The Centers for Medicare
& Medicaid Services (CMS) finalized new rules which require physicians and,
when applicable, other eligible professionals who write prescriptions for Part
D drugs to be enrolled in an approved status or to have a valid opt-out
affidavit on file for their prescriptions to covered under Medicare Part D.
According to CMS, prescribers of Part D drugs must submit their Medicare
enrollment applications or opt-out affidavits to their Medicare administrative
contractors (MAC) by June 1, 2015, to ensure that MACs have sufficient time to
process the applications or affidavits.
Medicare patients’ prescription drug claims will be denied by their Part D
plans, beginning December 1, 2015, if the prescriber does not have a valid
enrollment or opt-out status with Medicare.
Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) finalized CMS-4159-F
“Medicare
Program; Contract Year 2015 Policy and Technical Changes to the Medicare
Advantage and
the Medicare Prescription Drug Benefit Programs” on May 23, 2014. This rule
requires
physicians and, when applicable, other eligible professionals who write
prescriptions for
Part D drugs to be enrolled in an approved status or to have a valid opt-out
affidavit on file
for their prescriptions to be covered under Part D. The final regulation stated
that the effective date for this requirement would be June 1, 2015. However,
CMS is announcing that it will delay enforcement of the requirements in 42 CFR
423.120(c)(6)until December 1, 2015. Nevertheless, prescribers of Part D drugs
must submit their Medicare enrollment applications or opt-out affidavits to
their Part B Medicare Administrative Contractors (MACs) by June 1, 2015, or
earlier, to ensure that MACs have sufficient time to process the applications
or opt out affidavits and avoid their patients’ prescription drug claims from
being denied by their Part D plans, beginning December 1, 2015. Note that
enrollment functions for physicians and other prescribers are handled by Part B
MACs.
If you write prescriptions for covered Part D drugs and you are not enrolled in
Medicare in
an approved status or have a valid record of opting out, you need to submit an
enrollment
application or an opt out affidavit to your Medicare Administrative Contractor
(MAC) by
June 1, 2015, or earlier. You may submit your enrollment application electronically
using the Internet -based Provider Enrollment, Chain, and Ownership System (PECOS) located at
https://pecos.cms.hhs.gov/pecos/login.do or by completing the paper CMS-855I or
CMS-855O application, which is available at http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html on the CMS website. Note that an application fee is not
required as part of your application submission. If you wish to enroll to be
reimbursed for the covered services furnished to Medicare beneficiaries, you must
complete the CMS-855I application. The CMS-855O, which is a shorter, abbreviated form, should only be completed if you are seeking to
enroll solely to order and refer and/or prescribe Part D drugs. (While the
CMS-855O form states it is for physicians and non- physician practitioners who want to order and refer, it is appropriate for use
by prescribers, who also want to enroll to prescribe Part D drugs.) If you do
not see your specialty listed on either of the applications, select the
Undefined Physician/Non-Physician Type option and identify your specialty in
the space provided.
If you are a physician or eligible professional who wants to opt out of
Medicare, you must submit an opt-out affidavit to the MAC within your specific
jurisdiction. Your opt-out information must be current (an affidavit must be
completed every 2 years, and a National Provider Identifier (NPI)
is required to be submitted on the affidavit). For more information on the
opt-out process, refer to
MLN Matters® article SE1311, titled “Opting out of Medicare and/or Electing to
Order and Refer Services,” which is available at
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNMattersArticles/downloads/SE1311.pdf on the CMS website.
In an effort to prepare the prescribers and Part D sponsors for the December 1,
2015 enforcement date, CMS is making available an enrollment file that
identifies physician and eligible professional who are enrolled in Medicare in
an approved or opt out status. The first iteration of the enrollment file is
now available at
https://data.cms.gov/dataset/Medicare-Individual-Provider-List/u8u9-2upx on the
CMS website. The file contains production data but is considered a test file
since the Part D prescriber enrollment requirement is not yet applicable. An
updated enrollment file will be generated every two weeks and continue through
the December 1, 2015 enforcement date. The file displays physician and eligible
professional eligibility as of and after November 1, 2014,(i.e., currently enrolled,
new approvals, or changes from opt-out to enrolled as of November 1, 2014). Any
periods, prior to November 1, 2014, for which a physician or eligible
professional was not enrolled in an approved or opt-out status will not be
displayed on the enrollment file. However, any periods after November 1, 2014,
for which a physician or eligible professional was not enrolled in an approved
or opt-out status will be on the file with its respective end dates for that
given provider. For opted out providers, the opt out flag will display a Y/N
(Yes/No) value to indicate the periods the provider was opted out of Medicare.
The file will include the provider’s:
• (NPI);
• First and Last Names;
• Effective and End Dates; and
• Opt Out Flag
After the enforcement date of December 1, 2015, the applicable effective dates
on the file
will be adjusted to December 1, 2015, and it will no longer be considered a
test file. All
inactive periods prior to December 1, 2015, will be removed from the file and
it will only
contain active and inactive enrollment or opt out periods as of December 1,
2015, and after.
The file will continue to be generated every two weeks, with a purposeful goal
toward more
frequent updates on a set schedule. Part D sponsors may utilize the file to determine
a
prescriber’s Medicare enrollment or opt out status when processing Part D
pharmacy claims.
The file will not validate the provider’s ability to prescribe under applicable
laws.
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