Provider Enrollment Handout - Palmetto GBA

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Top Development Reasons Application is incomplete – Missinginformation Signature issues Missing CP-575 tax document Missing CMS 588 EFT application Wrong type of NPI - Type 2 needed NPPES mismatchAdd/Change /Delete□ Add = new enrollment for first time,new additional location or revalidation□ Change = submit change to existinginformation□ Delete = Removal of information□ Section 4 can be copied andsubmitted multiple times to completemultiple actions or locations22
Signature Requirements□ Signature verification required for:□ Change of practice location□ Change of Corr/Special Payment address□ Change EFT□ Revalidation or Reactivation□ Establishment of sole owner or soleproprietor when provider currentlyreassigning all benefitsParticipation vs. Opt Out□ Participating: Accepts Medicareassignment□ Non – Participating: Option to acceptor not accept Medicare assignment□ Opt Out: Not enrolled/ does notparticipate in Medicare program□ Opt Out period runs for two years23
Page 1: Provider EnrollmentPalmetto GBA J1
Page 5 and 6: What is Your Business Structure?□
Page 9 and 10: What is PECOS? Provider Enrollment
Page 11: CMS PECOS Webpage PECOS example Enr
Page 15 and 16: CAP vs. Reconsideration□ CAP = Co
Page 17 and 18: CR 6417: Expansion of the CurrentSc
Page 19 and 20: During Phase 2 (Start Date to BeAnn
Page 21: Application Fees Does not apply to
Page 25 and 26: Minimizing Risks Ensure information
Page 27 and 28: Resources Palmetto GBA Web site Res

Provider Enrollment Handout - Palmetto GBA

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