Medicare enrollment for LPCs and LMFTs: how to enroll in PECOS

At a glance

Who qualifies

The Consolidated Appropriations Act, 2023 created two new Medicare Part B provider types, and CMS put them into effect in the 2024 physician fee schedule (CMS's MFT and MHC FAQ). Medicare's definition of a mental health counselor in 42 CFR 410.54 has three parts. Marriage and family therapists have a matching definition. You need:

• A master's or doctoral degree that qualifies you for licensure as a mental health counselor, clinical professional counselor or professional counselor (or, for an MFT, as a marriage and family therapist) in your state.
• At least 2 years or 3,000 hours of supervised clinical experience after the degree, in a setting such as a hospital, skilled nursing facility, private practice or clinic.
• A current state license or certification in that field. In Texas, that's the LPC (the LPC Associate isn't independently licensed) or the LMFT (not the LMFT Associate).

Most Texas LPCs and LMFTs meet all three by the time they hold the full license, because the Texas boards require supervised post-degree hours before upgrading from associate. Your file should still show the dates.

What about LCDCs?

Some CMS guidance and counseling associations say addiction counselors can enroll as mental health counselors if they meet every part of the definition. A Texas LCDC license doesn't require a master's degree, so an LCDC alone usually won't qualify. An LCDC who also holds an LPC enrolls as an LPC. Check CMS's current addiction counselor guidance before you count on it.

Before you open PECOS

On the Texas roadmaps we run for clients, Medicare enrollment doesn't start until five things are done: both NPIs, the office, the business bank account and the credentialing packet. We budget about 60 days from there to an approval letter; Medicare is often among the faster enrollments, but your contractor sets the pace.

• Your individual NPI (Type 1) from NPPES, free, with the right taxonomy, and your NPPES record matching your license name and practice address.
• An Identity & Access Management (I&A) account with CMS. PECOS, NPPES and the reassignment step all sign in with it. If someone files for you, connect them as a surrogate in I&A instead of sharing your password. Our clients sign a one-page credentialing authorization that lets us act as their surrogate in NPPES, PECOS and I&A; it never lets us sign an application or attestation for them.
• Your practice location. Medicare enrolls you at a real address where you see clients, plus any telehealth arrangement you'll use. Have the lease or the group's address ready.
• Your license, degree and post-degree supervision dates, your Social Security number and date of birth, and bank details for direct deposit.
• If you'll bill through a group, the group's NPI (Type 2), its tax ID and whether it's already enrolled. If it isn't, it enrolls first or at the same time.

Enroll, step by step

1. Sign in to PECOS with your I&A account and start a new individual enrollment (the electronic CMS-855I).
2. Pick your specialty. PECOS lists Marriage and Family Therapist and Mental Health Counselor. CMS's early FAQ told paper filers to use the "undefined non-physician practitioner" line and write the specialty in; check the current paper form if you file on paper.
3. Add your practice locations, where your records are kept and who to call with questions. Use the exact legal name and address in NPPES and on your license.
4. Reassign your benefits if a group will bill for you (next section). If you bill as a sole proprietor under your own tax ID, you don't reassign.
5. Sign and submit, upload any requested documents, and watch your email. Your Medicare Administrative Contractor (for Texas, Novitas Solutions) reviews the application and may ask for more. Answer quickly; an unanswered request can end the application.
6. Get your approval letter. It gives your Medicare number (PTAN) and your effective date. Load both into your EHR and clearinghouse before the first claim.

Medicare limits how far back your billing can start, so file before you begin seeing Medicare clients rather than after. Claims for dates before January 1, 2024 were never payable for MFTs or MHCs.

Many older clients are on a Medicare Advantage plan rather than traditional Medicare. Each Advantage plan (Humana, UnitedHealthcare, Aetna, the Blue plans and others) credentials you separately, usually through its commercial network and your CAQH profile, and most expect you to be enrolled in Medicare first.

Reassigning to a group

If you work in a group practice or a program that bills under its own tax ID, you reassign your right to Medicare payment to that organization, so Medicare pays the group for your services.

• The group enrolls first (or alongside you) on the CMS-855B. There's no application fee for a group of practitioners.
• Reassignment now goes on the CMS-855I. CMS discontinued the separate CMS-855R; reassignments are reported on the individual application, and in PECOS the steps look the same as before (CGS Medicare's guide to the consolidated 855I).
• Both sides sign: you and an authorized or delegated official of the group.
• When you leave, end the reassignment in PECOS. A reassignment left open after you've gone can send payments for your work to the wrong place.

Groups adding several clinicians at once usually enroll the group, then file each clinician's 855I with reassignment in one batch so effective dates line up. Our Group Practice launch does exactly that.

What Medicare pays for

• The diagnosis and treatment of mental illness, other than for hospital inpatients. In practice that's diagnostic evaluations and psychotherapy: individual, family and group. Check the Medicare physician fee schedule lookup for the exact codes your specialty can bill.
• The rate: the lesser of 80% of your actual charge or 75% of what Medicare pays a clinical psychologist for the same code, as set in the CY 2024 physician fee schedule final rule (Foley & Lardner's summary of the rule). Rates vary by Texas locality.
• Assignment only. MFTs and MHCs must accept Medicare's allowed amount as payment in full. You can't balance-bill the client above it; the client still owes the usual Part B deductible and coinsurance.

Before you see a Medicare client, verify which plan they're actually on, traditional Medicare or Advantage, and whether a supplement or Medicaid is secondary. The VOB checklist covers what to ask.

The Texas Medicaid rule: Medicare first

Texas requires providers who serve people with both Medicare and Medicaid to enroll in Medicare before Medicaid (1 TAC 352.13). Once Medicare began paying LPCs and LMFTs, Texas applied that to them:

• Since March 1, 2024, Texas Medicaid LPCs and LMFTs must enroll in Medicare (Blue Cross and Blue Shield of Texas Medicaid notice) or get a pediatric practice exemption, claimed through a question in their TMHP (PEMS) enrollment record. Those without a Medicare number submit a Medicare Waiver Request for review.
• For dates of service from January 1, 2024, a Medicare number has to be on file with Texas Medicaid, and for clients with Medicare, Medicare is billed first or Medicaid denies the claim.
• An LPC or LMFT who sees mainly children and joins Medicaid through a Medicare-enrolled group still needs their own individual Medicare enrollment.

These rules come from 2024 notices sent by Texas Medicaid health plans. Check the current Texas Medicaid Provider Procedures Manual before you file. The whole Medicaid process, from PEMS to each managed care plan, is in our Texas Medicaid credentialing guide.

Why freestanding IOPs and PHPs can't bill Medicare for those levels

Medicare does pay for partial hospitalization and, since 2024, intensive outpatient services, but only in certain settings. CMS's 2024 outpatient rule lists hospital outpatient departments, community mental health centers, federally qualified health centers and rural health clinics for IOP, plus opioid treatment programs for opioid use disorder. PHP is paid to hospitals and community mental health centers.

A Texas chemical dependency treatment facility running an IOP or PHP out of an office suite isn't any of those, so it generally can't bill Medicare for the program day. Plan your payer mix without Medicare program revenue, and ask a billing advisor before you bill Medicare for any of your clinicians' services in a program setting. Our guide to starting an IOP or PHP in Texas covers the payers that do contract with freestanding programs, and TRICARE is one of them once you're accredited.

Keeping it current

• Revalidate about every five years, when CMS asks. CMS posts revalidation due dates; a missed one deactivates your billing. Our credentialing upkeep watches that date along with CAQH, license and malpractice renewals.
• Report changes (a new address, a new group, leaving a group, a name change) in PECOS promptly.
• Keep NPPES matching PECOS. A mismatch between the two is a common reason for rejected claims.

Mistakes that slow it down

• A name or address in PECOS that doesn't match NPPES, the license or the IRS letter.
• Filing under the wrong specialty, or as an associate who isn't yet independently licensed.
• Reassigning to a group that isn't enrolled yet, or that enrolled under a different tax ID.
• Missing a contractor's request for information, which can close the application.
• Seeing Medicare Advantage members as "in network" because you're enrolled in Medicare. Each Advantage plan is its own contract.

Getting help

Our credentialing service files the PECOS application, the reassignment to your group, and tracks the revalidation date so it doesn't sneak up on you. Medicare enrollment is $350 per clinician. If you also want Texas Medicaid, that's $350 per clinician, including TMHP and your first managed care plan. You see each application in your client portal as it moves (gathering documents, submitted, in review, payer asked for more, approved) and we follow up every two weeks until there's a decision.

Opening your own office rather than joining a group? The Solo Practice: Complete launch includes credentialing alongside the business setup, and our guide to starting a private practice in Texas shows where Medicare fits in the order of steps. Once you're billing, Cima EHR for therapists keeps your Medicare number, effective date and claims in one place.

Questions

More credentialing guides: Texas Medicaid: TMHP and managed care · TRICARE for Texas providers · Credentialing services and prices · Start a private practice in Texas

Sources

Checked October 24, 2026.

1. CMS, "Marriage and Family Therapists and Mental Health Counselors" FAQ. cms.hhs.gov
2. CMS, Change Request 12235 (MFT and MHC services). cms.gov
3. 42 CFR 410.54, Mental health counselor services. law.cornell.edu
4. Foley & Lardner, "CMS Expands Access to Behavioral Health Services" (CY 2024 physician fee schedule final rule summary), November 2023. foley.com
5. Honigman, "Medicare Now Covering Services Provided by Marriage and Family Therapists and Mental Health Counselors." honigman.com
6. CGS Medicare, consolidated CMS-855I/855R enrollment guide (855R discontinued; reassignment on the 855I). cgsmedicare.com
7. CMS, Medicare enrollment for providers (MLN9658742): application fee and who pays it. cms.gov
8. CMS, CY 2024 Hospital Outpatient Prospective Payment System final rule fact sheet (intensive outpatient program settings), November 2, 2023. cms.gov
9. Blue Cross and Blue Shield of Texas (Medicaid), "Reminder: Medicare requires LPC, LMFT enroll," May 14, 2024. bcbstx.com
10. Community Health Choice, "Reminder: LPC and LMFT providers must enroll in Medicare effective 03/01/2024." communityhealthchoice.org
11. 1 TAC 352.13 (Texas: Medicare enrollment before Medicaid enrollment). law.cornell.edu
12. Medicare PECOS. pecos.cms.hhs.gov

This guide is general information. Cima Consulting isn't a law firm or an accounting firm, and Medicare and its contractors make their own enrollment decisions; we don't guarantee approvals, rates or dates.