(040314) REVISED - PECOS "Dear Physician" Letter from the Four DME MAC Medical Directors
(112910) Claim Editing for Ordering/Referring Providers (PECOS Edit Announcement) 6417
(101110) Download the PECOS DMEPOS Fact Sheet
PECOS (6/30/2010 Update)
CMS Again Delays Implementation of Internet-based PECOS until Sometime This Fall
The July 6 implementation date of the Internet-based provider enrollment chain and ownership system (PECOS) placed added pressure and administrative burdens on pedorthists and other DMEPOS suppliers to inform those who have not yet registered in the system to do so, and thereby prevent claims from rejecting based on referrals made by physicians not yet registered in PECOS. Some of that pressure has been alleviated as the Centers for Medicare and Medicaid Services (CMS) has once again delayed the implementation date from July 6 to some yet-to-be-announced date this fall of PECOS for further development and testing and to allow more practitioners to register in the system.
CMS did not provide a new specific deadline date for implementation in their June 30 announcement. And while claims should process as usual even if a referring physician is not enrolled in PECOS, whether or not those claims made after July 6 are subject to recoupment has yet to be determined.
The Patient Protection and Affordable Care Act (PPACA) passed in March of this year accelerated the PECOS implementation date from the pushed-back date of January 3, 2011 to July 6, 2010.
PECOS (6/8/10 Update)
CMS Changes PECOS Implementation Date Again – to July 6, 2010
The Centers for Medicare and Medicaid Services (CMS) recently published an interim final rule that is a requirement of the Patient Protection and Affordable Care Act (PPACA) passed in March. The interim final rule moves the date that referring physicians must have be enrolled in the Provider Enrollment Chain and Ownership System (PECOS) from January 3, 2011 to July 6, 2010 – six months earlier than previously announced.
DMEPOS suppliers who take Medicare referrals on or after July 6 from referring physicians who are not enrolled in PECOS risk having those claims rejected, according to CMS. However, CMS will not begin to reject claims until January 3, 2011.
CMS is currently implementing system edits to detect if an ordering and referring physician is enrolled in PECOS. The edits may not be in place by the July 6 deadline, but CMS indicated that it reserves the right to go back and reprocess claims. When CMS implements edits to the system, if the correct name and National Provider Identifier (NPI) combination on the claim for the ordering and referring physician is not enrolled in PECOS, the claim will be rejected. CMS will give providers advance notice of when the edits will be in place.
To determine if a physician is enrolled in PECOS, visit CMS's Medicare Provider-Supplier Enrollment Web page at http://www.cms.gov/MedicareProviderSupEnroll. To get a list of eligible physicians, click on the Ordering Referring Report on the left-hand side of the page and scroll down to the downloadable file.
PECOS (2/18/10 Update)
Change Request 6421, Expansion of the Current Scope of Editing for Ordering/Referring Providers for DMEPOS, requires Medicare implementation of system edits to assure that DMEPOS suppliers bill for items or services only when those items or services are ordered or referred by physician and non-physician practitioners who are eligible to order/refer such services. Physician and non-physician practitioners must be enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and of the type/specialty eligible to order/refer services for Medicare beneficiaries.
The Phase 2 implementation of this requirement has been delayed to January 3, 2011, to 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.
Phase 1: Beginning October 5, 2009, if the billed Part B service requires an ordering/referring provider and the ordering/referring provider is not reported on the claim, the claim will not be paid. If the ordering/referring provider is reported on the claim but does not have a current enrollment record in PECOS or is not of a specialty that is eligible to order and refer, the claim will be paid and the billing provider will receive an informational message in the remittance indicating that the claim failed the ordering/referring provider edits.
Phase 2: Beginning January 3, 2011, Medicare will reject Part B claims that fail the Ordering/Referring Provider edits. Physicians and others who are eligible to order and refer items or services need to establish their Medicare enrollment records in PECOS and must be of a specialty that is eligible to order and refer.
Enrolled physicians and non-physician practitioners who do not have enrollment records in PECOS and who submit enrollment applications in order to get their enrollment information into PECOS should not experience any disruption in Medicare payments, as a result of submitting enrollment applications.
Enrollment applications must be processed in accordance with existing Medicare instructions. It is possible that it could take 45-60 days, sometimes longer, for Medicare enrollment contractors to process enrollment applications. All enrollment applications, including those submitted over the web, require verification of the information reported. Sometimes, Medicare enrollment contractors may request additional information in order to process the enrollment application.
Waiting too late to begin this process could mean that your enrollment application will not be able to be processed prior to the implementation date of Phase 2 of the Ordering/Referring Provider edits, which is January 3, 2011.
(061710) One-Time Mailing of Solicitation Letter to Physicians and Non-Physician Practitioners Who Are Currently Enrolled in Medicare But Who Do Not Have Enrollment Records in the Provider Enrollment, Chain and Ownership System (PECOS)- MM6842
(041910) Expansion of the Current Scope of Editing for Ordering/Referring Providers for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers' Claims Processed by Durable Medical Equipment Medicare Administrative Contractors (DME MACs)(Revised 3/31/10)
(040710) Special Edition MLN Matters Article # SE1011 - Edits on the Ordering/Referring Providers in Medicare Part B Claims (Change Requests 6417, 6421, and 6696) - The Centers for Medicare & Medicaid Services (CMS) has released a Special Edition MLN Matters article that provides guidance on the edits required to be identified in Part B claims from Medicare providers or suppliers who furnish items or services as a result of orders or referrals. Medicare providers and suppliers who order or refer items or services for Medicare beneficiaries must submit an enrollment application to Medicare by using Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or by completing the paper enrollment application (CMS-855I). The article, SE1011, "Edits on the Ordering/Referring Providers in Medicare Part B Claims (Change Requests 6417, 6421, and 6696).
(031910) Change Request 6696
(022810) Revised Change Request 6421
(022610) Change Request 6417
(021510) Scope of Claims Editing
(12/9/09) Physician PECOS Requirement Letter
(10/28/09) PECOS Q & A
04/24/09) Expansion of the Current Scope of Editing for Ordering/Referring Providers for claims processed by Medicare Carriers and Part B Medicare Administrative Contractors (MACs) (PECOS)(Change Request 6421)