Home Health Insight

From CMS:

At this time The Centers for Medicare and Medicaid Services (CMS) has not turned on the automated edits that would deny claims for services that were ordered or referred by a physician or other eligible professional simply for lack of an approved file in PECOS. However, providers have begun to see messages from Palmetto GBA, on the absent data message listing request for anticipated payment reports. Providers are reporting messages that state “Primary Physician not PECOS Verified” appearing in these reports.

Providers are reminded that claims submitted without PECOS validated physician information (Name and NPI number) will generate a warning message at this time, but according to Change Request 6421, dated December 16, 2010; CMS is re-issuing this CR with a placeholder future implementation date of July 5, 2011 for Phase 2. This placeholder date is being issued to give CMS more flexibility to determine the appropriate date for nonpayment of claims that fail the Ordering/Referring Provider edits.

CMS also released the following statement related to the updated CR:

“Due to recent inquiries, the Centers for Medicare & Medicaid Services (CMS) is clarifying its policy regarding expanded ordering/referring provider claim edits.  CMS has not yet decided when it will begin to reject claims if an ordering/referring provider does not have a record in the Provider Enrollment, Chain, and Ownership System (PECOS).  CMS will give providers ample notice before claim rejections begin.  Recent revisions to Change Requests (CRs) #6417 and #6421 require Medicare Administrative Contractors to delay rejecting claims until receiving further direction from CMS”.

Providers are encouraged to remind physicians or other eligible professionals who are not currently enrolled in PECOS to take the initiative to enroll sooner rather than later. If you know a physician is not yet in PECOS and/or he or she would like to enroll in the Medicare program, please advise them that the best way is to submit an application through the Internet-based PECOS.

Here are ways to verify if a physician has an enrollment record in PECOS:

1.       Check the Ordering and Referring Report.

2.       Use Internet-based PECOS to look for your PECOS enrollment record. If no record is displayed, you do not have an enrollment record in PECOS. A link to our Internet-based PECOS page is listed as the fourth (4th) link in the navigation menu on the left side of this screen.