Providers who are eligible to order and refer items or services, and have not yet done so, are highly encouraged by CMS to enroll in the Provider Enrollment, Chain and Ownership System (PECOS). CMS rescinded a January 3, 2011 deadline that would have withheld payment for items or services referred by for physicians and other eligible providers not enrolled in PECOS, nonetheless CMS strongly recommends enrollment and has indicated that this may still become mandatory.
How Do I Know If I Have Enrollment Records in PECOS?
If you are a physician/non-physician practitioner that enrolled in Medicare before November 2003 AND have NOT updated your Medicare enrollment information since then, you most likely Do NOT have an enrollment record in PECOS, unless you have recently done so.
- If you enrolled in Medicare after 2003, your enrollment record is in PECOS and CMS may have added your NPI to it.
If you are unsure, here are ways to verify that you have an enrollment record in PECOS for all of your PTANs:
- Check the Ordering Referring Report on the CMS website. If you are on that report, you have a current enrollment record in PECOS. However, you should ensure that all of your PTANS are in the PECOS system.
For the Ordering and Referring report click here, then scroll down and click on the report.
- Use Internet-based PECOS to look for the provider’s PECOS enrollment record. (Providers will need to first set up their access to Internet-based PECOS.) If no record is displayed, the provider does not have an enrollment record in PECOS.
How to enroll in PECOS:
a) Use Internet-based PECOS to submit your enrollment application over the Internet to your designated Medicare enrollment contractor. You will have to print, sign, and date the Certification Statement and mail the Certification Statement, and any required supporting paper documentation, to your designated Medicare enrollment contractor. The designated enrollment contractor cannot begin working on your application until it has received the signed and dated Certification Statement. If you will be using Internet-based PECOS, please visit the Medicare provider/supplier enrollment web page to learn more about the web-based system before you attempt to use it. Go to http://www.cms.gov/MedicareProviderSupEnroll, click on “Internet-based PECOS” on the left-hand side, and read the information that has been posted there. Download and read the documents in the Downloads Section on that page that relate to physicians and non-physician practitioners. A link to Internet-based PECOS is included on that web page.
b) Obtain a paper enrollment application (CMS-855I), fill it out, sign and date it, and mail it, along with any required supporting paper documentation, to your designated Medicare enrollment contractor. If you reassign all your Medicare benefits to a group/clinic, you will also need to fill out, sign and date the CMS-855R, obtain the signature/date signed of the group’s Authorized Official, and mail the CMS-855R, along with the CMS-855I, to the designated Medicare enrollment contractor. Enrollment applications are available for downloading from the CMS forms page (http://www.cms.gov/cmsforms)
Below are examples of some of these types of claims that will be denied for lack of enrollment in PECOS:
•Claims from laboratories for ordered tests;
•Claims from imaging centers for ordered imaging procedures;
•Claims from suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) for ordered DMEPOS; and
•Claims from specialists or specialty groups for referred services.
Physicians and non-physician practitioners that are eligible to order or refer items or services for Medicare beneficiaries are as follows:
•Physician (doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery, doctor of podiatric medicine, doctor of optometry, doctor of chiropractic medicine),
•Physician Assistant,
•Certified Clinical Nurse Specialist,
•Nurse Practitioner,
•Clinical Psychologist,
•Certified Nurse Midwife, and
• Clinical Social Worker.
To login or enroll in PECOS click here.