Hospice Certifying Physician Medicare Enrollment Information

Published 07/09/2024

Pursuant to our authority under section 6405 of the Affordable Care Act, and as part of CMS’ larger strategy to address hospice program integrity and quality of care, certifying physicians, including hospice physicians and hospice attending physicians, must be enrolled in or opted-out of Medicare for the hospice service to be paid.

Effective June 3, 2024, (delayed from May 1, 2024) CMS will begin implementing edits to enforce this new rule and will deny hospice claims if the physician entered in the Attending field on the claim is not in the Provider Enrollment Chain and Ownership System (PECOS) as an enrolled or opted-out physician.

There are three Medicare enrollment options for physicians who want to certify for the Medicare Hospice Benefit (these enrollment options also include enrollments for nonphysician practitioners, but they cannot certify for the Hospice Benefit). They are:

  • CMS-855I (PDF) Medicare Enrollment Application for Physicians and Nonphysician Practitioners
    • Complete this application if you are an individual physician, practitioner or eligible professional who plans to bill Medicare and/or certify, refer or order Medicare services
    • It is not required that the primary specialty of “Hospice/Palliative Care” is selected in Section 2G of the CMS-855I application, as a medical doctor of any specialty or doctor of osteopathy may certify or recertify an individual for the Medicare Hospice Benefit
  • CMS-855O (PDF) Medicare Enrollment Application for Eligible Ordering/Certifying Physicians and Other Eligible Professionals
    • Complete this application if you are an individual physician, practitioner or eligible professional and enrolling sole purpose of ordering or certifying items and/or services to beneficiaries in the Medicare program.
  • Opt-Out Affidavit for Eligible Physicians/Nonphysician Practitioners with Certifying Rights

Physicians must enroll with the MAC specific to the region where they practice. They can also check in with their MAC, which may differ from the hospice’s MAC, regarding their enrollment status. Please see Contact Your MAC (PDF) for MAC jurisdictions.

The CMS Order and Referring Dataset provides information on all physicians and nonphysician practitioners by their National Provider Identifier (NPI), who are of a type/specialty that is legally eligible to order, certify and refer in the Medicare program and who have current enrollment records in Medicare. A hospice column was added prior to the effective date of this requirement. A professional listed with an “N” in the hospice column of the CMS Order and Referring Dataset cannot certify for hospice. Non-physician practitioners cannot certify for hospice and therefore will have a “N” in the hospice column of the CMS Order and Referring Dataset.

If an opt-out physician does not appear on the CMS Order and Referring Dataset, they may not be eligible to order, certify and refer in the Medicare Program, including for hospice. You may access the Provider Opt-Out Affidavits Look-up Tool and see if the field “Eligible to Order and Refer” has a “Yes” or “No” populated. If “No” is populated, they do not have a PECOS record and cannot certify. The physician may contact their MAC for the reason they are not eligible to order, refer, or certify.

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