CMS TO REVIEW PECOS ENROLLMENT PROCESS
Medicare Working with Ordering and Referring Providers and Suppliers to Streamline Enrollment Process
The Centers for Medicare & Medicaid Services (CMS) is working with providers to address concerns about enrollment in the Provider Enrollment, Chain and Ownership System (PECOS) to ensure that Medicare beneficiaries continue to receive the health care services and items they need. PECOS is the electronic system used to enroll physicians and eligible professionals into the Medicare program.
As part of those efforts, CMS will, for the time being, not implement changes that would automatically reject claims based on orders, certifications, and referrals made by providers that have not yet had their applications approved by July 6, 2010. While more than 800,000 physicians and other health professionals have enrolled and have approved applications in the PECOS system, some providers have encountered problems. CMS is continuing to update and streamline the process, and more providers have been enrolled in the past few days.
CMS issued an interim final regulation on May 5, 2010 implementing provisions of the Affordable Care Act that permit only a Medicare enrolled physician or eligible professional to certify or order home health services, durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) , and certain items and services under Medicare Part B. The new law applies to orders, referrals and certifications made on or after July 1. The comment period for the regulation closes on July 6, after which the comments will be reviewed and considered before a final regulation is issued.
The Affordable Care Act provisions and the regulation were designed as steps to prevent fraud in Medicare by ensuring that only eligible and identifiable providers and suppliers can order and refer covered items and services to Medicare beneficiaries.
Many physicians and other providers and suppliers have continued to make good faith efforts to comply with the requirements of the law and regulation. These efforts will be a significant factor in determining the procedures and processes that will be incorporated in the final rule.
While the regulation will be effective July 6, 2010, CMS will not implement automatic rejections of claims submitted by providers that have attempted to enroll in PECOS. However, until the automatic rejections are operational, providers should not see any change in the processing of submitted claims, they will continue to be reviewed and paid as they have historically been reviewed and paid.
Additionally, though CMS is taking a more deliberative approach to using the PECOS enrollment system, the agency will employ a contingency plan to meet the ACA requirement that written orders and certifications are only issued by eligible professionals effective July 1.
CMS will continue to send informational notices to providers reminding them of the need to submit or update their enrollment and will work with the provider community to provide guidance on enrollment and will process all applications expeditiously.
Medicare Provider Enrollment, Chain and Ownership System (PECOS)
Database Lookup Tool
CLICK HERE to use the physician look-up tool from VGM to determine if your referral source is listed with PECOS.
June 10, 2010: MACs Perform One-Time Mailing of PECOS Solicitation Letters to Physicians
From http://www.miravistallc.com/blog/index.php
Good news for DME suppliers struggling to get physicians enrolled in PECOS! CMS has instructed the Part A and Part B MACs to perform a one-time mailing of a PECOS solicitation letter to every physician in their jurisdiction who is enrolled in Medicare, but who isn’t found in the PECOS system. Those physicians who need to establish an enrollment record in PECOS will soon receive a letter directly from their MAC, which provides them with instructions on how to enroll in the system and informs them of the consequences of non-enrollment (i.e. the inability to order or refer services for Medicare beneficiaries).
All solicitation letters must be sent to physicians no later than June 28, 1010. In the event that a letter is returned as undeliverable, CMS has instructed the MAC to place the letter in the physician’s file, but to take no further action otherwise.
A copy of the letter has been pasted below. The full instruction issued to the MACs is located at: http://www.cms.gov/transmittals/downloads/R712OTN.pdf.
PECOS Registration Scramble Resumes
From HomeCare Magazine June 7, 2010
BALTIMORE—Earlier this year, HME providers heaved a sigh of relief when CMS announced it would delay implementation of the PECOS edits—which require verification of a referral source's Medicare enrollment—until Jan. 3, 2011. But regulations related to the Patient Protection and Affordable Care Act have put them right back in the hot seat on making sure their referring physicians are registered in the Internet-based system.
The Provider Enrollment, Chain and Ownership System allows physicians and other practitioners to enroll in Medicare, check on the status of an application or make a change in their enrollment information. Under the edits in question, if ordering/referring physicians or other non-physician practitioners listed on DMEPOS claims are not in PECOS, those claims will reject.
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 passage of the new health care reform law, however, on May 5, CMS published an interim final rule stipulating that physicians and other eligible professionals who order items and/or services for Medicare beneficiaries must have an approved enrollment in PECOS by July of this year.
On a Special Open Door Forum May 19, CMS’ Jim Bossenmeyer noted that the new regulation would become effective July 6. Confused callers wondered: If they submitted claims for items and/or services ordered after July 6 by a physician who was not enrolled in PECOS, would the claims reject?
In an exchange with one caller, Bossenmeyer seemed to indicate the edits’ implementation date would remain Jan. 3, 2011. (See “New PECOS Chapter to Begin for HME Providers.”)
But on a subsequent call May 26, Bossenmeyer said CMS is developing the system edits now to check whether order/referring physicians or non-physician practitioners are enrolled in PECOS. The edits may not be active (which means claims will not reject) on July 6, but “we reserve the right to go back and reprocess claims,” Bossenmeyer said.
“When we implement those edits … if we don’t have the correct name and NPI combination on the claim for the ordering and referring [physician] or the individual is not enrolled in the Medicare program, your claim will be rejected,” he said, adding that CMS would notify providers in advance of when the edits will be implemented.
Comments on the IFR are being accepted until July 6.
Bossenmeyer said CMS “will carefully review all comments, including the concerns you have raised about compliance with the July 6 deadline.” However, he continued, “The interim final rule is effective until we publish a final version of this rule.”
CMS recently announced that HME providers would be able to utilize the PECOS system to manage their own enrollment processes beginning July 13. For more information, check CMS’ “Getting Started” guide for DMEPOS suppliers.
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Online comments on the interim final rule and the PECOS edits implementation date (CMS-6010, Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements) can be submitted at www.regulations.gov. Enter "CMS-6010" in the search bar.
Written comments can be mailed to:
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attention: CMS-6010-IFC
P.O. Box 8013
Baltimore, MD 21244-8013
From HME News: PECOS update
Twenty minutes with CMS's Jim Bossenmeyer
By Theresa Flaherty Managing Editor - 06.02.2010
BALTIMORE - Coming off last week's confusing Open Door Forum, HME News called Jim Bossenmeyer, director for the division of provider and supplier enrollment at CMS, for clarification on the Provider Enrollment, Chain and Ownership System (PECOS). For better or worse, here's what he had to say this morning:
When's the deadline: July or January?
READ MORE ...
From AAHomecare June 2, 2010
News Alert: Non-PECOS Compliant Claims NOT a Problem on July 6 Says CMS
AAHomecare received word from CMS officials earlier today that Medicare DMEPOS claims will not be denied on July 6, 2010 if the claims are not PECOS-compliant. There were some reports that claims could be denied starting July 6. The Medicare Provider Enrollment, Chain, and Ownership System (PECOS) manages, tracks, and validates enrollment data collected in both paper form and electronically via the Internet. CMS is seeking public comments on the effective date when claims that are not compliant with PECOS will be denied. Public comments on CMS-6010, which was published as an “interim final” rule, must be received by July 6, 2010. The interim final rule, however, is not effective until CMS publishes a final version of this rule later this year.
AAHomecare’s Regulatory Council is in the process of drafting comments on the recently issued CMS interim final rule (CMS-6010-IFC) (Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements). The AAHomecare Council will make a recommendation as to when CMS should begin denying claims without appropriate legal name and associated National Provider Identifier of the ordering physician or clinician. A key consideration in deciding upon a claims denial date will be an assessment of the number of physicians and clinicians not enrolled in PECOS.
From NAIMES June 1, 2010
It’s Officially Unofficial – DME Claims Will Be Rejected Because of PECOS Edits Beginning “Sometime” In The Future!
The latest news from CMS on PECOS is very interesting. It has been reported by HME News and repeated by NAIMES that the PECOS claims edits for DME will become effective on July 6, 2010.
But Hold on!!!!! The Federal Register announcing the interim final rule relating to provisions of the recently passed Affordable Health Act certainly set the effective date of the provisions of this rule at July 6, 2010.
But it does not mention a change in the effective date to apply the claims edits for PECOS.
When CMS officials were pressed on the recent Open Forum Call, they refused to directly answer the question “will claims begin to deny on July 6, 2010?” Instead the official stated that they may have the edits ready by July 6, 2010 and they reserve the right to apply those edits anytime in the future, after appropriate notice. He also stated that they may review and deny claims retroactively to July 6, 2010. Several suppliers on the call asked for a response, but he repeatedly evaded the question.
Suppliers are once again left to second guess CMS and regardless of what they do, could still have claims previously paid recouped if the retroactive application of the edits is applied.
NAIMES is seeking clarification to this issue as is HME News, who broke the story. We will keep you informed as we move forward. A call to CMS today has not yet been returned.
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IFR Mandates Physician Documentation on Products/Services Ordered From DME.
In the same interim final rule (IFR) issued in the Federal Register on May 5, 2010, CMS also put into regulation the requirement mandated by the healthcare reform law to reduce fraud and abuse.
This rule for the first time specifically spells out that physicians ordering DMEPOS must document and maintain documentation for the products and services they order in their records for 7-years. It further states that they must provide this documentation when requested by CMS.
The rule also included suppliers in the requirement to maintain and provide the required documentation.
NAIMES sees this as a positive move for suppliers who are unable to respond to audits because physicians do not have adequate records. This rule places the burden on the physician to maintain supporting documents for the orders they issue.
The rule further has teeth in that any provider or supplier who fails to maintain and provide such documentation may have their NPI number revoked for one-year. This also applies to suppliers who fail to maintain the required documents.
Click here for details of this IFR. http://edocket.access.gpo.gov/2010/pdf/2010-10505.pdf
May 25, 2010 Attn: DMEPOS Suppliers – Get Ready for Online Enrollment!
 By Andrea Stark, DME Consultant & Reimbursement Specialist, MiraVista LLC
The same system that currently allows physician and non-physician practitioners to enroll, reenroll and update their Medicare information online will soon be made available to DME suppliers! During an open door forum call held on May 19th, CMS announced that DMEPOS suppliers will be given access to Medicare’s online Provider Enrollment Chain and Ownership System (PECOS) by July 13th of this year.
In lieu of mailing traditional CMS-855 paper forms, suppliers will now be able to go online and use PECOS to quickly:
• Submit new enrollment applications,
• Complete the re-enrollment process,
• Track the status of their applications,
• View and make changes to their enrollment records,
• Voluntarily terminate their billing numbers, and
• Reactivate an inactive (but not terminated) billing number.
Suppliers who submit their applications online will notice that PECOS offers a much quicker processing time – just 45-days, versus the 60-day processing time for paper submissions. However, PECOS does not eliminate the need for paperwork entirely. When submitting an application via PECOS, you will be required to print, sign, date and mail a Certification Statement to the NSC. It’s important to do this immediately after submitting your application (no later than 7-days), as the NSC will not process online enrollments until a Certification Statement is received.
Unlike mail sent via the postal service, PECOS also offers suppliers the ability to track their applications. Beginning 15 days after submission, suppliers may log into PECOS and check to see if their application is:
• Submitted - Sent to the NSC,
• In Process - Being reviewed by the NSC,
• Returned for Corrections - Errors have been found and corrections must be made within 30-days,
• Resubmitted - You have made corrections and resubmitted the application, or
• Approved, Denied, or Rejected - Final status.
To prepare for the July 13th deadline, CMS will begin transferring all enrollment data for active DMEPOS suppliers from the NSC into PECOS on July 5, 2010. Just as with physician enrollments, if your billing number has become inactive, or if you have not enrolled, reenrolled, or made changes to your information since November of 2003, you will not be included in this initial transfer.
After July 13, 2010, you may access PEOCS and check to see if you are listed in the database by visiting https://pecos.cms.hhs.gov and logging in with your NPPES user ID and password (these were established when you applied for your NPI). If your information is not found, you will need to update your enrollment record with the NSC and may do this by submitting an online enrollment application via PECOS, or by mailing a paper CMS-855S.
[Note: If you submitted a paper application to the NPI Enumerator and need to establish an online NPPES user ID and password to log into PECOS, you may do so by visiting https://nppes.cms.hhs.gov/NPPES/CreateLoginForExistNPIPage.do. If you have forgotten your NPPES user ID or password you will need to contact the NPI Enumerator at 1-800-465-3203 or customerservice@npienumerator.com.]
For more information on using the PECOS system, see CMS’ Getting Started with PECOS Guide for DMEPOS suppliers, available under Downloads at: http://www.cms.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp. The guide provides: a breakdown of the PECOS enrollment process for individual and organizational providers, step-by-step instructions on how to submit an online enrollment application, information on checking the status of your application, and answers to frequently asked questions
PECOS Delay - From CMS February 19, 2010
The Centers for Medicare & Medicaid Services (CMS) will delay until January 3, 2011, the implementation of Phase 2 of Change Request (CR) 6417 (Expansion of the Current Scope of Editing for Ordering/Referring Providers for Claims Processed by Medicare Carriers and Part B Medicare Administrative Contractors (MACs)) and CR 6421 (Expansion of the Current Scope of Editing for Ordering/Referring Providers for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Supplier Claims Processed by Durable Medical Equipment Medicare Administrative Contractors (DME MACs)).
This delay will give physicians and non-physician practitioners who order items or services for Medicare beneficiaries or who refer Medicare beneficiaries to other Medicare providers or suppliers sufficient time to enroll in Medicare or take the action necessary to establish a current enrollment record in Medicare prior to Phase 2 implementation.
Although enrolled in Medicare, many physicians and non-physician practitioners who are eligible to order items or services or refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in Medicare. A current enrollment record is one that is in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and contains the NPI. Under Phase 2 of the above referenced CRs, a physician or non-physician practitioner who orders or refers and who does not have a current enrollment record that contains the NPI will cause the claim submitted by the Part B provider/supplier who furnished the ordered or referred item or service to be rejected.
CMS continues to urge physicians and non-physician practitioners who are enrolled in Medicare but who have not updated their Medicare enrollment record since November 2003 to update their enrollment record now. If these physicians and non-physician practitioners have no changes to their enrollment data, they need to submit an initial enrollment application which will establish a current enrollment record in PECOS.
Common Electronic Data Interchange (CEDI) errors C200, C201 and C202 are warning errors/edits indicating the Ordering/Referring Provider submitted on the claims was not eligible to order/refer for the service billed according to the Medicare Part A and Part B Provider Enrollment, Chain and Ownership System (PECOS). These edits will generate as a warning on the CEDI GENRPT until April 5, 2010. These errors/edits are in place as part of Centers for Medicare & Medicaid Services (CMS) Change Request 6421 and related Medicare Learning Network (MLN) article MM6421 implemented with the October 2009 Release.
CMS has completed the systematic loading of approximately 220,000 National Provider Identifiers (NPIs) to the existing PECOS records of providers who are eligible to order/refer. With this update to the PECOS records, CEDI has seen a drop in the number of warning messages being produced on the supplier’s GENRPT.
Prior to April 5, 2010, CMS will make publicly available on the Internet the names and NPIs of the Medicare physicians and nonphysician practitioners who are eligible to order or refer in the Medicare program. CMS will replace this file on a periodic basis. At any given time, only the most current file will be available. When the file is available for download, CMS will post an announcement on the “Ordering and Referring Provider” page on the Medicare provider/supplier enrollment Web site www.cms.hhs.gov/MedicareProviderSupEnroll. CMS will send notification of the availability of the file via the CMS provider and supplier Listservs and will announce its availability at the appropriate CMS Provider/Supplier Open Door Forums.
Should a supplier receive one of these warning errors/edits on a claim, CEDI recommends the following:
- Contact the Ordering/Referring Provider to verify their eligibility with PECOS.
- Contact the Ordering/Referring Provider to verify how their name is listed with their PECOS enrollment and ensure the name submitted on the claim matches the PECOS record.
- Verify the Type I (individual physician’s) NPI and name of the Ordering/Referring Provider is submitted on the claim. If the Type II (physician’s group) NPI and name is submitted, a match will not be found on the PECOS file.
Ordering/Referring providers may use the following Web site to obtain information in relation to PECOS and to enroll and/or access the PECOS system to ensure they are listed and authorized to order/refer services for Medicare http://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp.
If DME suppliers have questions, please contact your Medicare DME MAC Provider Contact Center:
- Jurisdiction A 866-590-6731
- Jurisdiction B 866-590-6727
- Jurisdiction C 866-238-9650
- Jurisdiction D 866-243-7272
Providers may also contact their Medicare Part A and/or Part B contractor's enrollment team in regards to their enrollment file as reflected in PECOS.
January 28, 2010 - downloadable file from CMS
As stated in the Centers for Medicare & Medicaid Services (CMS) provider listserv messages that were sent last fall concerning CRs 6417 and 6421, CMS has made available a file that contains the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS that contain an NPI). This file is downloadable from the Medicare provider/supplier enrollment web site: www.cms.hhs.gov/MedicareProviderSupEnroll: click on “Ordering/Referring Report” on the left-hand side.
This .pdf file contains approximately 800,000 records. A new file will be made available periodically that will replace the posted file; at any given time, only one file (the most recent) will be available. The file can be viewed online. In addition, it can be downloaded by users with technical expertise and further sorted or manipulated. It can also be used to search for a particular physician or non-physician practitioner by NPI or by name. Please note the following: (1) Records are in alphabetical order based on the surname of the physician or non-physician practitioner. (2) Name suffixes (e.g., Jr.), if they exist, are not displayed. (3) There are no “duplicates” in the file. Many physicians or non-physician practitioners share the same first and last name; their corresponding NPIs are the assurance of uniqueness. (4) Deceased physicians and non-physician practitioners are not included in the file. (5) If a user is unsure of a physician or non-physician practitioner’s NPI, he or she can look it up in the NPI Registry (https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do).
Keep in mind that the record in the NPI Registry is not the Medicare PECOS enrollment record.
Conquering PECOS: What You Can Do! Teleconference with Andrea Stark!
This teleconference is offered at a discount to GAMES members on November 23 and 24, 2009. CLICK HERE for detaols.
A Win for Providers in the PECOS Battle?
 By: Andrea Stark, Medicare Consultant & Reimbursement Specialist
On Friday, October 30, 2009, CMS expanded their guidance on CR 6421, and included some promising news for providers.
According to the release, CMS will be developing a tool which will allow providers to finally scrub a physician’s NPI against those listed in the PECOS database. That’s good news for providers who have taken action to identify which referral sources are resulting in warning messages on their GenResponse Reports, but have previously had no way to directly verify their NPIs in PECOS.
The new internet-based tool will allow providers to verify the NPIs of the referring physicians and the correct spelling of the physician’s name as listed in PECOS. Unfortunately, CMS has provided no expected date for the tool’s release beyond making it available prior to Phase 2 implementation on January 4, 2010, when claim rejections begin.
Another plus for providers is that CMS seems to recognize that the PECOS physician archive is incomplete in its current form and will be making updates to address this limitation. Many physicians were added to PECOS prior to May 2008, when the NPI became a mandatory identifier. That explains why many doctors can be located on the medicare.gov website, but still prompt warning messages on the GenResponse. Per the expanded guidance issued last Friday:
Prior to the implementation of Phase 2, CMS will systematically add the NPIs to the PECOS enrollment records of all physicians and non-physician practitioners whose PECOS records do not contain their NPIs. Because the NPI is one of the matching criteria used in implementing the edits, it is essential that the NPI be in the PECOS enrollment record. Because the PECOS List contains only physicians and non-physician practitioners who are in PECOS with NPIs in their enrollment records, this action will result in the addition of many more physicians and non-physician practitioners to the PECOS List (that is used to validate DME claims).
Once CMS implements these edits, the number of rejection warnings received by providers will definitely decrease, but will not be eliminated.
Also of note, is that CMS will be rolling out two additional Part B initiatives requiring several doctors who are not already in PECOS to enroll or update their records. This will be relayed from the Local Part B contractors directly to the physicians. The top 50 physicians in each state who are actively billing but are not in PECOS will be asked to re-enroll in the Medicare program, and all physicians will be sent a special mailing that will remind them of their obligation to update their enrollment information any time there is a change. In this second initiative, if the correspondence is not deliverable, the physician’s billing privileges will be revoked. This mailing will go out to doctors this month, so it is important that their information is updated to avoid further complications with their Local Medicare Carrier. These two Part B initiatives will reinforce the message being taken by DME providers - that PECOS is a legitimate database and CMS desires to have all doctors loaded into this system. The initiatives are being rolled out between November and December, and it remains to be seen how quickly this will take effect.
These changes do serve as a small victory in the provider vs. PECOS battle, but they do not negate the need for strong physician education initiatives on the part of DME providers. As has historically been proven, providers are often the ones left holding the bag when it comes to updating physicians on Medicare requirements.
In response to the growing need for physician education regarding the recent PECOS requirement, MiraVista has put together a special Physician PECOS Education Package to help take the educational burden off of DME providers. The package is the next step for providers who have identified which physicians need to update their status in PECOS to mitigate rejection on January 4th. If you haven’t done this yet, try ClaraVista’s free Pecos Warning Extractor tool.
As part of the physician education package, providers may opt to sponsor attendance for their physicians at one of Andrea Stark’s live “PECOS Q&A for Physician Offices” conferences. Sponsored physicians will receive a copy of Andrea’s “PECOS and Physician Enrollment Overview” digital recording, and each sponsoring provider will receive two customizable PECOS physician education letters written by Andrea.
For more information on how MiraVista can help educate your referral sources on the PECOS enrollment requirement, visit: http://www.miravistallc.com/products.php.
October 30, 2009 Message for Providers/Suppliers Concerning CR 6421-- Editing the Ordering/Referring Provider in DMEPOS Claims
Prior to the implementation of Phase 2, CMS will make publicly available on the Internet a national file of Medicare physicians and non-physician practitioners who are eligible to order/refer. The file will contain the NPI and the Legal Name (from the Medicare PECOS enrollment record). This will allow DMEPOS suppliers to determine if the ordering/referring provider has a current Medicare enrollment record and is eligible to order or refer.
CLICK HERE to read the entire message from CMS.
DME Suppliers should notify referring physicians if they are not enrolled in Provider Enrollment, Chain and Ownership System (PECOS)
CLICK HERE for a sample letter to send to physicians (courtesy of VGM).
October 22, 2009 - Submit data to CEDI in UPPER CASE
Attention All CEDI Trading Partners, Suppliers, Billing Services, Clearinghouses, and Vendors: Ordering/Referring Provider Case Sensitive Edits!
CEDI has front end edits in place to validate the data submitted conforms to HIPAA and Medicare requirements. As part of these edits, the Common Electronic Data Interchange (CEDI) utilizes external code sources to validate the data on inbound transactions. The Provider Enrollment, Chain and Ownership System (PECOS) file used to verify eligibility for ordering/referring providers is one of the external data code sources utilized by CEDI.
The information from PECOS is provided to CEDI using only upper case characters. The alpha character data on the claim for the ordering/referring provider must be in upper case in order to validate the name against the PECOS file.
CEDI will reject inbound transactions submitted with lower case characters where the external code source used to perform the edits is only provided in upper case. If a lower case character is submitted in the ordering/referring provider field, the claim will be rejected.
CEDI strongly encourages submitting all alpha characters in upper case to avoid this type of issue. For more information and questions, please contact the CEDI Help Desk at ngs.cedihelpdesk@wellpoint.com or at 866-311-9184.
New PECOS Edits Will Soon Result in Claim Rejections
CMS is expanding the claims editing process for DME MACs to include a new defense against claims containing missing, improper or fraudulent physician orders. The new edits require the verification of a referral source’s Medicare enrollment and were designed to ensure that medical equipment is ordered only by those individuals authorized to do so. However, as an unintended consequence, providers now risk having legitimate claims rejected if their referral sources are not properly registered with the Provider Enrollment Chain and Ownership System (PECOS).
The expanded editing process is supposed to allow the DME MACs to verify whether a claim’s ordering physician/practitioner is actively enrolled in the Medicare program by comparing the NPI on your claim to a national list of NPIs in the PECOS database. However, the process is deeply flawed, as registration in PECOS has only recently become a requirement and the database is incomplete.
As you might expect, physicians are required to enroll with their A/B MAC or Local Carrier to submit their own claims for patient encounters, just like DME suppliers have to enroll with the National Supplier Clearinghouse. Traditionally, this meant submitting a paper 855-I or 855-R application package. That is, until 2008 when the PECOS system was developed as a way for physicians to enroll online and update their applications via the internet. The online system was first made available to individual practitioners in December, 2008 and was opened to group practices /organizational providers in April, 2009. (Eventually, PECOS will be expanded to allow DME Providers to update their 855-S applications via the internet as well. However, this is not expected to happen anytime soon.).
Until recently, this internet based approach has been voluntary, and many physicians never setup an online PECOS account. The PECOS database feeds into, but is separate from, the carrier maintained file of approved physicians. While the contractors have been working to update PECOS with physician enrollments and changes, those updates only date back through November, 2003. That means physicians who have been enrolled in the Medicare program in excess of five years and who haven’t made recent updates or changes to their enrollment are not likely to be in the PECOS system. Notwithstanding, CMS has instructed CEDI and the MACs to use this developmental, online database to determine if claims should be processed.
The new editing process is being implemented in two phases.
Phase I:
Effective October 5, 2009, PECOS began providing CEDI and VMS with a list of all Medicare approved physicians/ practitioners who are eligible to order and refer beneficiary services as reported in the PECOS database. This list is updated on a daily basis.
During Phase I, claims are being reviewed for the requirement of a Medicare enrolled physician/practitioner by comparing the ordering physician’s NPI on the claim to the list of physician/practitioner NPIs in the PECOS database. If a valid NPI number is found, further verification will be made by comparing the first letter of the physician’s first name and the first four characters of the physician’s last name.
Initially, if a name or NPI is found to be invalid, the claim will still be processed and the provider will receive a warning message on their GenResponse report (for electronic claims).
Phase II:
Effective January 4, 2010, claims will be rejected if the ordering physician/practitioner’s NPI is not provided on the claim, not found in the PECOS list or found to be inactive. Also effective January 4, 2010, providers will no longer be permitted to utilize their own NPI in place of an ordering physician/practitioner’s NPI.
Rejection Messages:
If a claim is flagged for a warning message or eventually rejected, providers will receive a C200, C201 or C202 error code with a “Referring Provider Not Authorized” rejection message on their GenResponse report (for electronic claims) or Remittance Advice (for paper claims).
Most providers are already receiving these error codes on their GenResponse reports, but don’t know what to do with them. Currently, claims with these errors are still being processed; however, they will begin rejecting on January 4, 2010.
Preventing Rejections:
The first step to preventing rejections is to ensure that you are monitoring your GenResponse Reports and capturing all instances where referral sources are rejecting as not registered in the PECOS system.
To help providers quickly identify which physicians need to register or update their information in PECOS, MiraVista, LLC in collaboration with ClaraVista, LLC (a sister company specializing in outsourced DME billing solutions) has developed a free and simple tool known as the PECOS Warning Extractor (available for download at http://www.starkvistagroup.com). The PECOS Warning Extractor takes the complexity out of filtering through technical GenRseponse reports by finding the Phase I rejection warnings on your report and identifying which physician NPIs are related to those warnings. Once you have this list of NPIs you can quickly notify those physicians that need to begin the PECOS process.
Unfortunately, the PECOS database is not accessible to DMEPOS providers, so you cannot independently verify that a physician’s NPI is active. However, there are several steps you can take:
1. Identify all physicians with NPIs resulting in warning messages (visit http://www.starkvistagroup.com to download a free tool to help parse out this data).
2. Make sure the physician information contained in your billing software reflects the same NPI and spelling of the physician’s name as reported on the publically available NPPES system: https://nppes.cms.hhs.gov/NPPES/NPIRegistrySearch.do?subAction=reset&searchType=ind. Claims must be billed using the physician’s legal name (i.e. Robert, instead of Bob) and individual billing number, not the NPI for the group practice.
3. Once your software record is verified to be accurate, contact those physicians and practitioners for which you are receiving rejection warnings, and:
a. Refer them to MedLearn Matters publication SE0194 (page 3) for insight on how to enroll in PECOS and the documentation needed to get started. (http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0914.pdf.)
b. Provide them with contact information for the CMS External User Services (EUS) Help Desk for general questions about accessing and using the PECOS enrollment system. The Help Desk’s toll-free number is 1-866-484-8049 and their e-mail address is eussupport@cgi.com.
c. Ask them to enroll in PECOS at: https://pecos.cms.hhs.gov/pecos/login.do using the same user ID and password established with NPPES (the NPI contractor).
d. Provide the NPI Enumerator’s phone number and e-mail address for questions about their NPPES user ID and password. The NPI Enumerator may be reached, at 1-800-465-3203 or via email at: customerservice@npienumerator.com.
At this point many referral sources have obtained an NPI (through the NPPES system), but they may or may not have registered with the PECOS system. To make matters worse, many physicians remain unaware of the recent requirement to enroll in PECOS, as their claims are not likely to be affected by these new DME specific edits. In addition to ensuring claims for DME will be processed, physicians should also know that the PECOS database is used to populate the www.medicare.gov website. If they are not currently in the PECOS database, patients that search for a provider on the www.medicare.gov website will not be able to find them. By taking an aggressive, proactive approach to educating your referral sources you can lessen the impact of possible rejections at the first of the year.
Andrea Stark is a Medicare consultant and reimbursement specialist for medical equipment suppliers and pharmacies. She founded MiraVista LLC after working for the Region C DMERC, and now provides consulting and education services throughout the country. She also operates a medical equipment billing company, ClaraVista LLC for outsourced DME billing. Stark can be reached via e-mail: andrea@miravistallc.com.
Provider Enrollment, Chain and Ownership System (PECOS) and DME
 What is it?
PECOS is an Internet-based Medicare provider enrollment process, known as Internet-based Provider Enrollment, Chain and Ownership System (PECOS).
Internet-based PECOS is available to physicians, non-physician practitioners, and provider and supplier organizations in all States and the District of Columbia. Internet-based PECOS will allow physicians, non-physician practitioners, and provider and supplier organizations the option of enrolling, making a change in their Medicare enrollment information, viewing Medicare enrollment information, or tracking the status of their Medicare enrollment applications
PECOS is applicable to Part A and Part B providers
How does this affect DME?
Any physician who has not updated their provider enrollment since 2003 must update their application on PECOS. PECOS allows them the “option” of enrolling, and making changes/updates to their information. All physicians are required to re enroll by January 4, 2010.
How do they enroll?
They enroll by going to http://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS and following the instructions. They will need their NPPES user ID and password.
Then what happens?
The enrollment is processed by the local AB –MAC. However, the MAC may not complete the enrollments until 60 days.
What is the problem?
If a physician has not enrolled by January 4, 2010 and a DME supplier receives an order from this physician, the supplier will not receive payment for the items billed. The claim will be denied due to “NPI invalid”.
What should we do?
- Check the NPI and make sure you have it correct
- Make sure you have correct “LEGAL” name (Robert instead of Bob etc.)
- Check this site: http://www.medicare.gov/Physician/Search/chooseprovider.asp
If the physician is not enrolled notify him/her and the patient.
An ABN may be used if the physician refuses to enroll.
Also…
EDUCATE physicians and other practitioners! Many are not aware that it does affect them. In simple terms, if we do not educate our referral sources we will not get paid.
You can utilize the memo received from your local DME MAC, MLN Article MM 6421. Click here to view.
We suggest you compile a schedule of the physicians and practitioners who have reenrolled. Keep it updated to match the information you already have. Start educating your beneficiaries (and don’t forget about existing capped rentals) and suggest to them they may be responsible for their payments if their physicians do not reenroll!
Where are we now?
EDI indicates they have had 300,000 edits hit the first day. This may very well be a real problem.
If you have any questions, please call Peggy Walker at 800-401-3643 .
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