Posts tagged ‘pecos physician enrollment’

January 12, 2011

CMS clarifies July 5 PECOS implementation date

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.

September 8, 2010

Non-PECOS physician claims will be processed before Jan. 1

This is a PECOS update from TAHC

PECOS Update

The Centers for Medicare & Medicaid Services (CMS) has issued Transmittal 765 regarding expansion of claims editing to meet the July, 6 PECOS requirement. The transmittal states that the claims editing will be implemented in two phases. The initial phase begins October 1, 2010, and the second phase is set to begin on or after January 1, 2011.  These edits are being put into place to begin verification of physician’s name and NPI number as they appear on the “Medicare Ordering Referring File.” Agencies that bill the Medicare program must ensure that claims contain accurate information from the “Medicare Ordering Referring File.” The following describes the two phases and if you wish to read Transmittal 765, please click here.

Phase 1 (October 1, 2010 –December 31, 2010) – When a claim is received, CMS will determine if the attending physician is required for the billed service. If the attending physician’s NPI is on the claim, Medicare will verify that the attending physician is on the national PECOS file. If the attending physician NPI is not on the national PECOS file during Phase 1, the claim will continue to process but a message will be included on the remittance advice notifying the billing provider that claims may not be paid in the future if the attending physician is not enrolled in Medicare or if the attending physician is not of the specialty eligible to be an attending physician for HHA services.

Phase 2 (On or after January 1, 2011) – As stated above, Medicare will determine if the attending physician’s NPI is required for the billed service. If the billed service requires an attending physician and the attending physician’s NPI is not on the claim, the claim will not be paid. If the attending physician’s NPI is on the claim, Medicare will also verify that the attending physician is on the national PECOS file. If the attending physician is on the PECOS file, but not as a specialty eligible to be an attending physician, the claim, during Phase 2, will not be paid.