How to Enroll in Medicare and Medicaid as a Physician | Step-by-Step Guide

Medicaid provider enrollment and Medicare enrollment for physicians are both key components in building a long-term, successful medical practice. Once enrolled in Medicare by the Centers for Medicare & Medicaid Services (CMS), physicians will be able to bill over 65 million Medicare recipients. Also, once enrolled in Medicaid, physicians can expand their patient base to include low-income patients from all 50 states.  

If either CMS or state Medicaid enrollment has not been completed by a medical practice, the practice may experience a loss of revenue due to its inability to bill Medicare. This blog will detail the physician enrollment in Medicare application process using PECOS, the Medicaid provider application process for physicians, physician credentialing for Medicare, the Medicare provider application, and the Medicaid provider enrollment requirements for physicians, including other relevant entities such as PECOS, National Practitioner Data Bank (NPDB), Council for Affordable Quality Healthcare (CAQH), and Drug Enforcement Administration (DEA). 

Understanding Medicare and Medicaid Enrollment 

While Medicare and Medicaid have different target patient groups, both create complexities that can be very difficult for physicians to navigate.  

The Medicare enrollment process for physicians will fall under the jurisdiction of CMS, the federal agency that oversees all aspects of CMS provider enrollment for Medicare. To start billing as a Medicare physician, a physician must go through the Medicare physician enrollment process, most often this will occur using the PECOS (Provider Enrollment, Chain and Ownership System) system, which is an online portal created by CMS. 

To enroll as a Medicaid provider, a physician must submit a separate application for each state in which he wishes to practice medicine. This creates significant burdens, because each state has its own specific requirements for Medicaid provider enrollment, which may require additional screening fees and revalidation. High-risk providers also undergo enhanced reviews utilizing the NPDB (National Practitioner Data Bank) regarding any potential malpractice history. 

The difference? While the Medicare provider application process uses a uniform CMS-855I form, the Medicaid provider application process is highly variable from one state to another. Both use the National Provider Identifier (NPI) and are tied to physician credentialing for Medicare via CAQH ProView to share data. Registration for DEA purposes is required in both cases when prescribing controlled substances. 

For physicians who practice across multiple states, the process of enrolling as a Medicaid provider becomes significantly more complex due to the need for multistate Medicaid provider enrollment, which creates additional paperwork. Understanding these processes will ensure that a physician complies with applicable regulations and receives timely Medicare billing enrollment activation. 

Why Physician Enrollment Is Important 

Physician enrollment with Medicare allows physicians to receive stable reimbursement from Medicare. The number of elderly and disabled patients covered by Medicare is over 65 million and represents 20 to 30 percent of many physicians’ patient bases. By completing the Medicare provider’s enrollment process, a physician obtains a Provider Transaction Access Number (PTAN) which allows a physician to submit claims through Medicare. 

Medicaid is another area that has over 80 million enrolled members. These are typically individuals who live in underserved areas, and without Medicaid enrollment, physicians will lose their ability to bill Medicare and could be audited based on potential violations of the False Claims Act. In addition to being an essential part of a physician’s practice, enrollment is also associated with value-based care, expanded use of telemedicine, participation in MIPS, and other quality programs. 

Enrollment cycles can occur every three to five years. Failure to meet these cycles may result in the deactivation of your ability to bill. An entity such as NPDB lists any negative or adverse action against a physician, and CAQH helps streamline verification processes. Any lapse in a physician’s DEA certification will prohibit a physician from prescribing medicines and impact the physician’s credentialing process for Medicare. Overall, enrollment provides a means for a physician to protect their practice and ensure they remain compliant. 

Step-by-Step Medicare Enrollment Process 

The Physician Medicare enrollment process is done through Medicare Provider Enrollment Steps that are processed and managed by Medicare Administrative Contractors (MACs).  

Step 1: Create PECOS account  

Create an account through PECOS to begin the enrollment process. Obtain a free and immediate Type 1 NPI from NPPES if you need one. Use NPI login credentials to register at PECOS. The CMS’s Provider Enrollment, Chain, and Ownership System (PECOS) processes approximately 95% of all applications online. There are also CMS tutorials for Medicare provider enrollment.  

Add all locations associated with your practice; groups have a Type 2 NPI. This is the first step to enrolling in Medicare as a physician and typically takes 15-30 minutes. Identity verification is required through ID.me for security purposes. 

Step 2: Complete CMS-855I Form 

Complete your individual Medicare provider application, which is CMS-855I. Provide details for your practice, if you are using a billing agency to bill on behalf of your practice, and complete the CMS-588 EFT form and the CMS-460 Medicare Participation Agreement. Pay the $750 (2026 fee) for your application through PECOS.  

List ownership stakes of more than 5%, as well as employees that you manage. The core of physician credentialing in Medicare is to create transparency. Be sure to save drafts of each section, because mistakes during this process will cause delays with Medicare billing enrollment. 

Step 3: Submit Documents 

Upload all the necessary documentation and proofs required for physician enrollment in Medicare, such as:   

• Current, unrestricted state license  

•  DEA certificate, if applicable 

•  Malpractice insurance face sheet  

•  Board certifications 

•  5-year work history and CV  

•  IRS CP-575 or SS-4 TIN letter 

•  NPDB self-query report  

•  CAQH profile ID 

Step 4: Approval Process 

Use PECOS to submit your application. The MAC will review it in 30-90 days with a tentative effective date of 60 days. You can track the progress of the application on the PECOS dashboard. A provisional approval permits you to bill back to the date of your clean application.  

A rejection is usually due to incomplete information on the application (the rejection rate is approximately 10 to 15%), and you should appeal within 30 days. Once you receive your new PTAN number, you will be able to activate your Medicare billing enrollment. In some cases, fingerprinting may be required to complete the revalidation process. 

Medicaid Provider Enrollment Process 

Once Medicare enrollment for physicians is done, complete Medicaid provider enrollment on a state-by-state basis. Here is the Medicaid provider enrollment process for physicians:  

• First, you need an NPI number, and then you will be able to go to a website that is specific to your state, such as California Medi-Cal Provider Enrollment or Texas TMHP.  

• Once you are logged into the website, you will need to complete the Medicaid provider enrollment process. You will have to submit your W-9 licenses and report exclusions through the List of Excluded Individuals/Entities (LEIE) and NPDB. The fees for this service range from $0 to $50, and it may take anywhere from 45 to 120 days to process.  

• You will also have to separately enroll with managed care organizations (MCOS). Medicaid provider enrollment requirements vary by state. For example, in Florida, you will have to get fingerprinted.  

• You will have to revalidate your Medicaid enrollment every one to five years, and if you are licensed in multiple states, you will have to complete an application for each state. Your Medicaid provider enrollment may be tied to your Medicare credentialing through CAQH data. 

Here are some state-specific Medicaid provider enrollment process requirements: 

Documents Required for Physician Enrollment  

Common documents that are required to be submitted to get registered for insurance include: 

• NPI number  

• Physician license(s) 

• DEA number  

• Malpractice insurance with occurrence coverage or claims 

• Curriculum vitae  

• W-9 or TIN  

• NPDB report that is valid for 120 days 

• Proof of professional liability insurance coverage 

• Hospital privileges, if applicable 

• Check OIG exclusion 

• Complete CAQH (to expedite CMS provider enrollment process) 

In addition to the universal documentation, a physician will need to provide additional documentation when applying for Medicare through the Centers for Medicare and Medicaid Services. For example, an additional attachment to the CMS-855I form is typically necessary. In addition, the state-specific documentation requirements for Medicaid provider enrollment may require a lease agreement or contract with a managed care organization.  

Reminder, the DEA number expires every 3 years, and if it lapses, it can suspend the ability to practice medicine. 

Common Enrollment Mistakes Physicians Make  

The most common mistakes physicians make during the PECOS and Medicaid provider application and enrollment processes result in 40% of all delays. 

• Incomplete Medicare provider applications where CMS-588 is missing, or there are TIN mismatches. 

• Out-of-date credentials in a physician’s credentialing file for Medicare (e.g., an expired license). 

• No NPDB, LEIE background checks done on new hires by the physician, which will trigger the denial of their Medicare billings 

• The wrong Medicare Administrative Contractor (MAC) is used when submitting a new practice location. 

• Physicians fail to follow each state’s varying Medicaid provider enrollment requirements. 

• There is no revalidation plan for the physicians’ Medicare billing enrollments. 

• Ownership disclosures or CHOW notifications are overlooked. 

• Double-check using the MAC checklists and respond to the Request for Information (RFI) within 10 days. 

These are some of the most common mistakes physicians make when enrolling in PECOS and completing their Medicaid provider application. A proactive checklist system will allow physicians to avoid these entirely. This includes utilizing credentialing experts such as Credex Healthcare for auditing all documents and multi-state compliance.  

How Credentialing Companies Simplify Enrollment 

The purpose of credentialing firms is to speed up the physician’s Medicare enrollment process by managing the PECOS enrollment process, provider enrollment with CMS, and multiple state Medicaid provider enrollment. In doing so, they can achieve a 98% approval rate while reducing their enrollment timeline by 50%. 

Credex Healthcare, one of the top names in credentialing, licensing, and enrollment, has experience navigating physician Medicare, Medicaid provider enrollment, and insurance provider applications for over 2,000 payers. Credex also has expertise in assisting physicians navigate the requirements of each payer, as well as providing support for CAQH, NPDB inquiries, and follow-up. By delegating these tasks to a professional firm, you can focus on delivering exemplary patient care. 

FAQs 

How long does Medicare enrollment take for physicians?  

Medicare enrollment typically takes 30 to 90 days to complete the PECOS enrollment process. However, if you provide all the information required by CMS for a Medicare provider application at the same time as your PECOS application (i.e., all required documentation), it will be processed faster than 30 to 90 days.  

What documents are required for Medicaid enrollment?  

The NPI number, medical licensure number, DEA number, and NPDB number, as per state requirements, are needed for Medicaid provider enrollment.  

Can physicians enroll in Medicare online?  

Yes. Physicians can enroll in Medicare online through the PECOS website.  

What is PECOS in Medicare enrollment?  

PECOS (Provider Enrollment, Chain and Ownership System) is an online CMS system that physicians use to facilitate the PECOS enrollment process, or their Medicare enrollment process. 

Conclusion  

Physician practices can grow and thrive when they have mastered the processes of enrolling in Medicare and Medicaid (physicians) and becoming a Medicare provider. Utilize PECOS for your Medicare provider application, follow all Medicaid provider requirements, and work with professional service providers like Credex Healthcare for a smooth physician enrollment in Medicare and Medicaid.