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Every once in awhile, you’re asked for it, and can’t seem to understand why
you’re being asked for it again. Hopefully the following will clear up some questions regarding
what exactly is needed in regards to the Medicare Participation Letter.
Although Medicare Participation is not a requirement of PREFERRED
Therapy Providers, Inc., it is a requirement for some of our contracted health plans*. In order for
PREFERRED to comply with delegated credentialing obligations under
certain health plan agreements, we must have proof of your participation on file. From time to time we are
audited by our contracted health plans to ensure that our files meet these standards.
Recently, PREFERRED asked the payors that require proof of
Medicare participation on the basics of what is needed in terms of proof. The answers have returned,
and are listed below:
- Single Clinics = One letter stating that the entire facility is covered. The letter must include:
Practice Name, Practice address (a corporate address cannot be accepted), Effective Date,
Group number.
- Multiple Clinics = You may use one letter per clinic, or use a tie-in letter which will list each address
covered under the assigned group number. Letter must also include: Practice Name, Practice
Address (a corporate address cannot be accepted), Effective Date, Group Number.
- Individual Therapists = If your clinic is not covered as a whole, and/or each therapist has an
individual number, then one letter is needed per therapist with the following information: Therapist Name,
Effective Date, Therapist ID Number.
- Change of address = When requested, Medicare will provide a letter stating that they acknowledge
your new location address. NOTE: The new address must be listed on the letter. Address changes c
annot be accepted if handwritten on the original letter.
Corporate addresses are not accepted for a very simple reason. Should an individual clinic ever be
bought, sold, or merge with another, it must be able to stand on its own during an audit by any payor.
According to payors like Pacificare and Aetna (among others) using the facility address is mandatory in
order to prevent any confusion.
Originally the signed application page may have been accepted by PREFERRED
as proof to get a clinic started with the plans, but does need to be replaced with the actual approval letter.
PREFERRED has looked extensively, however has not been able to find
that one magical website or phone number to aid in getting the correct proof of participation. Your request
may have to be made in writing to Medicare directly.
If you have any questions about where to make that request, or if you have any questions on the
Medicare Mystery in general, contact PREFERRED at 800-664-5240.
*Proof of a certification equivalent to Medicare is requested for specialties where Medicare is not
applicable (e.g. Pediatrics).
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