Effective Date for Billing Medicare Claims

The determination of a provider’s effective date for billing Medicare claims is based upon the date an application is received from the following physicians, non-physician practitioners (NPPs) and organizations.

  • Certified Nurse Midwives 
  • Clinical Nurse Specialists 
  • Clinical Psychologists
  • Clinical Social Workers
  • CRNAs
  • Nurse Practitioners
  • Nutritional Professionals
  • Physicians
  • Physician Assistants
  • Physician / NPP organizations (group practices) consisting of any of the categories of individuals identified above
  • Registered Dieticians

In accordance with 42 CFR §424.520(d), the effective date for the individuals and organizations identified above is the later of either:

  • The date of filing the CMS-855 enrollment application
  • The date they first began furnishing services at a new practice location

Note: The date of filing means:
For Internet PECOS

  • The date we receive the 2-page signed certification statement pages in our mailroom
    • Send this and other supporting paper documentation within seven days of electronic submission

For paper applications

  • The date the entire (completed) application is received in our mailroom

In regard to billing Medicare claims, the individuals and organizations identified above may retrospectively bill for services dated up to 30 days prior to their effective date when the supplier has met all program requirements, including state licensure requirements and providing that the services were provided at the enrolled practice location. 

ScenarioEarliest Date of Service that May be Submitted / Rationale
Practice opens and first patient seen April 1; CMS-855 application not filed until May 30 April 30 – This is 30 days prior to the effective date
Physician begins treating patients on March 15; CMS-855 application submitted on April 3  March 15 – This date is within the 30-day time period  

MLN Matters® article MM6310 (PDF, 72 KB) 

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