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CMS Will Soon Require Enrollment Verification for Part D Prescribers

The “Medicare Program: Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs” (42 CFR 423.120(c)(6)) final rule, published in the Federal Register on May 23, 2014, requires physicians and other eligible professionals who write Medicare Part D prescriptions for Medicare patients to enroll in an approved status, or to have a valid opt-out affidavit on file for their prescriptions to be covered under Part D by June 1, 2015.

CMS announced on December 5, 2014 that it is delaying enforcement of this requirement until December 1, 2015. This delay, however, is for Medicare contractors, not prescribers.

CMS is only postponing enforcement of the requirement for six months to ensure that MACs have sufficient time to process provider enrollment applications and opt-out affidavits, and consequently to avoid prescription drug claim denials by beneficiaries’ Part D plans.

Prescribers may submit their enrollment applications electronically using the Internet-Based Provider Enrollment, Chain and Ownership System (PECOS) or by completing the paper CMS-855I (Medicare enrollment) or CMS-8550 (Part D – only enrollment) application. Opt-out affidavits are submitted to the MAC within the prescriber’s jurisdiction. Note that opt-out affidavits must be submitted every two years, and a National Provider Identifier (NPI) is required.