Getting certified to participate in Medicare and Medicaid requires a series of concrete steps: obtaining a National Provider Identifier, submitting the correct enrollment application, passing a compliance survey, and maintaining your certification over time. The process differs depending on whether you’re an individual practitioner or an institutional provider like a hospital, nursing facility, or home health agency. Here’s how each piece works.
Get a National Provider Identifier First
Before you can enroll in Medicare or Medicaid, you need a National Provider Identifier (NPI). This is a unique 10-digit number assigned to every healthcare provider in the U.S., and it’s required for billing and enrollment. You apply for one through the National Plan and Provider Enumeration System (NPPES) at nppes.cms.hhs.gov.
There are two types. A Type 1 NPI is for individual practitioners who personally render healthcare services. A Type 2 NPI is for organizations such as group practices, hospitals, or clinics. During the application, you’ll need to select at least one healthcare taxonomy code that describes your specialty or service type. The first one you enter becomes your primary taxonomy by default. An employer or authorized surrogate can also submit the application on a provider’s behalf.
Choose the Right Enrollment Application
Medicare enrollment uses different versions of the CMS-855 form depending on your provider type. Picking the wrong one will delay your application.
- CMS-855A: For institutional providers such as hospitals, skilled nursing facilities, home health agencies, and other facility-based providers.
- CMS-855B: For clinics, group practices, and certain suppliers. Sole owners who need to add an authorized official to their enrollment also use this form rather than the 855I.
- CMS-855I: For individual physicians and non-physician practitioners (nurse practitioners, physician assistants, clinical social workers, and other eligible professionals). This form is also now used for reassignment of benefits, since the old CMS-855R has been discontinued.
Both an individual practitioner and their group practice must be enrolled (or enrolling at the same time) before a reassignment of billing privileges can take effect. So if you’re joining a group, coordinate your CMS-855I submission with the group’s CMS-855B.
Submit Online Through PECOS
The fastest way to submit your enrollment application is through the Provider Enrollment, Chain, and Ownership System (PECOS) at pecos.cms.hhs.gov. PECOS lets you complete, sign, and submit your application electronically, upload supporting documents, and manage your enrollment record going forward. Because it’s paperless, you won’t need to mail anything. You can also use PECOS later for revalidation and updates to your enrollment information.
Paper submissions are still accepted, but they take significantly longer to process. CMS strongly encourages electronic submission for all provider types.
Application Fees
For calendar year 2025, institutional providers pay a $730 application fee when initially enrolling, revalidating, or adding a new practice location. This applies to Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).
Not everyone pays the fee. Individual physicians and non-physician practitioners submitting a CMS-855I are exempt. Medicaid or CHIP providers who are individual practitioners are also exempt. So are Medicaid or CHIP institutional providers that are already enrolled in Medicare or in another state’s Medicaid/CHIP program and have already paid the fee there.
Meeting the Conditions of Participation
Individual practitioners don’t face a facility inspection, but institutional providers must meet a detailed set of federal health and safety standards called the Conditions of Participation (CoPs). These are laid out in Title 42 of the Code of Federal Regulations and cover virtually every operational area of a facility.
For hospitals, the CoPs span more than two dozen categories: patient rights, governing body structure, emergency preparedness, quality assessment and performance improvement, medical staff credentialing, nursing services, medical records, pharmacy, radiology, laboratory, food and dietetic services, infection prevention, discharge planning, surgical and anesthesia services, emergency services, and the physical environment, among others. Other facility types (nursing homes, home health agencies, hospices) have their own tailored sets of conditions.
The practical takeaway is that your facility needs documented policies and procedures for each of these areas before you invite a survey. Gaps in any single condition can result in a citation of non-compliance and delay or denial of certification.
The State Survey and Certification Process
Once an institutional provider submits its enrollment application, a State Survey Agency conducts an on-site inspection. These agencies operate under agreements between each state and the federal Department of Health and Human Services, and they employ qualified health professionals to perform the surveys.
During an initial certification survey, the survey team evaluates how well your facility complies with the applicable Conditions of Participation. They review documentation, observe care delivery, interview staff and patients, and verify that your operations match what’s required by federal regulations. After the survey, the State Survey Agency submits its findings and a formal certification recommendation to the CMS Regional Office, which makes the final determination on whether to certify the facility.
If the survey identifies deficiencies, you’ll typically have an opportunity to submit a plan of correction and undergo a follow-up survey. Serious or widespread deficiencies can result in denial of certification or, for existing providers, termination from the program.
Deemed Status as an Alternative
Institutional providers can sometimes bypass the State Survey Agency inspection by obtaining accreditation from a CMS-approved accrediting organization. This is called “deemed status,” meaning CMS deems the facility to meet its Conditions of Participation based on the private accreditor’s standards and survey process.
Recognized accrediting organizations include the Joint Commission, the Accreditation Commission for Health Care (ACHC), the Community Health Accreditation Program (CHAP), the Healthcare Quality Association on Accreditation (HQAA), the National Association of Boards of Pharmacy, and The Compliance Team, among others. Not every accreditor covers every provider type, so you’ll need to confirm that the organization you choose is approved for your specific category of facility. Accreditation involves its own application, fees, and survey process, but many providers prefer it because accrediting bodies often provide more detailed guidance and ongoing support between survey cycles.
Medicaid Enrollment
Medicaid enrollment is administered at the state level, so the process varies depending on where you practice. Each state has its own Medicaid agency, application portal, and provider requirements. In many states, being enrolled in Medicare satisfies some or all of the Medicaid credentialing requirements, but you still need to complete a separate Medicaid enrollment application with your state agency.
For institutional providers, the same State Survey Agency that handles Medicare certification surveys typically also handles Medicaid compliance. If your facility passes the Medicare certification survey, the findings often apply to Medicaid as well, so you generally won’t face two entirely separate inspections.
Revalidation and Ongoing Requirements
Certification isn’t permanent. Medicare requires providers and suppliers to revalidate their enrollment every five years (every three years for durable medical equipment suppliers). CMS sends a revalidation notice by email or postal mail three to four months before your due date. There are no exemptions and no extensions.
Revalidation is most easily done through PECOS, where you can review the information currently on file, update anything that’s changed, upload supporting documents, and submit electronically. If you miss the deadline, CMS can place a hold on your Medicare reimbursements or deactivate your billing privileges entirely. Reactivation after deactivation requires submitting a complete new enrollment application, and you won’t be reimbursed for any services provided during the gap.
Beyond revalidation, you’re responsible for reporting changes to your enrollment information (new addresses, ownership changes, practice locations) within the timeframes CMS specifies. For institutional providers, periodic resurveys and complaint-driven surveys can happen at any time to verify continued compliance with the Conditions of Participation.