Medicare’s Integrated Model – 2025 Overview

Medicare’s integrated model in 2025 is focused on better serving individuals eligible for both Medicare and Medicaid—commonly known as dual-eligible enrollees—through enhanced integration via Dual-Eligible Special Needs Plans (D-SNPs). Nearly 28% of Medicare Advantage enrollment now comes from Special Needs Plans, with dual-eligible SNPs making up the majority of those enrollments

Policy changes are advancing care coordination: CMS will lower the D-SNP “look-alike” threshold from 80% to 70% in 2025, tightening the standards for qualifying as an integrated plan. . Additionally, from January 1, 2025, newly introduced integrated care Special Enrollment Periods (SEPs) allow eligible beneficiaries to enroll in both Medicare and Medicaid under a single insurer on a monthly basis

What Are Types of Provider Relationships with Medicare?

When enrolling with Medicare across the USA, providers can choose from three main participation options that directly affect billing, reimbursement, and patient financial responsibility. Each relationship requires accurate enrollment and credentialing to ensure compliance and smooth operations, which is where Preferred MB supports practices across the USA.

Participating Providers (PAR): These providers sign an agreement to accept Medicare’s approved rate as full payment and always take assignment. Enrollment ensures faster claims processing and direct reimbursements with minimal patient balance billing.

Non-Participating Providers (Non-PAR): These providers do not sign a participation agreement but still see Medicare patients. They may accept assignment case by case and can charge up to 15% above Medicare’s approved amount (the limiting charge). Correct enrollment ensures they stay compliant with these billing rules.

Opt-Out Providers: These providers formally opt out of Medicare and use private contracts with patients, meaning Medicare does not reimburse for their services. Enrollment is still required for the opt-out declaration, which lasts two years.

With the complexity of provider enrollment and revalidation requirements, partnering with Preferred MB ensures your Medicare credentialing is handled accurately, on time, and with a focus on maximizing your compliance and revenue opportunities.
The Medicare Provider Credentialing Process Overview
Becoming a Medicare-approved provider requires following a structured credentialing and enrollment process. Proper credentialing ensures compliance with CMS guidelines, timely reimbursements, and uninterrupted patient care. Preferred MB simplifies every step, guiding providers through the process with accuracy and efficiency.

What Are Key Steps in the Medicare Credentialing Process?

Determine Provider Type & Eligibility
⦁ Identify your provider classification (physician, nurse practitioner, DME supplier, etc.).
⦁ Ensure you meet all CMS eligibility requirements.
Obtain an NPI (National Provider Identifier)
⦁ Secure your unique NPI through the National Plan & Provider Enumeration System (NPPES).
⦁ This number is required for Medicare billing and claim submission.
Complete Medicare Enrollment Application (CMS-855 Form)
⦁ Submit the appropriate CMS-855 form (e.g., CMS-855I for individual providers, CMS-855B for group practices).
⦁ Applications can be filed electronically through PECOS (Provider Enrollment, Chain, and Ownership System).
Submit Supporting Documentation
⦁ Provide licenses, certifications, practice ownership details, and tax identification documents.
⦁ Accuracy is key to avoiding delays or denials.
Credentialing Verification by CMS/Medicare Contractor
⦁ Medicare Administrative Contractors (MACs) review, verify, and approve enrollment applications.
⦁ This step includes background checks and practice site verifications if needed.
Application Decision & Provider Number Assignment
⦁ Once approved, you receive your Medicare Provider Transaction Access Number (PTAN).
⦁ This number enables you to bill Medicare and receive reimbursement.
Revalidation & Ongoing Compliance
⦁ Providers must revalidate their enrollment every 5 years (or every 3 years for DME suppliers).
⦁ Ongoing compliance ensures continuous participation and uninterrupted reimbursements.

What Are Specific Requirements for Medicare Provider Enrollment?

Medicare provider enrollment is a detailed process that requires strict compliance with Centers for Medicare & Medicaid Services (CMS) guidelines. To participate in the Medicare program, providers must meet certain eligibility and documentation standards, ensuring they are qualified to deliver care and receive reimbursements. Preferred MB assists providers nationwide in meeting these requirements efficiently.

Key Requirements for Medicare Provider Enrollment

National Provider Identifier (NPI):
⦁ Every provider must obtain an NPI through the National Plan & Provider Enumeration System (NPPES) before applying.

Accurate Completion of CMS Enrollment Applications:
⦁ Use the correct form such as CMS-855I (individual providers), CMS-855B (group practices), or CMS-855S (suppliers like DMEPOS).
⦁ Applications can be submitted electronically via PECOS.

Licenses and Certifications:
⦁ Providers must have valid state licenses, board certifications, and practice permits.
⦁ This ensures compliance with both CMS and state-specific regulations.

Tax Identification & Ownership Details:
⦁ Submission of an EIN/SSN, business ownership records, and other required tax documents.

Practice Location Verification:
⦁ Medicare may conduct site visits to verify the physical location and operational status of the provider’s practice.

Background Checks and Compliance History:
⦁ Providers must pass CMS integrity checks, including screening against exclusion databases like OIG and SAM.gov.

Revalidation Requirements:
⦁ Providers are required to revalidate enrollment every 3–5 years, depending on their specialty.

Navigating Medicare Regional Structure

Medicare operates through a regional structure managed by Medicare Administrative Contractors (MACs), each responsible for a specific geographic area of the United States. These MACs handle provider enrollment, claims processing, audits, and appeals, making it essential for providers to understand their region’s rules and timelines.

Currently, the U.S. is divided into multiple jurisdictions for Part A (hospital services) and Part B (physician services), as well as separate contractors for Durable Medical Equipment (DME) suppliers. Each jurisdiction may have slightly different requirements for credentialing, claims submissions, and processing times, which can directly affect provider reimbursements.

For providers this structure can be challenging, especially when managing multiple locations or specialties across different states. That’s why partnering with a credentialing expert like Preferred MB ensures you remain compliant with your regional MAC, avoid enrollment delays, and streamline Medicare billing across jurisdictions.

The CAQH ProView Connection

CAQH ProView is the industry’s leading credentialing database, used by Medicare, Medicaid, and commercial payers to streamline provider enrollment and credentialing. It allows providers to store and update essential information, such as licensure, education, work history, malpractice coverage, and certifications, in one secure profile, which payers can access directly to verify credentials.
Keeping CAQH ProView accurate and up to date is important for preventing delays in payer enrollment, claims approval, and network participation. That’s where Preferred MB steps in, our credentialing experts manage your CAQH ProView profile, ensure compliance with payer requirements, and maintain updates so your enrollment process runs smoothly. With Preferred MB handling your CAQH connection, providers save time, reduce errors, and get credentialed faster.

Medicare Online Provider Portals

Medicare offers secure online provider portals to simplify enrollment, claims management, and compliance tracking for healthcare professionals. The most widely used system is PECOS (Provider Enrollment, Chain, and Ownership System), which allows providers to submit and manage enrollment applications electronically, track revalidation deadlines, and update practice information in real time.
In addition, each Medicare Administrative Contractor (MAC) maintains regional provider portals, giving practices access to eligibility verification, claims status checks, remittance advice, and appeals submission. Using these portals effectively is essential to keeping reimbursements on track and avoiding costly delays.
Because managing multiple online systems can be overwhelming, providers often rely on experts to handle updates and compliance. Preferred MB specializes in Medicare credentialing and portal management—ensuring your PECOS applications, MAC portal accounts, and revalidations are completed accurately and on time, so your practice stays compliant and revenue flows without interruption.

What Are Best Practices for Successful Credentialing with Medicare?

Successful credentialing with Medicare requires accuracy, compliance, and timely submissions. Best practices include maintaining up-to-date licenses and certifications, completing CMS enrollment applications correctly, keeping your PECOS and CAQH ProView profiles current, and preparing for Medicare revalidation well before deadlines. Consistency in documentation helps avoid delays and denials.

With the complexities of Medicare rules, partnering with a trusted expert makes the process easier. Preferred MB guides providers through every stage of credentialing, ensuring forms, documents, and compliance requirements are handled correctly. Our credentialing specialists use proactive approach minimizes errors, speeds up approval, and helps practices stay revenue-ready at all times.

What Are Medicare Special Considerations for Different Provider Types?

Medicare recognizes that not all providers fit into a single framework. Different specialties and provider types must meet unique enrollment, credentialing, and billing requirements to ensure compliance and proper reimbursement. Understanding these considerations is key to avoiding delays or denials.

Special Considerations by Provider Type

Physicians & Non-Physician Practitioners (NPPs):
⦁ Must enroll using CMS-855I (individual enrollment).
⦁ Must maintain state licensure and board certification.
⦁ NPPs (like PAs and NPs) may face scope-of-practice restrictions based on state laws.

Group Practices & Clinics:
⦁ Required to file CMS-855B for group enrollment.
⦁ Must also link individual providers to the group practice in PECOS.

Hospitals & Institutional Providers:
⦁ Enroll with CMS-855A and must meet additional accreditation and compliance standards.
⦁ Site inspections and compliance checks are more rigorous.

DMEPOS Suppliers (Durable Medical Equipment, Prosthetics, Orthotics, Supplies):
⦁ Must use CMS-855S.
⦁ Subject to surety bond requirements and stricter revalidation (every 3 years).

 Behavioral Health & Mental Health Providers:
⦁ Medicare only covers specific provider types (e.g., psychiatrists, clinical psychologists, clinical social workers).
⦁ Some professionals, such as licensed counselors, are not yet fully recognized for reimbursement.

Opt-Out Providers:
⦁ Providers may choose to opt out of Medicare but must file an official affidavit.
⦁ They work on a private contract basis with patients.

Managing these variations can be complex, but working with a trusted credentialing partner makes the process smooth. Preferred MB ensures each provider type—whether physician, clinic, or DME supplier—meets Medicare’s specific requirements, stays compliant, and receives timely reimbursements.

How Our Certified Medicare Credentialing Specialists Accurately Handle Your Medicare Credentialing Challenges

At Preferred MB, our certified Medicare credentialing specialists bring expertise in navigating CMS regulations, PECOS enrollment, and CAQH ProView updates. We ensure every detail, from application forms to compliance checks is accurate, minimizing delays, denials, and costly rework.
We handle credentialing challenges with precision, whether it’s initial enrollment, revalidation, or multi-state practice compliance. With Preferred MB managing the process, providers can focus on patient care while we secure faster approvals, stronger compliance, and uninterrupted Medicare reimbursements.
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