Posts tagged ‘pecos’

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.

July 1, 2010

PECOS rejections will de delayed

It looks like CMS will delay the rejection of claims and announces that CMS will develop a contingency plan regarding PECOS.


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June 28, 2010

PECOS verification needed or HHAs may face false claims liability, nonpayment

There is a regulation that will go into effect July 6, 2010, that could impact your ability to continue service to as many as 20-40% of the patients that you serve. This includes current patients in need of continued care, as well as new patients referred on or after that date.

PECOS is the electronic database of physicians enrolled in or opted-out of Medicare. A large percentage of physicians who have valid NPIs and are licensed doctors of medicine, osteopathy and podiatric medicine, are not enrolled in PECOS.

It takes 60-90 days after enrollment in PECOS before the verification of the physician’s enrollment appears. Until there is a PECOS record, home health agencies are at risk that they are without authorization to bill Medicare, and that any claim for payment will be denied on prepayment or post-payment review.

Home health agencies that knowingly bill Medicare for services ordered by a physician that is not enrolled in PECOS (including billing for visits made after July 6th during an episode that started before that date) face the following consequences:

  1. False claims act liability
  2. Non-payment by Medicare for billed services

The new regulation at 42 CFR 424.507 (Learn more about 42 CFR424.507.) stipulates that, effective July 6, 2010, in order for a home health agency to receive payment for services to a Medicare beneficiary:

  • The Part A or Part B home health services must have been ordered by a physician;
  • A claim for home health services must contain the legal name and the National Provider Identifier (NPI) of the ordering physician, and
  • The ordering physician must have an approved enrollment record or a valid opt-out record in the Provider Enrollment, Chain and Ownership System (PECOS)

The regulation goes on to say, “A Medicare contractor will reject a claim from a provider or a supplier for covered services described in paragraphs (a) and (b) of this section [referring to Part B services and home health care] if the claim does not…” meet the requirements as set forth above.

Action to Take NOW and June 28-30th:

1)     Check Medicare’s database for your referring physicians’ NPIs.
Or check this website for PECOS physicians: OAandP.

  • Click on the zip file for the more user-friendly database.
  • Click on Find in the upper right hand corner of the Excel file and type in the NPI number. If the physician is not listed in the excel spreadsheet, then the physician is not enrolled.

Any claims for patients for which that physician has signed the POC are in danger of being denied. Contact that physician immediately to educate and inform them of the requirements.

2)            Call your Congressional Representative and Senators and follow up with an electronic letter

3)     Fax Notice Letters and call Your Referring Physicians and Discharge Planners to alert them of the July 6th PECOS Registration Deadline. (This is not needed for physicians that are found in the database.)

3)     Submit formal comments electronically to the CMS Interim Final Rule on PECOS

We urge you to contact your members of Congress by phone or email in accord with the following instructions:

1) Urge CMS to delay implementation of the rule requiring that physicians ordering home health care be enrolled in the PECOS data base. Further, CMS should hold harmless home health providers until such time as physicians have had a reasonable opportunity to enroll, and

2) Urge Congressional leaders to intervene with CMS to resolve this issue.  Let them know that this is an important issue for you and your state as patients otherwise eligible for Medicare services will be denied care.

3) Utilize the sample letters below to fax to physicians and discharge planners to inform them of the impact the rule will have on their patients and the services you provide. Then follow up with phone calls to encourage PECOS registration.

4) Finally, we urge every home health agency to submit formal comments to the CMS Interim Final Rule that contains these new requirements and the July 6th deadline. The notice can be found at this link.  Instructions for submitting comments can be found on page 24437.

This is a critical issue, and much of the above call to action information is from the Texas Association for Home Care and Hospice.

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