Medicare
- Ivy Livengood
- Nov 10, 2025
- 3 min read
Updated: Nov 19, 2025
Let's demystify some things about Medicare. They tend to be the most difficult to credential with-- so I get a lot of questions about this payer. It doesn't matter what state you practice in, if you are a Medicare provider, this will be relevant to you. In this post, I'll cover some requirements needed prior to being able to credential with Medicare, necessary things to consider before/during the credentialing process, and claim filing/electronic remittance advice enrollments.
Traditional Medicare and Medicare Advantage Plans
Traditional Medicare (Original Medicare)
Paid directly by Medicare using the Medicare Fee Schedule.
Predictable reimbursement, low admin burden, fewer auths.
Clients can see most Medicare-accepting providers.
Medicare Advantage (Part C)
Paid by private insurance companies who run their own Medicare plans.
Each plan sets its own rates, networks, auths, and rules.
Often more admin work, variable reimbursement, restricted networks.
Short summary to remember for Part B: Original Medicare is federally standardized. Medicare Advantage behaves like commercial insurance.
In order to be in network with Medicare advantage plans you need to ensure you are FIRST credentialed with traditional Medicare then you need to ensure you are credentialed/contracted with Medicare line of business for that insurance payer. You can check with your provider representative.
Consistent Business Name
One reason Medicare is the most challenging payer to credential with is because they are very specific about your business name being consistent on the NPPES registry, your bank letter/voided check, and your CP 575 notice.
CP 575 Notice from the IRS- this is the letter you receive from the IRS that indicates your TIN/EIN after you register your business. The name on this letter must be consistent with what is on NPPES registry and the business name printed on your voided checks and/or bank letter.
The most common mistake I see people make is they will include LLC/PLLC after their business name when they set up their business bank account, but LLC/PLLC it not included after their business name on their CP 575 Notice from the IRS. Use the name that is printed on the CP 575 Notice exactly as it reads.
Role Requests
If you are submitting Medicare provider/group enrollment on behalf of someone else, you'll need to submit a role request first before you will be able to submit their enrollment. There are 3 different roles you can request: Staff End User, Access Manager, and Authorized Official. Here is a table to help break down the different roles and what their responsibilities are:
Role | Responsibilities |
Authorized Official (AO) | Represents the organization and has the legal authority to bind it. Can approve/manage connections and users. Acts on behalf of the organization in CMS systems. |
Access Manager (AM) | Represents the organization and can approve/manage connections and users. Manages staff users — grants or revokes access. Can access applications like PECOS on the organization’s behalf. |
Staff End User (SEU) | Individual employee invited by an AO or AM to work for the organization. No automatic access; needs permissions assigned by AO or AM. Works on behalf of the provider in approved CMS applications. |
Role Requests are completed through I&A: https://nppes.cms.hhs.gov/IAWeb/login.do
View this document to learn how to request and approve role requests for Medicare:
EDI Enrollment
Once you are credentialed... you need to complete EDI enrollments in order to be able to submit claims and receive electronic remittance advice.
What is an EDI Enrollment? EDI stands for Electronic Data Interchange.
This enrollment allows you/your practice or organization to be able to submit claims to Medicare electronically (through your EHR) and to receive remittance advice and payment electronically.
Contact:
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