November 12, 2015
Area(s) of Interest: Payor Contracting Payor Issues and Reimbursement Practice Management Public Payors
Beginning on June 1, 2016, all physicians and other providers who prescribe Medicare Part D drugs must be enrolled in Medicare or have a valid record of opting out. Failure to do so will result in a denial of the pharmacy claim or the beneficiary’s request for reimbursement.
The Centers for Medicare and Medicaid Services (CMS) had originally intended to begin enforcing this regulation last June, but the agency delayed implementation to allow sufficient time for beneficiaries and Medicare Part D plans to prepare.
All physicians and other prescribers who are not currently in compliance are encouraged to complete their Medicare enrollment or submit an opt-out affidavit no later than January 1, 2016. This will ensure sufficient processing time so that their Part D patients will continue to have access to necessary medication without interruption.
If you are unsure if you are compliant with this requirement, please review the CMS prescriber enrollment file.
Enrollment applications can be submitted on paper or online via PECOS. To enroll offline using a paper enrollment form, complete the CMS-855O application and mail to Noridian, California's Medicare contractor. Providers should be aware, however, that this form only allows you to enroll in Medicare for the purpose of ordering and certifying services and items, and to prescribe Part D drugs. It will not allow you to bill or be paid for Medicare services. To apply as a Medicare provider with full billing privileges, you will need to complete the appropriate CMS-855 form(s).
For more information, see the CMS Part D Prescriber Enrollment webpage and MLN Matters number SE1434. CMS has also put together a Part D Provider Enrollment FAQ.
For more information on opting out, see the Noridian website.