The simple answer is no; you cannot bill Medicare for services you render if you are not credentialed. Without proper credentialing and an approved enrollment status, Medicare will not recognize you as an eligible provider and will deny any claims submitted under your name. The Medicare provider enrollment process is a fundamental requirement to get paid for services. It is designed to ensure providers meet specific standards for care, safety, and compliance before they can receive public funds.
If a claim is submitted for services provided by an uncredentialed provider, it will be rejected. This can result in a significant financial burden for the organization, as there is no guarantee of reimbursement for services already delivered.
Medicare Credentialing Requirements
The inability to bill Medicare directly for non-credentialed providers is a critical operational issue for any healthcare facility. This is why understanding the rules around billing for non-credentialed providers is so important. In general, it’s not permissible to simply bill for services provided by a non-credentialed professional under the name or NPI of a credentialed one. This practice can be seen as fraudulent and can lead to severe consequences, including fines and potential legal action.
The question of “Can a non-credentialed provider bill under another provider?” has very limited exceptions. The most common scenarios are “incident-to” billing or locum tenens arrangements, both of which have strict requirements. In “incident-to” billing, a non-physician practitioner’s services can be billed under a supervising physician’s NPI, but only if the physician is physically present in the office suite and has established the initial plan of care. Similarly, locum tenens allows a substitute physician to bill under the regular physician’s NPI for a limited time, typically a maximum of 60 consecutive days, to cover for a temporary absence. These are not permanent solutions and must be handled with great care to avoid compliance issues.
When a claim is denied because a provider is not properly credentialed, the billing system will return a specific code. For example, a common provider not credentialed denial code you might encounter is B7, which indicates that the provider was not certified or eligible to be paid for a service on a specific date. Receiving this code is a clear signal the enrollment process was either incomplete, denied, or has not been finalized, and it requires immediate attention. APHL tells us laboratories that have moved from paper or manual entry to integrated systems consistently report higher accuracy and far fewer clerical errors, directly translating into better patient safety and fewer result corrections. This same principle applies to billing and credentialing—automation and a dedicated system can prevent these costly errors.
Medicare Credentialing Application
While a non-credentialed provider can see patients, you will not be able to get paid for those services by Medicare. The distinction between providing care and being reimbursed for that care is the core of the credentialing process. Seeing patients without the ability to bill creates a financial liability for the practice and can lead to patient frustration if they are unexpectedly faced with the full cost of their care. This is a common situation for new hires who are ready to begin work but are still waiting for their applications to be approved.
The key is to proactively manage the application process from the moment a new provider is hired. How to bill Medicare as a Provider starts with the official application to enroll. This involves two main components: obtaining a National Provider Identifier (NPI) and then submitting your enrollment application through the internet-based Provider Enrollment, Chain, and Ownership System (PECOS).
The PECOS system is the most efficient way to submit and manage your application. You will need to complete the CMS-855 form, which requires detailed information about the provider, their education, state license, and professional history. Any discrepancies or missing information will cause significant delays. It is important to stay on top of the process and respond quickly to any requests for additional information from your Medicare Administrative Contractor (MAC). The time it takes to process these applications is a critical part of a provider’s onboarding, and any hiccup can impact revenue.
Choosing the Right RCM Partner
Given the complexities of credentialing, many organizations choose to partner with a revenue cycle management (RCM) company. The best Medicare provider enrollment partner can help streamline the application process, ensuring all required forms and documentation are submitted correctly and on time. These partners have the expertise to navigate the intricate requirements of Medicare and other payers, reducing delays and minimizing the risk of costly denials. By outsourcing this administrative burden, your team can focus on its core mission of providing quality care.