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DMEPOS Accreditation: The Ultimate Guide

Overwhelmed and feel like you need help completing this? I'm now offering consulting services and can help you with this application.


In order for pharmacies to bill Medicare Part B for items like diabetic testing supplies, oral chemotherapy and immune suppressants, and all DME, they must first become an accredited provider of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).


This process is overwhelming, and for the first-time applicant it can be all-too-easy to make mistakes that lead to delays in processing the application. However, not becoming an accredited provider could mean thousands per year in lost business; in addition to losing the business from the products you could bill through Medicare B, you could also lose the accompanying prescriptions that patients will take elsewhere because they want to get everything in the same place.


For these reasons it is a really good idea to obtain DMEPOS accreditation.


You can also apply to only bill non-accredited products with it, which include oral chemotherapy, nebulized solutions, and immunosuppressants.


When I did this the first time I made tons of mistakes, which is why I’m writing this post: so you can avoid everything I did.


This guide take you step-by-step, through each part of the process and each page of the application, so you can get set up as quickly and easily as possible.


Glossary of Terms


More terms available here. I thought Medicare left some important ones out so I’m filling in those terms below/explaining the most important ones in plain language.


Accreditation Organization (AO): An independent company or organization approved by CMS, that “accredits” suppliers. “Accredit” in this case is basically verifying the supplier (i.e. you, as the pharmacy) complies with CMS quality standards.


CEDI: A “Common Electronic Data Interchange.” Basically an approved processor for your Medicare claims, like a PBM is for pharmacy claims. Information can be found on this page:

https://med.noridianmedicare.com/web/jddme/claims-appeals/cedi


Supplier Billing Number: Also called a PTAN, or Provider Transaction Access Number. It is issued by a MAC after the CMS-855S initial approval (you will not have a PTAN the first time you apply).


MAC: Medicare Administrative Contractor. A company contracted by Medicare to administer and process claims for Medicare Part A and Part B ("A/B MAC") and DMEPOS ("DME MAC") in each assigned Jurisdiction.


Here are the DME MACs, as of 2019, for each Jurisdiction:


Palmetto GBA is also in this business and occasionally shows up on the MAC list for DMEPOS.


National Supplier Clearinghouse (NSC): According to Palmetto GBA, the “single organizational entity responsible for issuing or revoking Medicare supplier billing privileges for suppliers of Durable Medical Equipment, Orthotics and Supplies (DMEPOS).”


Authorized Official: An owner or officer of the organization allowed to sign on behalf of, and contractually bind, the organization.


Delegated Official: An individual that an Authorized Official delegates their authority to for the purposes of DMEPOS accreditation.


Directory of Links



Step 1: Accreditation through an AO


You can get accreditation from any number of approved accreditors. NABP is one and you can find their accreditation site here.


As they state on their website, they will mail you materials to help you prepare for their accreditation process. Accreditation is required if you are wanting to bill for anything other than the products listed in Section


Because they have an in-depth applicant guide on their website, I won’t repeat everything here.


This step can be skipped if you only plan on billing for non-accredited products (See Step 3)


Step 2: Obtain a Surety Bond


This can be done before filling out any part of the application but will need to be obtained in

order for the application to be complete.


In order to bill Medicare for DMEPOS, Medicare requires a $50,000 Surety Bond be submitted with the CMS-855S application. There are numerous companies in the business of selling these "Medicare Bonds." But what exactly is that and why does Medicare require a pharmacy to have it?


Unfortunately, Fraud, Waste, and Abuse (FWA) is all-too common in the medical business; in fact, Medicare recovered $1.8 Billion and had 1,157 convictions related to FWA in 2017. A surety bond is actually a guarantee against fraudulent claims.


Here's how it works:

  • A pharmacy, with a Medicare surety bond, over-bills Medicare due to FWA

  • Upon discovery, Medicare responds by attempting to recover the losses, but the pharmacy is unable or unwilling to repay the debt.

  • Medicare responds by requesting payment from the bond company, up to the bond amount (again, $50,000 is the requirement) to recover the lost money.

  • Upon paying it, the bond company will then attempt to recover the money from the pharmacy.

Requiring a surety bond protects Medicare from FWA, can help deter FWA, and is considered more of a line of credit than insurance. The pharmacy does not have a right to the $50,000 in the case they do not pay Medicare for over-billed claims. This is important to understand because the surety bond protects Medicare, not the pharmacy. It is still the pharmacy's responsibility to accurately bill claims and not doing so can put the pharmacy at significant risk of financial and potentially criminal charges.


Here are some companies in the Surety Bond business:

Once you receive the Surety Bond, the Authorized Official MUST sign it! I’ve used Marsh in the past and they do state that in their cover letter they mail with the copy of the bond, but it is easy to overlook.


Also, make a copy of the Surety Bond. NSC will want to see it for their site visit (see Step 5).



Step 3: The CMS-855S Application


Go to this website and download the application.


Prepare yourself a stiff drink, because you’ll need it (see Step 9).


Fill it out electronically so you can save it. You will probably mess up and make changes a lot, so if you do it by hand older versions can easily get mixed in with the newest versions. Electronic makes it easy to print the most up-to-date copy as edits are made.


SECTION 1: BASIC INFORMATION

Fill in your state, NPI, Tax ID, etc.


One important point to note - the name you list under Legal Business Name must match the legal name provided to the IRS, the NABP, etc. If the names don't match exactly get them changed before submitting this application or it will get rejected.


At this point you will probably not have a Supplier Billing Number so just leave that blank.


Reason for submitting this application will be "new enrollee" if you have not ever submitted this application before.


What information is changing? fields can be left blank if this is a new application.

SECTION 2: IDENTIFYING INFORMATION


Date this business started at this location can typically be the initial licensure date, unless your business moved after getting licensed.


Leave the Change box and Effective Date blank if you are submitting a new application. That box is there in case an existing DMEPOS supplier needs to update their address with Medicare.


States where items provided: The boxes you check here will assign your application to the MAC for that jurisdiction. Future correspondence about this application will come from the MAC, not from CMS.


SECTION 3: PRODUCTS/ACCREDITATION INFORMATION


In this section you have two big options to choose from:

  • Become accredited

  • Only sell non-accredited products

If becoming accredited, you will need to first apply through an Accreditation Organization (AO); however, it can also lead to a large additional source of revenue so most pharmacies choose to pursue accreditation. For example, pharmacies must become accredited to bill CMS (i.e. Medicare B) for diabetic testing supplies.


As you can see on the application, the following products can be billed through Medicare B without Accreditation:

  • Epoetin

  • Immunosuppressive Drugs

  • Infusion Drugs

  • Nebulizer Drugs

  • Oral Anticancer Drugs

  • Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)