Medicare Enrollment, Participation Status, 

Revalidation, and Opt Out


  

 

Medicare Enrollment - 2 Options (PECOS or paper application)

 PECOS:

   Advantages of Internet-based PECOS 

  • Faster than paper-based enrollment (45 day processing time in most cases, vs. 60 days for paper)
  • Tailored application process means you only supply information relevant to YOUR application
  • Gives you more control over your enrollment information, including reassignments
  • Easy to check and update your information for accuracy
  • All documents can be submitted electronically. (No paper)  
   Login to PECOS as an Existing user or New user (registration required). 
   Access guides and video tutorials on how to use PECOS for assistance.
                                                   

 Paper Applications/Enrollment Forms:

   Go to Novitas. Click on Jurisdiction H. On the left side menu, hover over "Enrollment" and select "Enrollment Forms".


Re-Validation

All Medicare enrolled physicians, providers, and suppliers are required to revalidate their information with the CMS every three or five years. Novitas and HCMS will send out notices on a regular basis requesting physicians to update/revalidate their status. Failure to update the information or respond could result in the deactivation of your Provider Transaction Access Number (PTAN)


CMS provides a lookup tool that lists physicians, providers, and suppliers who are due to revalidate. For individual revalidation, form CMS-855I is used and can be found on the Novitas website along with instructions for its completion and a tutorial. Group revalidation is done using form CMS-855B and can also be found on the Novitas website along with a tutorial. These forms can be completed on paper and mailed, or online using the PECOS system. Online revalidation is the preferred method as it is faster and there’s no chance of the revalidation being lost in the mail or misrouted. If unsure if the revalidation request is for an individual or group enrollment, or for questions on how to complete the required forms, contact Novitas at 1-855-252-8782.  


 

Medicare Participation Options

There are three status types:

  • Participating (often referred to as "PAR")
    • Accept Medicare and always take assignment. Taking assignment means that the provider accepts Medicare’s approved amount for health care services as full payment.
    • These providers are required to accept assignment and file a claim to Medicare.
     
  • Non-participating physician (often referred to as NON PAR):
    • Accept Medicare but do not agree to take assignment in all cases (they may on a case-by-case basis). This means that while non-participating providers have signed up to accept Medicare insurance, they do not accept Medicare’s approved amount for health care services as full payment.
    • Non-participating providers can charge up to 15% more than Medicare’s approved amount known as the limiting charge.
     
  • Opting out
    • Physicians have the right to opt out of Medicare. According to the Balanced Budget Act of 1997, a physician may opt of out of Medicare and still care for Medicare patients. However, the physicians must have a signed private contract with the patient. The private contract informs the patient that Medicare will not pay for the services the physicians is providing and that there is no limit to what the physician my charge. Prior to enactment of the Medicare Access and CHIP Reauthorization Act (MACRA), physicians who elected to opt out of Medicare and enter into private contracts with Medicare beneficiaries had to update an affidavit every two years to maintain their opt-out status. A provision in MACRA eases these requirements so that valid opt out affidavits signed on or after June 16, 2015 will automatically renew every two years. Physicians filing affidavits effective on or after June 16, 2015 that do not want their opt out to automatically renew at the end of a two year period may cancel the renewal by notifying all Medicare Administrative Contractors with which they filed an affidavit in writing at least 30 days prior to the start of the next opt-out period. 

      • Chapter 9 Private Contracting (Opt-out) - To find the reference, go to the Novitas website. Click on Jurisdiction H. On the left-hand side menu, hover over "Enrollment" and select "Opt-Out Listings". 
      • Sample Private Contract .
      • Complete and mail or fax the signed affidavit. Novitas sample affidavit.
       
    To become a participating provider again, you must re-enroll at least 30 days prior to the start of the next opt-out period. The enrollment forms must be submitted again, either in PECOS or on paper, and a letter sent to Novitas stating you are cancelling your opted-out status to:  Novitas Solutions, Provider Enrollment Services, P.O.  Box 3095, Mechanicsburg, PA 17055-1813. You can verify your opt-out renewal date by accessing the list of physicians  who have opted out. Click on "View Data" to access the database. 


Resources   

Medicare Fee Schedule - Participating versus Non-Participating. To find the fee schedule, go to the Novitas website. Click on Jurisdiction H. On the left-hand side menu, hover over "Fee Schedules", then select "Search and Download Fee Schedules". Download the entire fee schedule or search individual codes. The results will show participating and non-participating rates.