Under Section 6405 of the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) requires certifying physicians to be enrolled in Medicare or to have an approved Medicare opt-out status before Medicare can pay for hospice services. This requirement applies to hospice physicians as well as hospice attending physicians and supports CMS’ ongoing efforts to strengthen hospice program integrity and improve the quality of patient care.
CMS Enforcement of Medicare Enrollment Requirement
CMS began enforcing this requirement on June 3, 2024 (previously scheduled for May 1, 2024). As a result, Medicare now validates the physician listed in the Attending field of a hospice claim against the Provider Enrollment Chain and Ownership System (PECOS).
If the physician is not enrolled in Medicare or properly opted out, CMS will deny the hospice claim.
Therefore, hospices should verify physician enrollment status before submitting claims to avoid unnecessary payment delays and denials.
Enrollment Options for Certifying Physicians
CMS offers three enrollment pathways for physicians and other eligible practitioners who certify hospice services.
1. CMS-855I (PDF)
CMS-855I (PDF) for Physicians, Nurse Practitioners (NPs), or Physician Assistants (PAs) — Complete this application if you are an individual practitioner or eligible professional who plans to bill Medicare, certify, refer or order services.
2. CMS-855O (PDF)
CMS-855O (PDF) for Ordering and Certifying Physicians/NPs/PAs — Complete this application if you are an individual practitioner or eligible professional and enrolling sole purpose of ordering or certifying items and/or services to beneficiaries in the Medicare program.
3. Opt-Out Affidavit
Opt-Out Affidavit for Eligible Physicians/NPs/PAs — Opt-Out Affidavit for Eligible Physicians/Practitioners (PDF)
Physicians who choose not to participate in Medicare may use the Opt-Out Affidavit, provided they meet CMS requirements.
Contact the Appropriate Medicare Administrative Contractor (MAC)
Physicians, NPs, and PAs must enroll with the Medicare Administrative Contractor (MAC) that serves the region where they practice. In addition, they should verify their enrollment status with their own MAC, even if it differs from the hospice organization’s MAC.
Please see:
Contact Your MAC (PDF) for MAC jurisdictions.
Verify Enrollment Through the CMS Order and Referring Dataset
CMS maintains the CMS Order and Referring Dataset, which lists physicians, nurse practitioners, and physician assistants who are legally eligible to order, certify, and refer services within the Medicare program. The dataset identifies providers by their National Provider Identifier (NPI) and includes current Medicare enrollment records.
A hospice-specific column was added before the enforcement date to help providers verify eligibility more efficiently.
Important Information for Opt-Out Physicians
Not every physician who has opted out of Medicare can certify patients for the Medicare Hospice Benefit.
If a physician did not submit all required information to obtain ordering, certifying, and referring privileges, or if CMS revoked the physician’s Medicare enrollment because of adverse actions, that physician cannot certify hospice services.
Providers should review the Provider Opt-Out Affidavits Look-up Tool and check the Eligible to Order and Refer field.
- If the field displays “Yes,” the physician has a PECOS record and may certify hospice services.
- If the field displays “No,” the physician does not have a PECOS record and cannot certify.
Billing Physician Services Under Hospice
When a hospice bills Medicare for medically necessary physician services performed by hospice-employed or hospice-compensated physicians, nurse practitioners, or physician assistants, those practitioners must have a CMS-855I Medicare enrollment with billing privileges.
A hospice cannot bill Medicare for physician services when the physician or practitioner does not have Medicare billing rights for physician services outside the hospice setting.
Furthermore, physician service billing remains separate from other hospice claim components, including:
- Level of care
- Skilled nursing services
- Medical social services
- Prescription drugs
- Other hospice-covered services
Hospices use revenue code 0657 to report physician services furnished to patients by physicians, NPs, or PAs employed by or receiving compensation from the hospice.
Payment for physicians’ administrative and general supervisory activities is included in the hospice payment rates and is not separately billable.
Why This Requirement Matters
Hospice organizations should routinely verify physician enrollment and PECOS records before submitting Medicare claims. Doing so helps reduce claim denials, supports compliance with CMS regulations, and ensures timely reimbursement for hospice services.
Resources
- Change Request 13342 (PDF)
- Become a Medicare Provider or Supplier
- Provider Opt-Out Affidavits Look-up Tool – Centers for Medicare & Medicaid Services Data
- See “Certification Requirements” in under the Hospice Payment System & Coverage topic
