Learn about Medicare credentialing in Washington D.C. and Maryland for healthcare providers. This guide covers enrollment steps, regional considerations, and the appeals process to help providers navigate the credentialing system.
Medicare credentialing is a crucial step for healthcare providers who want to serve Medicare beneficiaries. While the process follows federal guidelines, there are some regional differences that providers in Washington, D.C., a federal district, and Maryland, a U.S. state should be aware of.
In this article, we will explore the Medicare credentialing process, how it applies to healthcare providers in both regions, and the letter of reconsideration process for providers who face enrollment denials or revocations.
Understanding Medicare Credentialing
Medicare credentialing is the process by which healthcare providers and suppliers apply for enrollment in Medicare to receive reimbursement for covered services. The credentialing process ensures that providers meet all federal and regional standards, protecting both patients and the Medicare program.
Who Needs Medicare Credentialing?
Any healthcare provider or supplier who wishes to bill Medicare for services must go through credentialing. This includes:
- Physicians and specialists
- Nurse practitioners and physician assistants
- Physical, occupational, and speech therapists
- Home health agencies and hospices
- Durable medical equipment (DME) suppliers
- Behavioral health providers
Each provider type has specific enrollment requirements, but the general credentialing process remains the same.
Medicare Credentialing Process in Washington, D.C. and Maryland
Since Medicare is a federally administered program, the credentialing process is similar across all U.S. states and the District of Columbia. However, there are some regional considerations that providers should keep in mind.
Step 1: Obtain a National Provider Identifier (NPI)
Before applying for Medicare credentialing, a provider must obtain an NPI through the National Plan and Provider Enumeration System (NPPES) (nppes.cms.hhs.gov).
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- The NPI is a unique 10-digit identifier required for Medicare billing.
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- Individual providers (e.g., therapists, physicians) and healthcare organizations (e.g., clinics, hospitals) must each have an NPI.
Step 2: Enroll in Medicare Through PECOS
Providers must submit their Medicare enrollment application online via the Provider Enrollment, Chain, and Ownership System (PECOS) (pecos.cms.hhs.gov).
The application includes:
Personal and practice details
Licensing and certification information
Specialty designation (e.g., therapy, home health, DME supplier)
Banking information for direct deposit payments
Washington, D.C. and Maryland Regional Differences
Both D.C. and Maryland fall under the jurisdiction of the same Medicare Administrative Contractor (MAC): Novitas Solutions, Inc.
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- Novitas handles provider enrollment applications for both regions.
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- Local licensing and regulatory requirements may differ, so providers should ensure compliance with their respective state or district licensing boards before applying for Medicare enrollment.
Step 3: Verification & Background Check
Once an application is submitted, Medicare reviews the provider’s credentials. This includes:
Verification of licensure and certifications
Review of practice ownership and history
Background checks for fraud or past disciplinary actions
This process can take 45-90 days depending on the provider type and whether additional documentation is required.
Step 4: Site Visits (If Required)
Certain providers, such as home health agencies and durable medical equipment suppliers, may be subject to a Medicare site visit to confirm the legitimacy of their practice location.
Step 5: Approval & Medicare Billing Privileges
If approved, the provider receives a Medicare Provider Transaction Access Number (PTAN), which allows them to submit claims and receive reimbursements for Medicare-covered services.
What Happens If Your Medicare Enrollment is Denied or Revoked?
In some cases, a provider’s Medicare application may be denied, or their billing privileges may be revoked due to compliance issues, missing documentation, or background check concerns. If this happens, providers have the right to appeal the decision through a Letter of Reconsideration.
Letter of Reconsideration Process in Washington, D.C. and Maryland
If a provider’s Medicare application is denied or their privileges are revoked, they have 65 days from the date of the determination letter to submit a reconsideration request.
Step 1: Review the Denial or Revocation Letter
The Medicare denial letter will outline the reason(s) for rejection. Common reasons include:
Incomplete or incorrect information on the PECOS application
Failure to meet licensing or certification requirements
Issues flagged during background checks (e.g., past exclusions from Medicare)
Lack of compliance with Medicare’s enrollment standards
Step 2: Prepare the Letter of Reconsideration
A Letter of Reconsideration should be professionally written and clearly explain why the denial should be overturned. The letter should include:
Provider’s name, NPI, and PTAN (if applicable)
A detailed explanation addressing the issues cited in the denial letter
Any corrected or additional documentation (e.g., updated licensing, certification, or proof of compliance)
A request for reconsideration and reinstatement
Step 3: Submit the Request to Novitas Solutions
Since both Washington, D.C., and Maryland are under Novitas Solutions, reconsideration requests must be submitted to the correct Medicare Enrollment Appeals department for Novitas.
- Requests must be submitted within 65 days of the denial notice.
- Medicare aims to process reconsideration requests within 90 days of submission.
Step 4: Corrective Action Plan (If Applicable)
If the denial or revocation was due to non-compliance with Medicare policies, providers may need to submit a Corrective Action Plan (CAP).
- A CAP is required if the issue involves non-compliance (e.g., a missing site visit, improper billing practices).
- The CAP must demonstrate how the provider has corrected the issue to meet Medicare’s requirements.
- If approved, Medicare may reinstate the provider’s billing privileges.
Step 5: Further Appeals (If Necessary)
If the reconsideration request is denied, providers may escalate the appeal to:
Administrative Law Judge (ALJ) Hearing – The next level of appeal for unresolved cases.
Departmental Appeals Board (DAB) – A higher-level appeal for complex cases.
Providers should work with healthcare attorneys or credentialing experts to ensure a strong case at higher appeal levels.
Key Takeaways: Medicare Credentialing & Reconsideration in Washington, D.C., and Maryland
Washington, D.C., and Maryland share the same Medicare Administrative Contractor (MAC), Novitas Solutions, Inc.
The Medicare credentialing process involves obtaining an NPI, submitting an application through PECOS, and passing verification checks.
If denied, providers have 65 days to submit a Letter of Reconsideration, addressing the reasons for denial and providing necessary corrections.
Corrective Action Plans (CAPs) may be required if a provider was revoked due to non-compliance.
Higher-level appeals (ALJ and DAB) are available for cases where reconsideration requests are denied.
Final Thoughts
Medicare credentialing can be complex, especially when navigating regional requirements. For providers in Washington, D.C., and Maryland, understanding the enrollment and reconsideration process is crucial to maintaining compliance and ensuring smooth billing operations.
If you are going through Medicare credentialing or facing enrollment challenges, consider consulting with a credentialing specialist or your regional MAC (Novitas Solutions) for guidance.
Are you a provider in D.C. or Maryland going through the credentialing process? Share your experience in the comments below!