PECOS Q & A
Share |

Information you need to know about your referring physicians Provider Enrollment, Chain and Ownership System (PECOS) and DME

Questions and Answers to Assist in Clarifying the Program

As of Oct. 1, 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.  These changes will impact DMEPOS claims received and processed on or after October 5, 2009.

Earlier in October, providers began reporting that they have started receiving Medicare Error Codes:  C202, CR45, or CO145 (ordering provider not authorized) on electronically submitted claims because the referring physician may not be enrolled in PECOS.  NOTE: These initial error codes are warnings – NOT denials.

CMS is using two phases to notify the DMEPOS providers:

Phase 1 (October 5, 2009-January 3, 2010):  If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and is eligible to order/refer in Medicare.  If the ordering/referring provider is not in PECOS or is in PECOS but is not of the type/specialty to order or refer, the claim will continue to process.

• If the DMEPOS supplier claim is an ANSI X12N 837P standard electronic claim, the DMEPOS supplier will receive a warning message on the Common Electronic Data Interchange (CEDI) GenResponse Report.

• If the DMEPOS supplier claim is a paper CMS-1500 claim, the DMEPOS supplier will not receive a warning and will not know that the claim did not pass these edits.

During Phase 2, (January 4, 2010 and thereafter):  If the ordering/referring provider is not on the claim, the claim will not be paid.  If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and eligible to order and refer.  If the ordering/referring provider is not in PECOS or is in PECOS but is not of the specialty to order or refer, the claim will not be paid. It will be rejected.

• If the DMEPOS supplier claim is an ANSI X12N 837P standard electronic claim, the DMEPOS supplier will receive a rejection message on the CEDI GenResponse Report.

• If the DMEPOS supplier claim is a paper CMS-1500 claim, the DMEPOS supplier will see the rejection indicated on the Remittance Advice.

More information on this may be found in the MLN Matters article MM6417 by clicking here.

The following question/answer was compiled by VGM Billing Advisor, Peggy Walker.

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 to see if your physician is enrolled by:

Checking the NPI and make sure you have it correct;

Make sure you have correct "LEGAL” name (Robert instead of Bob etc.);

Visit: http://www.medicare.gov/Physician/Search/chooseprovider.asp%20 NOTE: It is a process to search through this site, and many providers have reported that a minimal amount of physicians were found. Information on this process is being compiled and will be forwarded to CMS.

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 you do not educate your referral sourcesyou will not get paid.  You can utilize the memo received from your local DME MAC, MLN Article MM 6421, which can be viewed by clicking here.

It is suggested that 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.

Additional information on entering physician/non-physician information to verify eligibility

When submitting the referring physician/non-physician's information, UPPER CASE letters must be used.  See note below from CMS:

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.

Association Management Software Powered by YourMembership.com®  ::  Legal