CMS Delays PECOS Implementation Until April 5, 2010
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CMS Delays PECOS Implementation until April 5, 2010

With about 300,000 physicians and 150,000 dentists still unregistered, the Centers for Medicare & Medicaid Services (CMS) has decided to delay until April 5, 2010 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)).  CRs 6417 and 6421 are applicable to Part B claims only.

The delay in implementing Phase 2 of these CRs 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 also contains the physician/non-physician practitioner's National Provider Identifier (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.

For physicians and non-physician practitioners who order or refer—

  • If you are not enrolled in the Medicare program, or if you enrolled more than 6 years ago and have not submitted any updates or changes to your enrollment information in more than 6 years, you do not have an enrollment record in PECOS. In order to continue to order or refer items or services for Medicare beneficiaries, you will have to submit an initial enrollment application.  You may do so either by (1) using Internet-based PECOS (which transmits your enrollment application to the Medicare carrier or A/B MAC via the Internet—be sure to mail the signed and dated Certification Statement to the carrier or A/B MAC immediately after submitting the application), or (2) filling out the appropriate paper Medicare provider enrollment application(s) (CMS-855I and CMS-855R, if appropriate) and mailing the application, along with any required additional supplemental documentation, to the local Medicare carrier or A/B MAC, who will enter your information into PECOS and process your enrollment application.  Information on how to enroll in Medicare is found on the Medicare provider/supplier enrollment web site at www.cms.hhs.gov/MedicareProviderSupEnroll.
  • If you are already enrolled in Medicare, make sure you have a current enrollment record.  You can find out if you have an enrollment record in PECOS by calling your designated carrier or A/B MAC or by going on-line, using Internet-based PECOS, to view your enrollment record.  We will be posting information to the Medicare provider/supplier enrollment web site that will guide you through this process.  Information about Internet-based PECOS and a link to Internet-based PECOS can be found on the Medicare provider/supplier enrollment web site.  Before using Internet-based PECOS, we recommend that you read the information that is posted there and that is available in the downloadable documents section.
  • If you are a dentist or a physician with a specialty such as a pediatrics who is eligible to order or refer items or services for Medicare beneficiaries but have not enrolled in Medicare because the services you provide are not covered by Medicare or you treat few Medicare beneficiaries, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.
  • If you are a physician who is employed by the Department of Veterans Affairs, the Public Health Service, or the Department of Defense Tricare program but have not enrolled in Medicare because you would not be paid by Medicare for your services, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.
  • If you are a resident who has a medical license but have not enrolled in Medicare because you would not be paid by Medicare for your services, you do not need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.  The teaching physician—not the resident—should be identified in claims as the ordering/referring provider when a resident orders or refers items or services for Medicare beneficiaries.

CMS actions to mitigate the number of informational messages:

Since many Part B providers and suppliers are receiving a high volume of informational messages in their Remittances, CMS is taking the following actions to reduce the number of informational messages being generated:

1. 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 enrollment records are in PECOS but do not contain their NPIs.  Because the NPI is one of the matching criteria used in implementing the two new edits on the Ordering/Referring Provider, it is essential that the NPI be in the PECOS enrollment record.  Because the data file used to implement the two edits contains only the eligible physicians and non-physician practitioners who are in PECOS with NPIs in their enrollment records, this action will add many more physicians and non-physician practitioners to that data file.

2. Prior to the implementation of Phase 2, CMS will make publicly available on the Internet the names and NPIs of the Medicare physicians and non-physician practitioners who are eligible to order or refer in the Medicare program. The name displayed will be that of the physician or non-physician practitioner as it appears in his or her PECOS enrollment record.  This will allow Part B providers and suppliers who furnish and bill for items or services based on orders or referrals to determine if the Ordering/Referring Provider being identified in their claims will pass the two new edits prior to submitting the claims to Medicare.

3. Prior to the implementation of Phase 2, CMS will issue instructions to carriers and A/B MACs that will assist them in processing enrollment applications from physicians who are employed by the Department of Veterans Affairs, the Public Health Service, and the Department of Defense Tricare program.  The instructions will also state that the teaching physician should be reported as the Ordering/Referring Physician in situations where a resident orders or refers items or services for Medicare beneficiaries.  The instructions will also note that dentists and pediatricians, who sometimes order or refer items or services for Medicare beneficiaries, may be enrolling in Medicare in order to continue to order and refer.

4. CMS will be preparing a Special Edition Medicare Learning Network (MLN) Matters Article on the implementation of these two new edits.  This MLN Matters Article will expand upon the information currently available in MLN Matters Articles MM 6417 and MM 6421. (112309)

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