. All therapists working in a PTPP setting who bill Medicare are required to enroll using the 855I application to receive Medicare payment for services rendered. For all other treatment settings, the facility has a provider number, and the therapist's services are billed under that provider number, making the 855I unnecessary. A PT may bill for the services of a properly supervised PTA under the PT's provider number.  

Please note that on both the 855B and 855I forms, the effective date is the later of the date your license/certification was issued or the date you started with the practice. Additionally, whenever additional information is added and/or changes are made in the certification section of either the 855I and 855B, certification is updated from that date forward.

Citation: Medicare Program Integrity Manual, Chapter 10, Sec.. 10.1.4 

• CMS-460-Medicare Participating Physician or Supplier Agreement 
• This agreement establishes that the Medicare provider/supplier accepts assignment of the Medicare Part B payment for all services for which the participant is eligible to accept assignment under the Medicare law and regulations and which are furnished while the agreement is in effect.  
• CMS-588-Electronic Funds Transfer, or EFT, Authorization Agreement 
• The EFT Agreement authorizes CMS to deposit Medicare payments directly into a provider/supplier's bank account. 
• CMS Standard Electronic Data Interchange, EDI, Enrollment Form
• All Medicare providers, except for small providers, must submit claims electronically, with limited exceptions. To electronically submit claims, Medicare providers must enroll and register with CMS EDI. For more information, visit EDI Support.
• EDI Registration
• EDI Enrollment Form

Citation(s): Medicare Claims Processing Manual, Chapter 23, Sec. 90.1; 42 CFR 424.32(d)(3).

In most cases, yes. In accordance with the Administrative Simplification Compliance Act of 2001, or ASCA, Medicare is prohibited from paying for nonelectronic claims that do not meet the limited exception criteria codified at 42 CFR 424.32(d)(3). These criteria provide an exception to this e-filing requirement when the provider either: (1) has no method available to them for submission of electronic claims; or (2) is considered a small provider.

Most solo practitioners will meet the exception as a "small provider of services," defined as a physician, practitioner, facility, or supplier with fewer than 10 full-time equivalent employees, or FTEs. Additionally, any other PT practice with fewer than 10 FTEs would not be required to file claims electronically.

Citation(s): 42 CFR 410.60(c)(1)(iii); Medicare Program Integrity Manual, Chapter 10, Sec. 10.2.3.10.G.

Possibly. The answer depends primarily on the location and nature of your practice. Generally, CMS requires verification of a lease agreement that shows an applicant operating an individual or group private practice has the right to exclusive use of their office space for PT/OT services. This is because the lease is primary evidence CMS can use to ensure an applicant's compliance with the regulatory requirement that "any space used for private practice must be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice."

For this reason, the answer differs primarily based on the following situations:

Applicant Represents the Individual or Group Practice. An applicant seeking to enroll as a new individual private practice (855I) or new organizational OPT (855B) would be required to furnish their lease agreement if they meet any of the following criteria:

• Maintain private office space;
• Own, lease, or rent their private office space; or
• This office space is used exclusively for the group or individual's private practice.

Individual Acting as Employee of Existing Practices. Conversely, you do not need to submit your lease information if you are an individual applicant reassigning all of your benefits to an established group, clinic, or practice organization (via 855I, Sec. 4F). These applicants are not required to provide the lease as evidence because that information would be captured on the established group’s existing CMS-855B application.

Citation(s): Medicare Program Integrity Manual 10.2.1.11.B.

The answer depends on the type of 855 form you are submitting. PTPPs who submit CMS 855I as individual applicants do not need surveys performed to receive Medicare NPI or TIN numbers.

Group practices that are submitting CMS 855B are required to have the state agency survey the premises in order for the enrollment application to be approved. For more information about these surveys, visit CMS’ Quality, Safety & Oversight- General Information webpage.

The CP-575 letter provides confirmation of both an applicant’s employer ID number, or EIN, a specific type of tax identification number, also known as a TIN, as well as the applicant’s legal business name, or LBN.

Applicants must submit a copy of their IRS CP-575 to verify the listed EIN and LBN submitted on the enrollment application — regardless of whether the applicant is submitting the CMS 855I, CMS-855A, or 855B, the IRS CP-575 is requested in the section entitled "Supporting Documentation Information" on the application form. 

You should have access to both a digital and mailed copy of the CP-575 automatically following approval of your EIN application. However, if you are unable to locate your CP-575, the IRS will not directly replace it with a duplicate; instead, you must request an official replacement in the form of the EIN Verification Letter, also known as LTR 147C, which Medicare should accept in place of the CP-575.

Applicants should be aware that there is a difference between the LBN and DBA names. While the LBN is formally registered with the IRS and associated with incorporation, the DBA name represents the marketing name and commonly does not require formal registration. Medicare enrollment forms typically request information on both the LBN and DBA name in separate fields. Applicants should take care to enter the correct names in each field, but contractors reviewing enrollment applications may be able to use supporting documentation to verify that the LBN and DBA match.

There are two participation options for providers enrolled in the Medicare program: participating or nonparticipating. Providers are required to fill out the Medicare Participating Physician or Supplier Agreement, also known as CMS-460, with their initial Medicare enrollment application. Under this agreement, providers must choose whether they want to maintain participating or nonparticipating status with Medicare. Providers can modify their decision annually, between mid-November and Dec. 31.

The practical impact of a provider's participation status is that it dictates whether the provider is required to accept "assignment" of Medicare claims — generally, "accepting assignment" indicates the provider's agreement to accept the Medicare-approved amount for Medicare-covered services dictated by the Medicare Physician Fee Schedule. As a result, a provider's participation status can have practical implications on the payment amount a provider can accept for rendering covered services to Medicare beneficiaries, whether payment comes from Medicare or the beneficiary.

The term participating means that the provider always accepts assignment on claims submitted on behalf of a Medicare beneficiary. Although participating providers do not have flexibility in accepting assignment, this option offers comparatively greater administrative simplicity since Medicare pays the provider directly and forwards claims information to Medigap insurances for processing, when applicable; as of 2024, approximately 42% of traditional Medicare beneficiaries have a Medigap plan, conferring additional value to Medicare participation.

However, as a participating provider, you cannot attempt to collect additional payment beyond the beneficiary's deductible and applicable co-payment for the service provided. Doing so is a breach of the assignment agreement and may result in monetary penalties or exclusion from the Medicare program — the latter can be financially devastating for providers that treat substantial shares of Medicare beneficiaries.

Note: For providers treating patients with Medicare Supplemental Insurance (also known as "Medigap" plans), which cover the beneficiary's out-of-pocket costs, Medicare will only forward claims to the Medigap policy under certain circumstances (this is formally known as the "Medicare claims crossover process"). Of note, the claims crossover process only applies to Medigap plans that are purchased independently, meaning employer-provided Medigap insurance plans do not qualify. Additionally, the beneficiary must have assigned both their Medicare and Medigap payments to participants on the Medicare health insurance claim form, CMS-1500, which the provider submits to Medicare for all claims. For additional information on structuring your billing to ensure the Medicare claims crossover process is available to you, refer to Ch. 28, Sec. 20.1 of the Medicare Claims Processing Manual.

For Medicare claims that qualify for the claims crossover process, the Medicare administrative contractor forwards the claim to the Medigap insurer for payment of all coinsurance and deductible amounts due under the Medigap policy. The Medigap insurer must pay the participant directly. 

As a nonparticipating provider, you do not have to accept assignment for Medicare beneficiaries; instead, the provider reserves the right to either accept or not accept assignment on a claim-by-claim basis. The primary trade-off for this added flexibility is that Medicare pays only 95% of the Medicare Physician Fee Schedule amount to non-participating providers for covered services in cases where the provider accepts assignment. Operationally, Medicare pays 80% of that amount, and the remaining 20% is collected directly from the beneficiary.

Although the reduced rate is undesirable, a nonparticipating provider that does not accept assignment also has a flexibility not afforded to participating providers: they are permitted to bill the patient up to Medicare's "limiting charge." This amount is 115% of the approved Medicare payment amount for nonparticipating providers (in other words, 115% of 95% of the fee schedule amount — if that seems confusing, see the example in the next section).

Example: Calculating the Limiting Charge Using 2025 National Medicare PFS Rates

Using the example above, a participating provider performing one unit of therapeutic exercise (CPT 97110) can charge $28.79. Comparatively, a nonparticipating provider who accepts assignment for the same service can only charge $27.35, or 95% of the fee schedule rate. However, if that same nonparticipating provider elects not to accept assignment, they are permitted to collect up to $31.45, 15% more than the nonparticipating provider rate.

Clearly, the permissible rate for nonparticipating providers is higher, but providers should also be aware of two other considerations when they do not accept assignment. First, the provider can charge the beneficiary the entire limiting charge amount, which would otherwise be inappropriate. However, this does not relieve them of a responsibility to bill Medicare; the provider is still required to file a claim to Medicare (as required by the Mandatory Claims Submission rule) but Medicare would then pay its 80% share directly to the beneficiary rather than to the provider. Most importantly, if you elect not to accept the assignment, you cannot charge a beneficiary more than the limiting charge; if you do, you must refund the difference. Medicare takes this issue very seriously, and providers should take great care in billing the limiting charge.

Finally, unlike participating providers, nonparticipating providers that do not accept assignment will not have their claims automatically processed through the secondary insurance. However, if you agree to accept assignment on an individual claim, that claim will automatically cross over and the Medicare secondary will pay you directly. If you do not accept assignment, the secondary payment will go directly to the beneficiary. 

Regardless of participation status, all providers are required to file claims for Medicare beneficiaries under the Mandatory Claims Submission rule. 

Please refer to this article for more information on participating in Medicare: Medicare Participation: You Have Options.

No, this is not permitted. Providers cannot attempt to circumvent the Medicare allowed amount limitation by "fragmenting" their patients' bills. Bills are "fragmented" when a physician/supplier accepts assignment for some services and claims payment from the enrollee for other services performed at the same place and on the same occasion. When a Medicare Administrative Contractor becomes aware that a provider is fragmenting bills, it must inform them that this practice is unacceptable and that they must either accept assignment for, or bill the enrollee for, all services performed at the same place and on the same occasion. 

Citation(s):Social Security Act Section 1802(b)(5)(B).

No, physical therapists cannot opt out of the Medicare program. Section 1802(b)(5)(B) of the Social Security Act limits the types of clinicians who may opt out of Medicare to: Doctors of Medicine and Osteopathy, dentists, podiatrists, and optometrists. The opt-out law's definition of a "physician" excludes PTs; therefore, PTs who treat Medicare beneficiaries must be enrolled in the program as either participating or nonparticipating. For this reason, PTs that wish to provide services to Medicare patients cannot yet operate exclusively cash-based practices, at least insofar as they are not restricted by the nonparticipation rules described elsewhere in this FAQ.

For more information on Medicare Opt-Out, please visit Manage Your Enrollment and scroll down to the "Opt Out of Medicare" section. To learn more about APTA's advocacy efforts to permit PTs to opt out of the Medicare program, visit APTA's webpage.

Sometimes, the answer depends on the applicant's practice setting. If the applicant is enrolling as a Medicare PT in private practice, they can start to provide services under the direct supervision of an enrolled therapist beginning on the date the Medicare Administrative Contractor received the enrollment application. Direct supervision requires that the supervising therapist be present in the office at the time services are provided. The major caveat is that the provider should "hold" those claims (i.e., do not submit those claims) until confirmation from the MAC that the enrollment has been approved and processed.

While you are generally restricted from billing "incident to" another PT and must have your own provider number, per the Medicare Benefit Policy Manual, Chapter 15, Section 230.4(B), "If a therapist is not enrolled, the services of that therapist must be directly supervised by an enrolled therapist. Direct supervision requires that the supervising private practice therapist be present in the office suite at the time the service is performed. These direct supervision requirements apply only in the private practice setting and only for therapists and their assistants. In other outpatient settings, supervision rules differ."

If your practice setting requires a state survey (e.g., a rehab agency, a SNF, a CORF), your services will not be covered if provided before the survey date. Services provided after the survey date could be covered; however, you cannot submit claims for these services until your practice is enrolled. 

The processing time for enrollment applications varies. Some factors that may influence the processing time include whether the application was complete (or additional documentation is required), whether the application was web-based or paper, or whether a site visit is required.

Generally, Medicare standards require Medicare Administrative Contractors to process enrollment applications within a prescriptive timeline. For instance, MACs are required to process 95% of web-based applications that do not require a site visit or additional documentation within 15 days, and 100% of applications within 100 calendar days. Many Medicare Administrative Contractors provide these timeframes, as well as their own performance data on processing times for both web-based and paper applications, on their websites.

However, once the MAC has processed the application within the mandated timeframe, the application is forwarded to CMS for final processing. Comparatively, there is no required timeframe for CMS itself to finalize the application, and in some extreme instances it can take six to nine months beyond the MAC's processing. 

Members should be aware that APTA is not able to fast-track or monitor the status of an individual's application. For questions on the status of your application, contact your Medicare Administrative Contractor.

PTs who provide outpatient therapy services in certain shortage areas may bill for services provided by a "locum tenens" PT under the regular PT’s NPI if certain conditions are met. The areas include: 

• health professional shortage areas, 
• nonmetropolitan statistical areas, or 
• medically underserved areas 

Enter your practice address into the Health Resources and Services Administration's shortage area search tool to determine if your practice is located in one of these areas.

If you are in one of those areas, a locum tenens arrangement may be utilized if you are absent for a limited period of time for vacation, disability, continuing education, etc. During that time, you can bill Medicare for services performed by a locum tenens PT under the regular PT’s NPI as long as the following conditions are met: 

• The PT is unavailable. 
• The locum tenens PT is compensated on a per diem or similar fee-for-time basis. 
• The Medicare beneficiary seeks to receive the services from the regular PT. 
• The regular PT does not bill for the services of a locum tenens PT for a continuous period longer than 60 calendar days. If, after returning to work for a brief period of time, the regular PT must be absent again, the same locum tenens PT may be re-hired, and a new 60-day period begins. 
• Regarding billing of the services, the PT uses a modifier to indicate that the services were provided by a locum tenens PT. 

If you are not located in one of these areas, you cannot bill for a contract or substitute PT's services under your NPI in a private practice setting. If you need to be out of the office and have found someone to see your patients in your absence, that PT should be enrolled in Medicare, have their own NPI, and bill Medicare for the services provided under their own NPI.  

For more information on Locum Tenens, visit Locum Tenens: The Basics. For Medicare billing guidance on Locum Tenens arrangements, such as reciprocal billing arrangements and fee-for-time compensation arrangements, see CMS' Medicare Claims Processing Manual, Chapter 1 Sec. 30. For non-Medicare payers, review each policy to determine if the payer permits locum te

Reassigning benefits allows your employer (business) to bill on your behalf and receive payment for services you render as an employee of the practice. Ordinarily, CMS processes Medicare claims for individual PTs’ services under the therapist's NPI. However, if you are employed (in a contractual employment arrangement) with a group practice, you will likely reassign your benefits to the group — you get paid directly from your employer (as a salaried employee), and they bill and receive payment from Medicare on your behalf. For physical therapists, this applies primarily to PTs in private practice, who may be chosen or be required to reassign payment to their group practice as part of their employment arrangement.

Previously, providers would submit a CMS-855R to reassign their benefits, but effective September 1, 2023, the CMS-855R form has been merged into the CMS-855I paper enrollment application. With this change, providers now reassign or terminate an existing reassignment of Medicare benefits using the CMS-855I via PECOS or the paper CMS-855I application.

No, there is currently no limit on how many different practices to which a PT may reassign their benefits. The provider wishing to reassign benefits should complete Sections 4(F)(1) and (2) of the Form CMS-855I for each practice they are assigning benefits to. The provider can report multiple new, changed, or terminated reassignments to parties with the same or different employer identification numbers on a single Form CMS-855I by submitting separate Section 4(F)s and Section 15(C)s. These sections need the signature of the PT who is reassigning the benefit and the signature of the PT receiving the benefit.

Citation(s): 42 C.F.R. 489.18

A change of ownership, or CHOW, typically occurs when a Medicare provider has been purchased (or leased) by another organization. The CHOW results in the transfer of the old owner';s Medicare Identification Number and provider agreement (including any outstanding Medicare debt of the old owner) to the new owner. If the purchaser (or lessee) elects not to accept a transfer of the provider agreement, then the old agreement should be terminated, and the purchaser or lessee is considered a new applicant. 

You must report the following changes in your enrollment information to your MAC via PECOs or CMS-855 within 30 days of the change: 

• A change in ownership 
• An adverse legal action, or 
• A change in practice location. 

All other changes must be reported to the MAC within 90 days of the change.  If you have any questions on whether an ownership change should be reported as a CHOW or a change of information, contact your Medicare Administrative Contractor or CMS Regional Office. 

If you are a supplier of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies, you must report any changes in information supplied on the enrollment application within 30 days of the change to the National Supplier Clearinghouse. Please visit your carrier's website for additional information on the change of ownership. 

Yes, all providers and suppliers enrolled with Medicare must revalidate their Medicare enrollment every 5 years ("on cycle") or when CMS requests it ("off cycle"). Revalidation effectively requires providers to resubmit the relevant 855 form (described in Section 1 of this FAQ); however, compared to initial enrollment, revalidation should be a quicker process, since much of the submission information has not changed, and you are updating information where appropriate.

Medicare provides notice of your revalidation date in several ways. However, regardless of any notice from CMS, providers should expect to prepare for revalidation five years from their initial enrollment and every five years following revalidation.

First, if you are currently enrolled, it's best practice to use the Medicare Revalidation Lookup Tool to find your revalidation due date. Often, these due dates are labeled as "TBD" until closer to the five-year mark, so expect to start checking monthly approximately toward a the beginning of the fourth year of your revalidation cycle (e.g. if you initially enroll on Jan. 1, 2026, you may want to begin seeking your revalidation due date around Jan. 1, 2030 in preparation for a revalidation window about 6 months before Jan. 1, 2031, approximately). While MACs are not required to post due dates so early, they are often posted up to seven months in advance to provide sufficient notice and time for the provider/supplier to comply with revalidation requirements.

Additionally, Medicare administrative contractors are required to provide notice of revalidation via PECOS or by mail to affected providers to the address (physical or email) on file. While the MAC may provide notice in both forms, it is not required to do so.

You can submit your revalidation package before your due date, but only within limits. Specifically, providers are only permitted to submit their revalidation application package within 6 months of their prescribed due date; earlier submissions (>7 months early) will be returned to the applicant. You may want to refer to your MAC’s website, some of which indicate that you should wait until you receive a request to revalidate before submitting. This may be closer to 2-3 months before your revalidation due date. Regardless of when you submit, you should aim to be proactive in preparing your application for submission.

Failure to submit your revalidation application by the assigned due date will restrict your ability to submit and receive payment for Medicare claims. The severity of the action taken may vary, but at a minimum will result in a temporary stay of enrollment, which will last 60 days or until you submit and have your revalidation approved, whichever happens first. This means that all claims you submit during this period will be automatically rejected, as noted in 42 CFR §424.555(b).

If you prolong your revalidation, Medicare will escalate its approach and may deactivate your billing privileges or suspend you from the Medicare program. Deactivation is similar to a stay of enrollment, but a provider will have to reactivate their enrollment through a considerably more arduous process. Suspension takes this one step further, denying the provider's ability to reactivate during the suspension period.

Functionally, all these actions result in nonpayment of Medicare claims with no option to retroactively bill Medicare for services provided during a stay of enrollment, deactivation, or suspension of Medicare billing privileges. This can be financially devastating to your practice and should be avoided at all costs.

No, submitting revalidation by your specified due date is a statutory requirement for which CMS offers noexceptions or extensions. However, at least one MAC indicates hardship exemptions may be granted, which conflicts with CMS' explicit position that it does not allow for extensions or exceptions. Regardless, there is no guarantee this flexibility is permitted or allowed in all MAC jurisdictions.

Additionally, your MAC will also send you a notice by mail and through PECOS to revalidate, usually between 3-4 months before your revalidation due date. If you submit your application after the due date, the MAC may place a hold on your Medicare payments, deactivate your Medicare billing privileges, or revoke your existing billing privileges. The most efficient way to submit your revalidation information is by using PECOS.

The filing date marks the date on which enrollment becomes effective following approval of a revalidation activation. This is the case whether the revalidation application was timely or late.

Yes, with notable limitations. First, a provider can bill Medicare for services rendered up to 30 days prior to the enrollment effective date; this is known as the "retrospective billing date." As noted above, the effective date of your enrollment is usually the later of the: (1) date of filing; or (2) the date when the provider first began furnishing services at the new practice location.

However, in order to qualify, there had to have been "circumstances that precluded enrollment in advance of providing services to Medicare beneficiaries." According to CMS, this only means that the applicant met all program requirements during the retrospective billing period, and that no final adverse action precluded enrollment. In short, this is a minimal standard that indicates that a provider that otherwise meets the requirements and is approved to participate in the Medicare program. For this reason, providers may wish to track, document, and submit claims during the retrospective period.

No, CMS and its MACs will not retrospectively process claims during your stay of enrollment. While you can appeal this decision, you should be aware that: one, administrative law judges, who hear appeals of Medicare claims, are generally limited in reviewing whether the effective date was determined appropriately ("I may only decide whether the contractor reactivated Petitioner's billing privileges consistent with the application for reactivation that it completed on June 18, 2018. And, as I have found, the contractor did so."). Further, you may still need to go through this process to exhaust Medicare's multistage administrative appeals process before pursuing formal legal action in federal court. Even if you succeed, this process will almost certainly be time-consuming and expensive; for many, it will be financially prohibitive.

For more information on renewing your enrollment, refer to CMS' Revalidation webpage.