Medicare Compliance & Reimbursement

Ensure you have these critical documentation items upfront.

There’s no denying that the application process for Medicare provider enrollment can be challenging. There are a lot of t’s to cross and i’s to dot. However, registering as a provider in Medicare’s Opioid Treatment Program (OTP) makes regular enrollment seem like short work.

That was the word from NGS Medicare’s Susan Stafford in the Part B Medicare Administrative Contractor’s (MAC’s) webinar, “Provider Enrollment Opioid Treatment Program.” Read on for more details.

First, before you apply, there are a few critical pre-enrollment steps you’ll need to know to ensure an easier process. Check out these five OTP facts that may give you an edge on completing your application thoroughly and efficiently.

1. The OTP is open to both Part A and Part B providers now.

“Originally the program started with Part B, but now Part A providers can join, too,” Stafford said. On Jan. 1, 2020, the Centers for Medicare & Medicaid Services (CMS) first started paying Part B providers treating beneficiaries with opioid use disorder (OUD) as part of the OTP. On Jan. 1, 2021, CMS opened the opportunity up to Part A providers, NGS guidance says.

2. Enrollees use traditional CMS forms for their provider classification.

As with basic Medicare provider enrollment, OTP providers use the application that specifies the part they’re applying under. Currently, the agency accepts the traditional paper applications — CMS-855A for institutional providers and CMS-855B for group practices, clinics, and other suppliers — as well as online applications through the Provider Enrollment, Chain and Ownership System (PECOS). If both types of application are an option for your organization, “CMS recommends applying electronically, which will allow your application to be processed faster,” the Medicare OTP fact sheet indicates.

Important: This may sound simple, but there are other CMS-855 forms’ problems to contend with. For example, “OTPs may enroll (and be enrolled) in Medicare via the Form CMS-855A or the Form CMS-855B but not both,” the fact sheet cautions.

Plus, if you decide to switch your enrollment from Part A to Part B or vice versa, you’ll need to complete the necessary risk screenings, both limited and moderate/high levels, during the submission process. Additionally, the effective billing date attached to your original enrollment stays the same, no matter if you re-enroll under a different form — and you will likely be charged an application fee for the switch, CMS says.

Tip: “On the application, in the specialty section, you need to specify ‘OTP’ if it’s not already selected,” Stafford instructed. You can also list “other” or “type ‘opioid treatment provider,’” point out NGS materials.

3. You need specific licenses, authorizations, and registrations before applying.

SAMHSA certs: If you apply with a provisional SAMHSA certification, your organization should expect your MAC to deny your application.

“In order to become an opioid treatment provider each location must be fully certified by the Substance Abuse and Mental Health Services Administration better known as SAMHSA,” Stafford noted.

“You need to make sure that you have every SAMHSA certification, including renewal letters for each location,” she cautioned. “When you go through PECOS, there will be a section that says licenses, certifications, DEAs. You need to identify every single one of your SAMHSA certifications in the certification section as well as add the supporting documents — and there can be more than one.”

Plus, CMS requires that providers receive “accreditation from an accrediting body approved by SAMHSA” before they can supply OTP services, agency guidance maintains.

You can apply for a SAMHSA certification at www.samhsa.gov/medication-assisted-treatment/become-accredited-opioid-treatment-program.

Professional licensure: Medical licensing is essential for providers interested in OTP enrollment. You must be licensed in the state where you’ll be operating and offering OTP services. These criteria are also required to get the SAMHSA certification. You need to list every state operation license, Stafford said.

DEA registration: Another necessary pre-enrollment item that providers must follow up on is their Drug Enforcement Agency (DEA) registration, which is also mandated by SAMHSA for its certification.

If you’re wondering why, it has to do with the treatments and services you’ll be offering as an OTP provider. “Register with the local DEA office because you’re going to be dispensing,” Stafford reiterated.

Contact your local DEA office at www.dea.gov/divisions and review the ins and outs of getting your DEA license at www.deadiversion.usdoj.gov/drugreg/reg_apps/pract_state_lic_require.htm.

CMS-1561 form: “An authorized or delegated official must sign the provider agreement, which is the CMS-1561, and submit that form also with the application,” Stafford related.

Tax info: It’s also essential that you have the correct Internal Revenue Service (IRS) information on your application. “We also want to make sure you have a copy uploaded of your CP575 [letter] or 147C [letter] identifying your legal business name as well as the 501(c)(3) [status] if you’re a nonprofit,” explained Stafford. “It could just be one document for all; it just depends on how you are set up as an entity.”

4. You might want an NPI specifically for your OTP enrollment.

In order to enroll in Medicare, you must have a National Provider Identifier (NPI), which you can apply for through the National Plan and Provider Enumeration System (NPPES) site. It takes about 10 days to get an NPI via the online application. You can find details about the application process at https://nppes.cms.hhs.gov.

Reminder: The NPI is a 10-digit “intelligence-free” numeric identifier that does not showcase any information about a provider’s specialty or location. Under HIPAA provisions, covered healthcare providers, as well as all health plans and healthcare clearinghouses — and any other necessary entity — have to use the NPI on administrative and financial transactions, says the MLN Booklet “NPIs: What You Need to Know.”