In May 2014, CMS (Centers for Medicare & Medicaid Services) issued a final rule (CMS 4159-F) that revised the MA (Medicare Advantage) and Part D prescription drug benefit programs regulations. This regulation, authorized under Section 6405 of the Affordable Care Act, requires physicians and other eligible professionals who write prescriptions for covered Part D drugs to be validly enrolled in, or opted out of the Medicare program. Medicare Part D may no longer cover drugs that are prescribed by physicians or other eligible professionals who are neither validly enrolled nor opted out of Medicare. Some of the prescribers impacted by this requirement would not normally enroll in, or opt out of the Medicare program (e.g., general dentists). This requirement will help CMS ensure that Part D drugs are prescribed only by qualified individuals.
CMS previously announced that enforcement of the prescriber enrollment requirement would begin on February 1, 2017. However, in effort to minimize the impact on the beneficiary population, full enforcement of the Part D prescriber enrollment requirement will begin on January 1, 2019.
Between now and the new enforcement date, CMS will begin phasing in targeted enforcement and will follow a specific strategy in order to be fully committed to the implementation while protecting beneficiaries and the Medicare program. More details of the initiatives and the strategy are forthcoming.
While the full enforcement date is January 2019, CMS encourages all physicians and eligible professionals who prescribe Part D drugs, but are not yet enrolled or validly opted out of Medicare, to enroll in the Medicare Program.
If you wish to enroll to be reimbursed for the covered services furnished to Medicare beneficiaries, in addition to prescribing Part D covered drugs, you must complete the CMS-855I application. You may submit the CMS-855I using the paper version of the application or via Internet-based PECOS.
The CMS-855O, which is a shorter, abbreviated form, should be completed if you are seeking to enroll solely to prescribe Part D drugs. This will allow prescribers to verify their personal information and credentials for the sole purpose of prescribing; however, prescribers who complete the CMS-855O will not have Medicare billing privileges.
You may also use Internet-based PECOS to submit your enrollment information as an online alternative for enrolling in the Medicare program. For guidance on using Internet-based PECOS to submit your CMS-855O enrollment, please view the CMS’ how-to guide, Enrolling Solely to Order and Certify Items and Services and/or Prescribe Part D Drugs via the Internet-based PECOS (Provider Enrollment, Chain and Ownership System).
Note: If you do not see your specialty listed on the CMS-855O application, select the “Undefined Physician Type” option and identify your specialty in the space provided (e.g., general dentistry).
If you elect to opt out of Medicare, you must submit an opt-out affidavit. Your opt-out information must be current and a NPI (National Provider Identifier) is required to be submitted on the affidavit. A provider with an opt-out status may still order/refer and prescribe for Medicare beneficiaries, but may not bill the Medicare program. Providers with opt-out statuses enter into private contracts with beneficiaries. Prescribers wanting more information about opting out may refer to the Novitas Enrollment Guide: Chapter 9 – Private Contracting (Opt Out)
Note: To improve the timeframe associated with identifying and routing all Part D applications and affidavits to the proper team for processing, we strongly encourage you to attach a cover letter with your application/affidavit indicating the reason for submission is in conjunction with the Part D Prescriber initiative.
You are always welcome to use the Novitas Enrollment Center (JH) (JL) for CMS Forms, (including the CMS 855O), tutorials, and additional help.