Medicare refers to a government-run program providing health insurance to Americans above the age of 65 and covers disabled people too. A health practitioner or health service
provider has to receive Medicare certification in order to bill Medicare for services provided to their patients.
For a healthcare provider to be certified, they need to meet the Conditions for Coverage (CfCs) and Conditions
of Participation (CoPs) which are requirement guidelines laid out by the Centre for Medicare and Medicaid Services (CMS).
The process of Medicare Certification may be lengthy initially and generally includes the following steps:
Application for the National Provider Identifier number (NPI) which is a unique 10-digit code that acts as the anonymous identifier of the health service provider is the first step. This is the number that is used in billing of clients or patients.
Next one has to check for eligibility which involves compliance with Conditions for Coverage or Conditions of Participation. State agencies may conduct visits to determine eligibility of
the applicant. The government has mandated some private organizations to ensure compliance with Medicare’s conditions of coverage and they include The Joint Commission, American Association for Ambulatory Healthcare or Healthcare Facility
An enrollment form is then filled and mailed to the CMS for validation. Institutional service providers fill form 855a while sellers of medical equipment are required to fill form 855s.
All service providers are required to submit data electronically hence they need to enroll in the CMS Electronic data Interchange (EDI). This is essential in submitting claims and receiving payouts from Medicare.
It is important to note that there are different Medicare plans categorized as:
Plan A which includes inpatient services, skilled nursing, laboratory tests, surgeries etc.
Plan B involves outpatient services, medically necessary doctors’ services, medical equipment etc.
Plan D covers outpatient prescription drugs and is usually provided by private insurance companies who have a
contract with the government.