Part D PrescribersMedicare Prescription Drug Plan (Part D) is an optional drug insurance program available to Medicare beneficiaries. However, medical billing for Part D drugs can be efficient only if the prescribers fulfill certain requirements. In May 2014, the Centers for Medicare & Medicaid Services (CMS) published the final regulation that requires physicians and other eligible professionals (when applicable) who write prescriptions for Part D drugs to be enrolled in Medicare in an approved status or have a valid opt-out affidavit on file for their prescriptions in order to be covered under Part D.

Though the effective date for the enforcement of this requirement was announced as June 1, 2015, CMS announced on December 5, 2014 that it will delay the final date until December 1, 2015. This announcement seems to suggest that Part D prescribers have been given a six month reprieve from certain program requirements supposed to go into effect from June. However, this is not the actual case. The delay is for Medicare contractors, not prescribers. Prescribers must submit their Medicare enrollment applications or opt-out affidavits to their Part B Medicare Administrative Contractors (MACs) by June 1, 2015, or earlier. The delay is to make sure that there is enough time for MACs to process provider enrollment applications and opt-out affidavits and thereby avoid a lot of prescription drug claim denials by beneficiaries’ Part D plans.

In order to prepare the prescribers and Part D sponsors for the December 1, 2015 enforcement date, CMS is making available an enrollment file. This file identifies physician and eligible professional enrolled in Medicare in an approved or opt out status. Though the first iteration of the enrollment file is now available at CMS website, it is considered to a test file. An updated enrollment file will be generated every two weeks and this will be continued through the enforcement date in December.

The file shows provider eligibility as of and after November 1, 2014 (currently enrolled, new approvals, or changes from opt-out to enrolled as of November 1, 2014). Inactive providers or existing providers having periods of inactivity prior to November 1, 2014 will not be displayed on the enrollment file. But any enrollment that became inactive after November 1, 2014 will be on the file along with its respective end dates for that given provider. In case of opted out providers, the opt-out flag will display a Y/N value in order to indicate the periods the provider was opted out of Medicare. The file will include the following details of the provider.

  • National Provider Identifier (NPI)
  • First and Last Name
  • Effective and End Dates
  • Opt Out Flag

In short, physicians must be ready to prepare for the enforcement date with all the relevant documents to avoid claim denials. They can conduct internal audits to make sure everything is alright. A professional medical billing company can prove to be of invaluable assistance when it comes to managing the entire revenue cycle of the practice as well as claim denial management.