Medicare, the federal health insurance program for people aged 65 or older and certain younger people with disabilities, processes billions of dollars in claims annually. This system relies on unique identifiers to ensure payments are directed only to legitimate providers for covered services. The Medicare Provider Number (MPN) is a specific identifier assigned by the Centers for Medicare & Medicaid Services (CMS). Obtaining this number is the formal step that grants a healthcare organization or individual the legal authority to bill the program and establishes a contractual relationship with Medicare.
Defining the Medicare Provider Number
The Medicare Provider Number (MPN) is an internal identifier that formally authorizes a provider or supplier to receive payment from Medicare. This number signifies that the holder has met all federal requirements to furnish covered health services. For individual practitioners and certain Part B suppliers, the MPN is called the Provider Transaction Access Number (PTAN). For institutional providers, such as hospitals and skilled nursing facilities, the number is known as the CMS Certification Number (CCN). Both the PTAN and the CCN establish the accountability of the entity to Medicare. The MPN is assigned to the legal entity or practice location, not the individual clinician.
How Providers Obtain Enrollment
The process of obtaining a Medicare Provider Number is formally known as Medicare enrollment, managed through the Provider Enrollment, Chain, and Ownership System (PECOS). Before initiating the application, a provider must first secure a National Provider Identifier (NPI), which is a prerequisite for all Medicare billing privileges. The PECOS application requires detailed documentation, including licensure, certifications, and information about the practice’s ownership and control. Once submitted, the application is routed to the appropriate Medicare Administrative Contractor (MAC) for review. MACs are private companies contracted by CMS to process Medicare claims for a specific geographic region. The MAC performs thorough background checks and verification to confirm the provider meets all program integrity standards. After MAC approval, the Medicare Provider Number (PTAN or CCN) is assigned, granting the organization or individual the ability to bill. Providers must comply with periodic revalidation requirements to ensure their information, location, and eligibility status remain current. Failure to complete timely revalidation can result in the temporary deactivation of billing privileges.
Clarifying NPI and Other Identifiers
A common point of confusion is the difference between the Medicare Provider Number (MPN) and the National Provider Identifier (NPI). The NPI is a 10-digit number mandated by HIPAA as a universal identification standard for all covered healthcare providers. It identifies who provided the service, regardless of the payer, and is used across all electronic transactions. The NPI is obtained through the National Plan and Provider Enumeration System (NPPES) and remains with the practitioner or organization throughout their career. In contrast, the MPN (PTAN/CCN) is specific to the Medicare program and identifies the entity authorized to receive payment for that service. A provider must possess both a valid NPI and an MPN to successfully bill Medicare. The Tax Identification Number (TIN) is also necessary and is included in the enrollment application. The TIN is used for financial purposes, linking the provider’s billing activities to their legal tax entity and ensuring proper remittance and reporting of income.
Using the Number for Claims and Reimbursement
The Medicare Provider Number is essential for the final authorization of payment during the claims submission process. When a provider submits a claim for services, they include both their NPI and their MPN on the form. Part B services typically use the CMS-1500 claim form, while institutional services under Part A use the UB-04 form. The Medicare Administrative Contractor (MAC) uses the submitted MPN to verify that the entity is enrolled and has active billing privileges. The MAC system matches the NPI (identifying the rendering clinician) to the corresponding PTAN or CCN (identifying the billing organization). This matching process ensures the claim is valid and the payment is directed to the correct, authorized entity. If the MPN is incorrect, expired, or does not match the information on file, the claim will be rejected or denied, halting the reimbursement process.