DME Supplier Intake | Provider Enrollment Credentialing Services

1What do you need?

Medicare DMEPOS enrollment (CMS-855S): $1,000 per location
New Medicare enrollment for an accredited supplier, through fingerprints, the site visit and any development requests, to approval. Half at engagement, half at approval. Medicare DMEPOS revalidation: $500 per location
Due every three years. CMS posts due dates about seven months ahead. Add a location to an existing enrollment: $500 per new location Medicaid DME enrollment: $500 per state Commercial or Medicaid managed-care DME plan applications: $200 per plan Becoming a DME supplier (not yet accredited): quoted
Accreditation, surety bond, licensure and supplier-standard readiness before enrollment. We quote after a short call.

Not included: CMS's application fee, the surety bond, accreditation fees and fingerprinting fees, which are paid by the supplier.

2Supplier

Legal business name (as on IRS records) *

DBA (if any)

Entity type

EIN

Organization NPI (Type 2)

Medicare supplier number (PTAN) (if enrolled)

Taxonomy (if known)

Website

Mailing / correspondence address

Contact name *

Title

Contact email *

Contact phone

Medicare revalidation due (if known)

3Locations

Each physical location enrolls separately. Medicare requires a staffed, accessible location with posted hours (at least 30 hours a week in most cases).

4Owners and managing employees

List everyone with 5% or more ownership, plus officers, directors and managing employees. Owners of 5% or more of a newly enrolling supplier are fingerprinted; we book the appointments. We never ask for Social Security numbers or dates of birth on this form. When an application needs them, we send a one-time encrypted link.

5Accreditation, surety bond and insurance

Accrediting organization

Accreditation date

Accreditation expires

Product categories covered by the accreditation

Surety bond company

Bond number

Bond amount

Liability insurance carrier

Policy number

Policy expires

6Products and payers

Product categories you supply

Other products (optional)

States where you supply patients

Medicaid states to enroll in

Commercial or managed-care plans to apply to

7Documents (PDF, JPG or PNG)

Accreditation letter

Surety bond

State licenses and permits

Liability insurance certificate

IRS EIN letter (CP 575 or 147C)

Voided check or bank letter (for Medicare payments)

Lease or proof of each location

Anything else (ownership chart, prior CMS letters)

Missing something? Submit anyway and we will follow up for the rest.

8Authorization and submit

How did you hear about us? (optional)

Anything we should know? (deadlines, prior denials, site-visit notes)

I am authorized to act for this supplier, the information above is accurate to my knowledge, and I authorize Provider Enrollment Credentialing Services to prepare enrollment applications from it. Owners and officers sign their own certifications. I agree to the Terms and have read the Privacy Policy.