Posts Tagged ‘PECOS’

PECOS/Ordering & Referring Issue Redux

In Uncategorized on August 23, 2013 at 6:03 pm

As some of you may recall, there was a flurry of activity a couple of years ago regarding PECOS – CMS’s online provider enrollment system – and the need for all providers to be enrolled in PECOS.  CMS’s incentive (or, “stick”), if you will, for getting all providers on board was to deny any claims related to providers not enrolled in PECOS, and identified in the PECOS “ordering and referring” list.  That deadline for compliance, and the subsequent enforcement was slated to be May 1, 2013 – as of that date, any claim relating to an ordering/referring provider not enrolled in PECOS was going to be summarily denied.  However, just prior to that enforcement date, CMS announced that:

Due to technical issues, implementation of the Phase 2 ordering and referring denial edits is being delayed. These edits would have checked the following claims for an approved or validly opted-out physician or non-physician who is an eligible specialty type with a valid individual National Provider Identifier (NPI). If either of these were missing or incorrect, claims would deny.  

  • Medicare Part B claims from laboratories, imaging centers and Durable Medical Equipment, Orthotics, and Supplies (DMEPOS) that have an ordering or referring physician/non-physician provider; and
  • Part A Home Health Agency (HHA) claims that require an attending physician provider. 

CMS will advise you of the new implementation date in the near future. In the interim, informational messages will continue to be sent for those claims that would have been denied had the edits been in place.

You may be questioned by any facilities, labs, or DME providers to which you refer patients regarding your PECOS status….  This is what they are talking about, and the potential for their claims to be denied if you are not in PECOS is the root of their concern.


CMS’ Revalidation Effort Delayed

In Uncategorized on November 7, 2011 at 9:28 pm

Over the past few months, much has been discussed about CMS’s “revalidation” effort.  Essentially, all providers and suppliers enrolled in the Medicare program prior to March 25, 2011, will be required to submit their enrollment information so they can be revalidated under new risk screening criteria required by the Affordable Care Act (Section 6401a).  Providers/suppliers who enrolled on or after March 25, 2011, have already been subject to this screening and need not revalidate at this time.

CMS & MACs have advised providers and suppliers not to take any action intil they have received a “revlidation letter” from their MAC, for this is going to be a staged process in which all providers and suppliers would be revalidated over the course of the next two years (by March 23, 2013).  The followig link provides an example of what a validation letter would look like:$File/J11_Revalidation_Letter_Web_Example.pdf

Once your office receives such a notice, please notify M.E.D.I.C., Inc. ASAP, for at that point, you have only 60 days in which to complete the revalidation process.  Providers failing to respond to such a revalidation request run the risk of being deactivated from the Medicare program.

Just this past week, however, CMS announced that it would “delay” this revalidation effort in order to streamline the process by improving the PECOS online registration system prior to revalidating all Medicare providers.  According to the Medical Society of Virginia’s website (–.aspx):

In order to comply with the program integrity screening provisions of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) launched an effort to revalidate the enrollment of every provider and supplier by March 23, 2013. This effort has now been pushed back to 2015. Physicians will be among the last to revalidate.
In addition to pushing back the revalidation efforts, CMS made improvements to the online Medicare Provider Enrollment, Chain and Ownership (PECOS) system, which include:

  • E-signatures
  • Electronic document upload
  • Batch upload capability
  • Seamless password reset
  • Enhancements for authorized officials
  • Reassignment reports
  • New “my enrollments page” and “fast track view” screens
  • Fewer duplicative document submission requirements

CMS stated that the PECOS improvements will be implemented before most physicians are asked to revalidate.

CMS Delays PECOS Phase II Implementation Date

In Uncategorized on March 30, 2011 at 3:11 pm

CMS has recently issued a statement that it will NOT implement Phase 2 of PECOS on July 5th, as was originally published (point of reference:  during Phase I, which is currently underway, claims will have an appended warning when the ordering/referring proivider is not enrolled in PECOS; during Phase 2, which has yet to begin, all claims processed with an ordering/referring provider who is not enrolled in PECOS will be denied…  for more information on what PECOS is, see post published June 8, 2010):

“It has come to CMS’ attention that there was an editorial oversight in the OIG Compendium of Unimplemented Recommendations (March 2011 Edition). The OIG report states that the CMS will delay the implementation of Phase 2 of Change Request (CR) 6417 and CR until Tuesday, July 5, 2011.  This is incorrect. 

 CMS has not yet determined when it will begin to apply the ordering/referring provider claim edit to ordering/referring providers that do not have a record in the Provider Enrollment, Chain, and Ownership System (PECOS).  As previously stated, CMS will give providers ample notice before the ordering/referring provider claim edit is applied.  Recent revisions to CRs #6417 and #6421 require MACs to delay rejecting claims until receiving further direction from CMS.”  (emphasis added)

So, the net result is that parties to whom patients are ordered/refered will continue to receive EOB warnings regarding the PECOS status of the referring provider, but will be paid.  For now. 

When will this change?  I have no idea, so it would be advisable for all providers who have not enrolled in PECOS to date to do so as soon as practicable.  Anyone needing assistance in a) checking to see whether they are currently enrolled in PECOS, or b) enrolling in PECOS can contact M.E.D.I.C., Inc. ( — we are happy to assist! 

Be Sure To Enroll/Update PECOS Database ASAP!!!

In Uncategorized on June 8, 2010 at 7:00 pm

The Centers for Medicare & Medicaid Services (CMS) requires physicians and non-physician practitioners to enroll and maintain Medicare program enrollment to be eligible to receive Medicare payments for covered services furnished under Medicare.  Similarly, all Medicare providers must be enrolled in PECOS (Medicare’s Provider Enrollment, Chain, and Ownership System), the system which supports the Medicare provider and supplier enrollment process by capturing provider/supplier information from the CMS-855 family of forms.  PECOS manages, tracks, and validates enrollment data collected in both paper form and electronically via the Internet.

It is important to note that although some providers may be enrolled in Medicare, those enrollment records might not be in PECOS.  Generally, the lack of a current enrollment record in the PECOS (i.e., one that is in the PECOS and also contains the National Provider Identifier (NPI)) is a result of not having submitted any enrollment information updates since November 2003.  Such providers must update their enrollment record now.

Why all the fuss?  The Protection and Affordable Care Act, which finally passed in March of this year, provides for the verification of a referral source’s Medicare enrollment.  Under the Medicare edits in question, if an ordering/referring physician or other non-physician practitioner listed on DMEPOS claims are not in PECOS, those claims will reject.  Note that I write “DMEPOS claims” – durable medical equipment suppliers’ claims were the first categpory of claims to be targeted by this new Medicare edit, however, it is foreseeable that this edit will in fact apply to all of the following:  DME, orthotics, prosthetics, supplies, home health items/services, laboratory services, imaging services, specialist services.  Further, there is rumor of CMS’s extending the provision to Part B drugs within the next year.

CMS had originally set Jan. 4, 2010, as the effective date for the system edits, but later pushed that date out to April 5 and then to Jan. 3, 2011.  Following the recent passage of the new health care reform law, however, CMS published an interim final rule stipulating that physicians and other eligible professionals who order items and/or services (ex: durable medical equipment, tests, etc…) for Medicare beneficiaries must have an approved enrollment in PECOS by July 6, 2010 – effectively advancing the compliance date by 6 months.

NOTE – Providers who do not participate in Medicare also need to be enrolled in PECOS or any DME/tests that they order will not be reimbursed.

What Can You Do?  Basically just ensure that you and all providers referring to you have a current PECOS enrollment record.  To determine if you have a current enrollment record in the PECOS, you can utilize the national file of Medicare physicians and non-physician practitioners who are eligible to order/refer and have current enrollment records in the PECOS (  This file is made available by the Centers for Medicare & Medicaid Services’ (CMS) and contains the provider’s NPI and his/her legal name (from the PECOS enrollment record). 

If you do not have a current enrollment record in the PECOS and will be ordering or referring services, particularly items of durable medical equipment (e.g., oxygen, diabetic supplies, and wheelchairs), you should use Internet-based PECOS to complete and send your enrollment application.  For more information regarding submissions via Internet-based PECOS, you can refer to the CMS website (