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• An active National Provider Identifier (NPI).
• Pecos Identification and Authentication (I&A) user Id and password
  • Be an authorized official
  Note: If you are an Authorized Official or acting on behalf of a provider you will need to get your own user ID. For complete instructions, please visit:
  http://www.cms.gov/MedicareProviderSupEnroll/Downloads/OrganizationGettingStarted.pdf.
• Personal identifying information. This includes:
  • Type of Provider/Supplier (Part A and DMEPOS applicants only)
  • Legal Business Name on file with the Internal Revenue Service(IRS)
  • Tax Identification Number or Employer Identification Number
  • Business Structure, Incorporation Date and State Where Incorporated (if applicable)
• State Business license information. This includes:
  • State license number
  • Original effective date
  • Expiration/Renewal date
  • State where issued
• Certification information. This includes:
  • Certification number
  • Original effective date
  • State where issued
• Recognition Status (Medicare Diabetes Prevention Program (MDPP) supplier applicants only)
  • Recognition Status
  • Organizational Code
  • Recognition Status Effective Date
  • Recognition Status Expiration/Renewal Date
• Correspondence Information (Part A and DMEPOS applicants only)
• Accreditation Information (Part A and DMEPOS applicants only, if applicable)
  • Date of Accreditation
  • Name of Accrediting Body
  • Type of Accreditation or Accreditation Program
• Supplier Type
• If applicable, information regarding any final adverse actions. A final adverse action includes:
  • a Medicare-imposed revocation of any Medicare billing privileges;
  • suspension or revocation of a license to provide health care by any State licensing authority;
  • revocation or suspension by an accreditation organization;
  • a conviction of a Federal or State felony offense (as defined in 42 CFR 424.535(a)(3)(A)(i)) within the last ten years preceding enrollment or revalidation;
  • or an exclusion or debarment from participation in a Federal or State health care program.
• Practice location information. This information includes:
  • Organization's medical practice location
  • Base of Operations location (Part A applicants only)
  • Special Payment Information
  • Medical Record Storage Information
  • Rendering Services in Patient's Homes (Part B applicants only)
  • Mobile or Portable Providers Only - Location of Business Office or Dispatcher/Scheduler (Part A applicants only)
  • Vehicle Information (Part A applicants only, if applicable)
  • Geographic Location for mobile or portable providers where the base of operations and/or vehicle renders services (Part A applicants only, if applicable)
  • Medicare Diabetes Prevention Program (MDPP) Location information, including any Community Settings
• Ownership Interest and/or Managing Control Information for Organizations
  • If applicable, information regarding any final adverse actions.
• Ownership Interest and/or Managing Control Information for Individuals
  • If applicable, information regarding any final adverse actions.
• Medicare Diabetes Prevention Program (MDPP) Coach Information (MDPP supplier applicants only)
  • MDPP Coach Name
  • MDPP Coach SSN
  • MDPP Coach NPI
  • MDPP Coach Start Date
• Chain Home Office Information (Part A applicants only, if applicable)
• Billing Agency Information (if applicable)
• Capitalization Requirements (HHAs only)
• Authorized/Delegated Officials
• Any Federal, State, and/or local (city/county) business licenses, certifications and/or registrations specifically required to operate as a health care facility.
• Electronic Funds Transfer documentation - mechanism by which providers and suppliers receive Medicare Part A and Part B payments directly into a designated bank account.

Please Note: Before any enrollment action can be taken by an individual using Internet-based PECOS on behalf of a provider or supplier organization, a number of processes must be completed. These processes will register and authenticate the Authorized Official (AO) of the provider or supplier organization and the individual(s) who will be using Internet-based PECOS on behalf of the provider or supplier organization. In addition, these processes will establish the relationship between the provider or supplier organization and the organization whose employee(s) will use Internet-based PECOS on behalf of the provider or supplier organization. These processes begin with the AO of the provider or supplier organization, and they may take several weeks to be completed. For complete instructions, please visit:
http://www.cms.gov/MedicareProviderSupEnroll/Downloads/OrganizationGettingStarted.pdf.

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