Medicare Enrollment for Opioid Treatment Programs

Medicare pays opioid treatment programs (OTPs) for opioid use disorder treatment through a dedicated Part B benefit, in bundled payments for an episode of care, which the rule defines as "a one-week (contiguous 7-day) period" (42 CFR 410.67(b)). CMS describes it simply: "We pay OTPs through bundled payments for OUD treatment services for Medicare Part B patients." Covered services include FDA-approved MOUD and its dispensing and administration, substance use counseling, individual and group therapy, toxicology testing, intake activities and periodic assessments, intensive outpatient program services, care coordination, patient navigation and peer recovery support (CMS OTP page; 42 CFR 410.67). To bill for any of it, the program first has to enroll.

Who may enroll as an OTP?

A program that qualifies as an OTP under Part 8 and enrolls under 42 CFR 424.67 (424.67(a)). The core conditions:

• Full SAMHSA certification. The OTP must "have a current, valid certification by SAMHSA," and "a provisional certification ... does not meet the requirements" (424.67(b)(4)). CMS's enrollment page says programs "that are fully-certified by SAMHSA and accredited by a SAMHSA-approved accrediting body can enroll." A new program bills Medicare only after it moves from provisional to full certification; see provisional certification.
• A complete application. The CMS-855A or 855B, with the OTP supplement listing every physician, other eligible professional and pharmacist legally authorized to prescribe, order or dispense controlled substances for the OTP, with name, Social Security number, NPI and license number, whether or not they are W-2 employees (424.67(b)(1)(i)).
• The application fee, under 424.514, which CMS adjusts each calendar year (424.67(b)(2)).
• Risk screening at the assigned level (424.67(b)(3)); see below.
• Managing employees reported, including the medical director and the program sponsor (424.67(b)(5)).
• A provider agreement under part 489 (424.67(b)(7)). OTPs "may enter into provider agreements only to furnish opioid use disorder treatment services" (42 CFR 489.2(c)(3)).

Which staff would disqualify the program?

Part 424.67(b)(6) bars an OTP from employing or contracting with:

• A prescribing or ordering physician or eligible professional, or anyone legally authorized to dispense narcotics, who within the preceding 10 years was convicted of a federal or state felony that CMS deems detrimental to the Medicare program, whether or not that person currently dispenses at the OTP.
• Any personnel revoked from Medicare or on CMS's preclusion list.
• Any personnel with a prior adverse action by a state oversight board, such as a reprimand, fine or restriction, "for a case or situation involving patient harm that CMS deems detrimental."

These apply at enrollment and continuously after, so they belong in the OTP's hiring and credentialing checks (424.67(e)(1)).

Should the OTP use the 855A or the 855B?

Either, but not both: "An OTP may only be enrolled as an OTP via the Form CMS-855A or Form CMS-855B but not both" (424.67(c)(1)). The CMS-855A itself notes that "Opioid Treatment Programs may complete the CMS-855A or CMS-855B enrollment application." CMS's OTP enrollment page lays out the practical difference:

• CMS-855A (institutional providers): claims on the 837I or paper CMS-1450.
• CMS-855B (clinics, group practices and certain other suppliers): claims on the 837P or paper CMS-1500.

The choice usually follows the program's billing setup and its relationship to a hospital. For drug payment, the prescribing or ordering practitioner's NPI must appear on Field 17 of the CMS-1500 (424.67(f)(1)). A program can switch forms later; the earlier billing effective date carries over, and it completes only limited screening if it already passed moderate or high screening (424.67(b)(3)(ii), (c)(2)).

What screening applies?

It depends on the program's certification history. Newly enrolling OTPs "that have not been fully and continuously certified by SAMHSA since October 23, 2018" are high risk, which adds fingerprint-based criminal background checks of every person with a 5 percent or greater direct or indirect ownership interest (42 CFR 424.518(c)). Newly enrolling OTPs certified continuously since that date are moderate risk, which includes an on-site visit (424.518(b)). Every OTP is screened at the moderate level when it revalidates (424.67(e)(1)(iii)). See why newer OTPs get high-risk screening.

Can a hospital outpatient department enroll as an OTP?

Yes. CMS's OTP enrollment page says "Part B covers OTP services at freestanding OTP facilities and hospital outpatient departments," and that an OTP "can enroll as a Part A or a Part B provider for this Part B benefit." A hospital-based program still needs its own SAMHSA certification, OTP accreditation and DEA narcotic treatment program registration; the hospital's own approvals do not substitute for them.

How does the bundled payment handle add-on services?

The weekly bundle covers the core OUD treatment services, and 42 CFR 410.67(d) adds adjustments for extra services in a week. Two that shape program design:

• Intensive outpatient services. An adjustment applies when at least nine OTP intensive outpatient services are furnished in a week, based on the hospital-based IOP per diem multiplied by three (410.67(d)(4)(i)(F)). A physician or non-physician practitioner must certify the patient's need for at least nine hours of services per week (410.67(b)).
• Navigation and peer recovery support. An adjustment applies for each additional 30 minutes of patient navigational or peer recovery support services (410.67(d)(4)(i)(H)).

Services furnished from an OTP mobile unit are treated, for payment, as if furnished at the OTP's physical location registered with DEA and certified by SAMHSA (410.67(d)(4)(ii)). See adding a medication unit and Medicare's intensive outpatient benefit.

Who signs, and how does it get submitted?

For an organization, the certification statement is signed by an authorized official, an individual with authority to bind the organization legally and financially and an ownership or control interest, such as a CEO, CFO, general partner or board chair (42 CFR 424.510(d)(3)). The initial application and revalidations must be signed by an authorized official; later changes may be signed by a delegated official. CMS accepts enrollment through PECOS or on paper. If a paper application is used, CMS says "your signature must be handwritten."

We work through PECOS as a surrogate. Once your authorized official approves White Glove Medical as a surrogate in CMS's Identity and Access system, we enter and submit the application in PECOS, and your official signs. We never hold your I&A login, MFA device or PIN. Our sister site has a walkthrough of enrolling in Medicare through PECOS.

What keeps the enrollment in good standing?

• Continuous SAMHSA certification. CMS may revoke enrollment if certification lapses (424.67(e)(2)). See SAMHSA certification renewal.
• Reporting changes. Changes of ownership or control, including authorized or delegated officials, within 30 days; other changes within 90 days (42 CFR 424.516(e)).
• Revalidation every five years (42 CFR 424.515), at the moderate screening level for OTPs. Our sister site covers Medicare revalidation in general.
• Staffing bars, checked at every hire.

Does Medicare Advantage need separate contracting?

CMS's OTP page says Medicare Advantage plan participants and dually eligible patients get OTP services. Plan contracting and credentialing are separate from Medicare enrollment; see our sister site, behavioral health credentialing.

How do we help?

We prepare the 855A or 855B and the OTP supplement, check the controlled-substance roster against the staffing bars with the program, prepare owners for fingerprinting when high-risk screening applies, and submit as your PECOS surrogate once your authorized official approves us. The scope and the flat fee are set in a $149 Facility Readiness Review, credited toward the work. You pay CMS's application fee directly. See pricing and the OTP approval hub.