How to Determine if the Provider is Active and Get the Provider Enrolled in Medicare Part B
Table of Contents
Determine if the Provider Has an Active Enrollment
Navigate to the Medicare Fee-For-Service Public Provider Enrollment data web page.
For information on the tool scroll down and read Summary or select “Download Fact Sheet” under Resources for Using and Understand the Data.
Begin search, select "View Data.”
In the Search box, key the NPI and then press Enter.
Important: Data updated quarterly; verify “Last Update” date at the top of the screen.
If no data is displayed, this provider does not have an active enrollment in any state.
If data is displayed, this means the provider has an active enrollment in a particular state(s).
Note: Provider Type 33-XX identifies providers with an active enrollment solely to order or refer services. This provider type will need to initial enroll if they start billing Medicare. See Medicare Fee-for-Service Public Provider Enrollment Data Dictionary for further details on Provider Types.
Now that you have determined if the individual provider has an active enrollment with Medicare Part B, move to the next step below to determine how to enroll the provider.
How to Enroll the Provider in Medicare Part B
National Government Services encourages provider to electronically submit enrollment information via the PECOS. For more information, see Learn about PECOS Web.
These instructions were created to enroll using the PECOS system, the corresponding CMS-855 paper application is indicated beside each action.
Question 1: Will the provider be billing Medicare for services rendered for a group or individual private practice?
| If | Then |
|---|---|
| No, | the provider should enroll in PECOS, by selecting Eligible Ordering, Certifying, and Prescribing Physicians, and Other Eligible Professionals, (CMS-855O), or the provider should determine if they want to Opt Out of Medicare. |
| Yes, | move to question 2. |
Question 2: Will the provider be rendering services for a group, which the individual provider has no ownership interest and the group will be billing Medicare?
| If | Then |
|---|---|
| No, | move to question 3. |
| Yes, | the provider should enroll in PECOS, by selecting "Individual Physician or Non-Physician Practitioner“ then "Group Member Only,” the PECOS system will automatically prompt the provider to complete the required topics (sections) if they do not have an active enrollment (CMS-855I). If the provider has an active enrollment, the provider would enter the PECOS system through the active enrollment and make any changes to the topics (sections) (CMS-855I), including adding the reassignment or employment arrangement. |
Question 3: Will the provider be billing Medicare for service rendered under an EIN, TIN or an SSN?
| If | Then |
|---|---|
| EIN or TIN, | move to question 4. |
| SSN, | the provider should enroll in PECOS, by selecting "Individual Physician or Non-Physician Practitioner“ then "Self-Employed/Sole Proprietor,” the PECOS system will automatically prompt the provider to complete the required topics (sections) if they do not have an active enrollment (CMS-855I), including the Electronic Funds Transfer PECOS topic (CMS-588 EFT). If the provider has an active enrollment, the provider would enter the PECOS system through the active enrollment and make any changes to the topics (sections) (CMS- 855I), including the Electronic Funds Transfer PECOS topic (CMS-588 EFT). |
Question 4: Is the EIN or TIN for a separate business entity or for a sole proprietor?
| If | Then |
|---|---|
| Separate business entity, | move to question 5. |
| Sole Proprietor, | the provider should enroll in PECOS, by selecting "Individual Physician or Non-Physician Practitioner" then “Self-Employed/ Sole Proprietor,” the PECOS system will automatically prompt the provider to complete the required topics (sections) if they do not have an active enrollment (CMS-855I), including the Electronic Funds Transfer PECOS topic (CMS-588 EFT). Additional documentation to upload (PDF or TIFF) to PECOS would be the IRS documentation verifying the EIN. |
Question 5: Is the provider the sole owner of a PC, a PA or a LLC and will be rendering services?
| If | Then |
|---|---|
| No, | move to question 6. |
| Yes, | the provider should enroll in PECOS, by creating an initial enrollment through their individual NPI Type I, select "Individual Physician or Non-Physician Practitioner" then select “Sole Owner of a PA, PC or LLC,” the PECOS system will automatically prompt the provider to complete the required topics (sections) (CMS-855I), including the Electronic Funds Transfer PECOS topic (CMS-588 EFT). Additional documentation to upload (PDF or TIFF) to PECOS would be the IRS documentation verifying the TIN. |
Question 6: Is the provider the sole owner of a business entity and will not be rendering services?
| If | then |
|---|---|
| Yes, | the provider should enroll as a group in PECOS, by creating an initial enrollment through their Organization NPI Type II, then select "Clinics/Group Practices and Certain Other Suppliers." The PECOS system will automatically prompt the provider to complete the required topics (section) if they do not have an active enrollment (CMS-855B), including the Electronic Funds Transfer PECOS topic (CMS-588 EFT). Additional documentation to upload (PDF or TIFF) to PECOS would be the IRS documentation verifying the TIN |
| No, | visit our Contact Us page for more information and select Provider Enrollment to discuss business structure of individual and/or entity. |
Revised 7/30/2024