Medicare Provider Enrollment (PECOS) Guide for Therapists

What Is Medicare Provider Enrollment?

Medicare provider enrollment is the process of registering with the Centers for Medicare & Medicaid Services (CMS) to become an approved Medicare provider. Once enrolled, you can bill Medicare directly for covered services provided to Medicare beneficiaries. Enrollment is handled through PECOS (Provider Enrollment, Chain, and Ownership System), CMS's online enrollment portal, or through the paper CMS-855I application.

For mental health providers, Medicare enrollment is a significant business decision. Medicare beneficiaries represent a substantial portion of the population seeking mental health services, particularly older adults. However, Medicare reimbursement rates, administrative requirements, and billing rules differ from commercial insurance, so understanding the full picture before enrolling is important.

Medicare enrollment is separate from commercial insurance credentialing. Being credentialed with Blue Cross, Aetna, or UnitedHealthcare does not enroll you in Medicare. Medicare has its own application, its own verification process, and its own timeline.

Verify with your payer: Medicare rules and processes are governed by CMS and administered by regional Medicare Administrative Contractors (MACs). Some requirements may vary by MAC. Always verify specific requirements with your MAC.

Who Can Enroll as a Medicare Mental Health Provider?

Medicare recognizes specific provider types for independent mental health billing:

• Clinical psychologists — Doctoral-level (PhD, PsyD, EdD in psychology) with state licensure
• Clinical social workers — Master's-level social workers with clinical licensure (LCSW or state equivalent)
• Licensed professional counselors (LPCs) — Became eligible for Medicare billing under recent legislative changes
• Licensed marriage and family therapists (LMFTs) — Also became eligible under recent legislative changes
• Psychiatric nurse practitioners — Advanced practice registered nurses with psychiatric-mental health certification
• Clinical nurse specialists — With psychiatric-mental health specialty
• Psychiatrists — Physicians (MD or DO) with psychiatric specialty

Each provider type has specific documentation requirements. The common thread is that you must hold an active, unrestricted state license that qualifies under Medicare's provider type definitions.

PECOS vs. Paper Application (CMS-855I)

You have two options for submitting your Medicare enrollment application:

Feature	PECOS (Online)	CMS-855I (Paper)
Processing time	60-90 days typical	90-120+ days typical
Status tracking	Yes, online	No, must call MAC
Error correction	Immediate online editing	Requires resubmission or amendment by mail
Document upload	Electronic upload	Mail or fax copies
CMS recommendation	Preferred method	Accepted but slower

CMS strongly encourages using PECOS for faster processing and easier application management. The instructions below focus on the PECOS process.

Step-by-Step PECOS Enrollment

Step 1: Obtain Prerequisites

Before starting your PECOS application, you must have:

• NPI number — Your Type 1 individual NPI, registered and active in NPPES
• PECOS/I&A account — A CMS Identity & Access Management account (same system used for NPPES)
• State license — Active and unrestricted
• Malpractice insurance — Current professional liability coverage
• EIN or SSN — Your tax identification number for the practice

Step 2: Access PECOS

Go to pecos.cms.hhs.gov and log in with your I&A credentials. If you do not have I&A credentials, you will need to create an account at the CMS Identity & Access Management portal (the same account used for NPPES access).

Step 3: Start a New Application

From the PECOS dashboard:

1. Select "New Enrollment Application"
2. Select "Individual Practitioner" as the enrollment type
3. This generates the electronic equivalent of the CMS-855I form

Step 4: Complete the Application Sections

The PECOS application includes the following sections:

Identifying Information

• Legal name, date of birth, SSN, gender
• NPI number
• Provider type and specialty

Practice Location Information

• Physical address where you provide services to Medicare beneficiaries
• Whether you provide services at multiple locations
• Phone number and fax number
• Hours of operation
• Whether the location is ADA accessible

Billing Information

• How you want to receive Medicare payments (electronic funds transfer is required)
• Tax identification information
• Billing address

Licensure and Certification

• State license information for every state where you are licensed
• License numbers, issue dates, expiration dates
• Any specialty board certifications

Employment and Practice History

• Current and previous practice affiliations
• Employment history for the past five years

Adverse Actions

• Questions about malpractice history, criminal convictions, license revocations or restrictions, exclusions from federal programs, and loss of hospital privileges
• Honest disclosure is critical — misrepresentation on a Medicare application is a federal offense

Step 5: Upload Supporting Documents

PECOS allows electronic document upload. Required documents include:

• Copy of your state professional license
• Proof of malpractice insurance (certificate of insurance)
• Copy of your Social Security card or ITIN documentation
• Any documents supporting "yes" answers to adverse action questions

Step 6: Sign and Submit

Review your entire application for accuracy. PECOS requires either:

• Electronic signature — Available if you are submitting as an individual
• Paper signature page — If electronic signature is not available, PECOS generates a signature page that you must print, sign, and mail to your MAC

An application without a valid signature cannot be processed.

Step 7: Track Your Application

After submission, you can track your application status in PECOS. Statuses include:

• Received — Application received and in queue
• In Review — MAC is actively reviewing your application
• Returned/Rejected — Application has issues that need correction
• Approved — You are enrolled and assigned an effective date

If your application is returned, log in to PECOS to see the specific issues, correct them, and resubmit.

Medicare Effective Date

Your Medicare effective date — the date from which you can bill Medicare — depends on when your application is processed:

• If approved, your effective date is typically the date your application was filed or the date you began furnishing services, whichever is later
• There is a limited retroactive billing period — you cannot bill for services provided before your effective date unless within the retroactive filing window
• Plan accordingly: do not see Medicare clients expecting to bill retroactively without confirming the policy with your MAC

The Medicare Opt-Out Option

If you do not want to participate in Medicare, you can formally opt out by filing an opt-out affidavit with your MAC. This is different from simply not enrolling.

What Opt-Out Means

• You cannot bill Medicare for any services
• You can enter into private contracts with Medicare beneficiaries
• Beneficiaries who see you under a private contract pay your full fee and cannot submit claims to Medicare for your services
• The opt-out period is two years and automatically renews unless you cancel
• You must give each Medicare beneficiary a private contract to sign before providing services

When Opt-Out Makes Sense

• You maintain a fully private-pay practice
• You do not want to accept Medicare reimbursement rates
• You prefer the simplicity of private-pay arrangements
• Your practice model is not compatible with Medicare billing requirements

How to Opt Out

1. Complete the Medicare opt-out affidavit (available from your MAC)
2. File the affidavit with your MAC at least 30 days before the opt-out is intended to begin
3. Maintain copies of all signed private contracts with Medicare beneficiaries
4. If you ever want to rejoin Medicare, you must wait until your current opt-out period ends

Revalidation

Medicare requires periodic revalidation of your enrollment — typically every five years. CMS will send a revalidation notice to the address on file in PECOS. You must:

1. Log in to PECOS
2. Review and update all enrollment information
3. Upload any updated documents (renewed license, updated malpractice certificate)
4. Submit the revalidation application

Failure to revalidate by the deadline results in deactivation of your Medicare billing privileges. Reactivation requires submitting a new enrollment application, which means additional processing time during which you cannot bill Medicare.

Common Medicare Enrollment Mistakes

Not Having an NPI Before Applying

You cannot submit a PECOS application without an NPI. If you have not yet obtained your NPI, do that first through NPPES. The NPI application is free and typically processes within 10 business days.

Inconsistent Information Across Systems

Your name, address, NPI, and license information must be consistent across NPPES, PECOS, CAQH, and each insurance company. Inconsistencies trigger delays and additional verification requests. Before submitting your PECOS application, verify that your NPPES record is current and accurate.

Missing the Signature Step

A surprising number of applications are delayed because the applicant completed the online form but did not submit a signature. If PECOS requires a mailed signature page, print it, sign it, and mail it the same day you submit the electronic application. An unsigned application will not be processed.

Not Tracking Application Status

PECOS allows you to check your application status online. Check it every two to three weeks. If your application has been in "Received" status for more than 45 days, contact your MAC to inquire about the timeline. Proactive follow-up can identify issues before they become significant delays.

Ignoring Revalidation Notices

When you receive a revalidation notice from CMS, respond promptly. Providers who miss the revalidation deadline have their billing privileges deactivated, which means all Medicare claims will be denied until you submit a new enrollment application and it is approved. This can take months and creates significant financial disruption.

Medicare Billing Basics for New Enrollees

Once enrolled, you will need to understand the following:

• Fee schedule — Medicare pays according to the Medicare Physician Fee Schedule. Look up current rates for your CPT codes at the CMS fee schedule lookup tool
• Assignment — Accepting assignment means you accept the Medicare-approved amount as full payment. Most mental health providers must accept assignment
• Timely filing — Medicare claims must be submitted within one calendar year of the date of service
• ABN (Advance Beneficiary Notice) — If you provide a service that Medicare may not cover, give the beneficiary an ABN before the service so they can make an informed decision about financial responsibility
• Claims submission — Medicare claims are submitted electronically through a clearinghouse or your EHR/billing system