Podcast: Medicare Applications by the Numbers: Pharmacy Compliance Guide


Medicare Application by the Numbers: Pharmacy Compliance Guide Summary

Applying for a Medicare number, also known as PTAN, can be time-consuming, confusing and quite daunting as there are almost 50 pages in the CMS 855B alone! First, you need to determine which application needs completed based on the services you hope to offer.  Then the next challenge is to determine which sections need completed. Are there additional forms to complete, what extra documents need included, how and where to submit payment? Then the longest part, waiting to see if you have been approved or denied!

Let’s start by clarifying the differences between the applications. The two most common CMS applications are the CMS 855S and CMS 855B. The 855S is used if you intend to bill for non-accredited drugs and/or DME products while the 855B can be used for billing immunizations. These applications are actually processed by various contractors of Medicare. All CMS 855S applications are processed by National Supplier Clearinghouse (NSC). The 855B applications are processed by 7 different regional contractors based on your state.

While the applications require some related information, the only true similarity is the price. Regardless of the state, practice, or application type, the current cost in 2018 to submit an application is $569 payable via PECOS. A few differences to keep in mind, the 855S may require owners/managers to get fingerprinted and certain documents must accompany your application including a Certificate of Liability with the certificate holder listed as NSC and a Surety Bond for $50,000 coverage. If accredited you would also need a certificate of accreditation and a Certificate of Liability with the accreditation organization as the certificate holder. The 855B does not require these items.  The 855S gives you the option to accept or not accept assignment-this is a big decision and should be discussed with your billing person. However, with the 855B you have to accept assignment. Prepare to wait 2-3 months for the 855B and 3-4 months for the 855S.

People often ask if they can have a PTAN without being accredited. The answer is yes, if you plan to bill only non-accredited drugs; use the 855S. By doing so you would be able to bill Medicare for: Epoetin, Immunosuppressive Drugs, Infusion Drugs, Nebulizer Drugs, Oral Anticancer and Oral Antiemetic Drugs. Once you are assigned a PTAN for non-accredited drugs, you may consider applying for accreditation to offer DME products. This would require another application and to be accredited by one of the nine accreditation organizations such as BOC, ACHC, and The Compliance Team.

Regardless of doing the application on your own or using a specialist to help with the process, there is always a risk your application will be rejected because a page was omitted, a box was not checked, a date was missing, or the wrong color ink was used. If you ever get a request from Medicare-answer immediately, as there is only a small window of time that you can submit requested information or the application will be rejected. Please keep in mind, if this happens, you have to pay the application fee of $569 and start the process again.

If you are feeling overwhelmed or even just slightly apprehensive about tackling a new application, a re-validation request, or you're trying to reactivate your PTAN, consider R.J. Hedges & Associates Medicare Application Team! Historically, this was a service we only provided to our customers, but with so many pharmacy owners needing help, we are pleased to now offer a Medicare Application Preparation Service.

Rather than researching "how to complete a Medicare Application" you can complete our web based questionnaire. Our experienced and knowledgeable staff will tailor an application for your location. We will complete the Medicare application and send you a version the will only need signatures and PECOS payment prior to submitting to the Medicare contractor in a prepaid envelope.

Jenny Schell

Jenny is a Board Certified DME Specialist and for the last 9 years has assisted independent pharmacies, home health care facilities, medical supply companies, physicians and small healthcare practices in choosing the best comprehensive customized healthcare compliance and consulting services they require.

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