CMS will hold a National Provider Call to discuss the revalidation of Medicare provider enrollment information on Thursday, October 27th, 2011; from 12:30 – 2PM Eastern. Most providers and suppliers who are enrolled in the Medicare program will have to revalidate their enrollment which will be reviewed under the new risk screening criteria required by the Affordable Care Act Section 6401(a). Learn what you can expect and how to prepare for this process.
Target Audience: All providers and suppliers enrolled with Medicare prior to March 25, 2011 and who expect to receive payment from Medicare for services provided!!!!!! (I had to add those exclamation points – what a statement – if you expect to be paid, you need to revalidate.)
The agenda will include:
- What is Revalidation?
- ACA Screening Requirements
- Electronic Funds Transfer
- Streamlining the Process
- Phased Revalidation
- Tips on Revalidation
- Question and Answer Session (my favorite!)
Registration Information: In order to receive the call-in information, you must register for the call. Registration will close at 12pm on Thursday, October 27, 2011 or when available space has been filled; no exceptions will be made, so please register early. For more details, including instructions on registering for the call, click here. The audio recording and written transcript will be posted after the call.
Presentation: The presentation will be posted at least one day before the call in the Downloads section of the page here.
For more information about provider enrollment revalidation, review the Medicare Learning Networks publication here.
Announcement from CMS:
All providers and suppliers who enrolled in the Medicare program prior to Friday, March 25, 2011, will be required to revalidate their enrollment under new risk screening criteria required by the Affordable Care Act (section 6401a). Providers/suppliers who enrolled on or after Friday, March 25, 2011 have already been subject to this screening, and need not revalidate at this time.
New Screening Criteria
In the continued effort to reduce fraud, waste, and abuse, CMS implemented new screening criteria to the Medicare provider/supplier enrollment process beginning in March 2011. Newly-enrolling and revalidating providers and suppliers are placed in one of three screening categories limited, moderate, or high each representing the level of risk to the Medicare program for the particular category of provider/supplier, and determining the degree of screening to be performed by the Medicare Administrative Contractor (MAC) processing the enrollment application. More information on the screening categories is here.
Notices Will Be Sent to Providers/Suppliers
Between now and March 2013, MACs will be sending notices to individual providers/suppliers; please begin the revalidation process as soon as you hear from your MAC. Upon receipt of the revalidation request, providers and suppliers have 60 days from the date of the letter to submit complete enrollment forms. Failure to submit the enrollment forms as requested may result in the deactivation of your Medicare billing privileges. The easiest and quickest way to revalidate your enrollment information is by using Internet-based PECOS (Provider Enrollment, Chain, and Ownership System), at https://pecos.CMS.hhs.gov.
Fees Levied
Section 6401a of the Affordable Care Act requires institutional providers and suppliers to pay an application fee when enrolling or revalidating (institutional provider includes any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A; CMS-855B, not including physician and non-physician practitioner organizations; CMS-855S; or associated Internet-based PECOS enrollment applications); these fees may be paid via www.Pay.gov.
In order to reduce the burden on the provider, CMS is working to develop innovative technologies and streamlined enrollment processes including Internet-based PECOS. Updates will continue to be shared with the provider community as these efforts progress.
For more information about provider revalidation, review the Medicare Learning Networks Special Edition Article #SE1126, titled Further Details on the Revalidation of Provider Enrollment Information.
First the facts on what has taken place so far in the 2011 EHR Incentive Programs.
- As of June 30th, the total of Medicare EHR Incentive Program payments is over $94 million.
- As of June 30th, over $166 million has been paid in Medicaid EHR incentives since the program began in January. In May and June, four states launched Medicaid EHRIncentive Programs – Indiana, Ohio, Pennsylvania, and Washington, bringing the total states with Medicaid EHR Incentive Programs to 21. More states will launch in July.
- There are 68,001 active registrations of eligible professionals and eligible hospitals for the Medicare and Medicaid EHR Incentive Programs.
If your group hasn’t received a check and hasn’t registered for the Medicare or Medicaid Incentive Program, then this blog post is for you! For anyone who is really just beginning their EHR journey, today’s presentation clarified previous information given by CMS, as well as giving listeners new information about the programs.
The Centers for Medicare & Medicaid Services (CMS) has the continuing goal of reducing fraud, waste, and abuse through all available avenues. The Affordable Care Act requires CMS to determine the level of screening to be conducted during provider and supplier enrollment based on the level of risk posed to the Medicare system. With the enactment of the Affordable Care Act, CMS has the increased ability to focus efforts on prevention, rather than simply acting after the fact. The use of risk categories and associated screening levels will help ensure that only legitimate providers and suppliers are enrolled in Medicare, Medicaid, and CHIP, and that only legitimate claims are paid.
Effective Friday, March 25, 2011, newly-enrolling and revalidating providers and suppliers will be placed in one of three screening categories limited, moderate, or high. These categories represent the level of risk for fraud, waste, and abuse to the Medicare program for the particular category of provider/supplier, and determine the degree of screening to be performed by the Medicare Administrative Contractor (MAC) processing the enrollment application.
Providers/suppliers in the limited screening category will include:
o Physicians
o Non-physician practitioners other than physical therapists
o Medical groups or clinics
o Ambulatory surgical centers
o Competitive Acquisition Program / Part B Vendors
o End-Stage Renal Disease facilities
o Federally-Qualified Health Centers
o Histocompatibility laboratories
o Hospitals (including Critical Access Hospitals, Department of Veterans Affairs hospitals, and other federally-owned hospital facilities)
o Health programs operated by an Indian Health Program (as defined in section 4(12) of the Indian Health Care Improvement Act) or an urban Indian organization (as defined in section 4(29) of the Indian Health Care Improvement Act) that receives funding from the Indian Health Service pursuant to Title V of the Indian Health Care Improvement Act
o Mammography screening centers
o Mass immunization roster billers
o Organ procurement organizations
o Pharmacies that are newly enrolling or revalidating via the CMS-855B application
o Radiation Therapy Centers
o Religious non-medical health care institutions
o Rural Health Clinics
o Skilled Nursing Facilities
Providers in the moderate screening category will include:
o Ambulance service suppliers
o Community Mental Health Centers (CMHCs)
o Comprehensive Outpatient Rehabilitation Facilities (CORFs)
o Hospice organizations
o Independent clinical laboratories
o Independent Diagnostic Testing Facilities (IDTFs)
o Physical therapists enrolling as individuals or as group practices
o Portable x-ray suppliers (PXRS)
o Revalidating Home Health Agencies (HHAs)
o Revalidating DMEPOS suppliers
Providers in the high screening category will include:
o Newly-enrolling DMEPOS suppliers
o Newly-enrolling Home Health Agencies (HHAs)
o Providers and suppliers reassigned from the limited or moderate categories due to triggering events.
Triggering events include the following instances:
- imposition of a payment suspension within the previous 10 years;
- a provider or supplier has been terminated or is otherwise precluded from billing Medicaid;
- exclusion by the OIG;
- a provider or supplier has had billing privileges revoked by a Medicare contractor within the previous 10 years and such provider/supplier is attempting to establish additional Medicare billing privileges by enrolling as a new provider or supplier or establish billing privileges for a new practice location;
- a provider or supplier has been excluded from any federal health care program;
- a provider or supplier has been subject to any final adverse action (as defined in 42 CFR 424.502) within the past 10 years; or
- instances in which CMS lifts a temporary moratorium for a particular provider or supplier type and a provider or supplier that was prevented from enrolling based on the moratorium, applies for enrollment as a Medicare provider or supplier at any time within 6 months from the date the moratorium was lifted.
The enrollment screening procedures will vary depending upon the categories described above. Screening procedures for the limited screening category will largely be the same as those currently in use; screening procedures for the moderate screening category will include all current screening measures, as well as a site visit; screening procedures for the high screening category will include all current screening measures, as well as a site visit and, at a future date a fingerprint-based criminal background check.
CMS will continuously evaluate whether a change of the assignment of categories of providers and suppliers to the various risk categories is necessary. If CMS assigns certain groups of providers and/or suppliers to a different category, this change will be proposed in the Federal Register. However, CMS will not publish a notice or a proposed rule in the Federal Register that would include instances in which an individual provider/supplier is reassigned based upon meeting one or more of the triggering events.
NOTE April 2011: CMS recently announced that July 5, 2011 will not be the date that claim editing will begin.
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If you read my post on November 29th, you already know that CMS delayed pulling the trigger on January 1, 2011 to require PECOS enrollment for ordering and referring providers and enforcing nonpayment of claims that fail the ordering/referring provider edits.
CMS has just announced a new implementation date (calling it “a placeholder future implementation”) of July 5, 2011 – unknown.
As a refresher, the only providers who can order/refer Medicare beneficiary services are:
doctor of medicine or osteopathy;
dental medicine;
dental surgery;
podiatric medicine;
optometry;
chiropractic medicine;
physician assistant;
certified clinical nurse specialist;
nurse practitioner;
clinical psychologist;
certified nurse midwife;
clinical social worker
Claims that are the result of an order or a referral must contain the National Provider Identifier (NPI) and the name of the ordering/referring provider and the ordering/referring provider must be in PECOS or in the Medicare carriers or Part B MACs claims system with one of the above types/specialties.
The claim editing that will begin on July 5, 2011 date not known will verify the ordering/referring provider on a claim is eligible to order/refer and is enrolled in Medicare.
The process to be used to determine if the ordering/referring provider on the claim matches the provider in the national PECOS file or in the contractors master provider file is as follows:
- MCS (Multi-Carrier System) will verify the National Provider Identifier (NPI) of the ordering/referring provider reported on the claim against the national PECOS file.
- If a match is not found, the MCS will verify the NPI of the ordering/referring provider on the claim against the MCS master provider file.
- If a match is found, the MCS will then compare the first letter of the first name and the first 4 letters of the last name of the matched record.
- If the names match, the ordering/referring provider on the claim is considered verified.
If you’ve not verified that your providers are properly enrolled in PECOS, you have yet another chance to get it figured out.
Here’s the Cheat Sheet:
- Check to see if your provider is enrolled by reviewing the Ordering and Referring file found in the download section of the OrderingReferringReport tab (click here) on the Medicare Provider and Supplier Web Site. The report is currently more than 15,000 pages but you can view it on the screen.
- If not enrolled, you can get your provider enrolled by paper or electronically. The Internet-based PECOS application is here.
- After submitting an enrollment application via Internet-based PECOS, you must:
- Print, sign and date (blue ink recommend) the Certification Statement(s), and
- Mail the Certification Statement(s) and applicable supporting documentation to the designated Medicare contractor (no later than 7 days after you complete the online portion.)
NOTE: The Medicare contractor will not be able to begin to process your enrollment application until it receives a signed and dated Certification Statement.
For more detailed information on PECOS, click on the PECOS category on the right-hand side of this web page.
NOTE: The date has been changed to July 5, 2011 delayed indefinitely.
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The following statement was released by CMS on November 26, 2010:
The Centers for Medicare & Medicaid Services (CMS) previously announced that, beginning January 3, 2011, if certain Part B billed items and services require an ordering/referring provider and the ordering/referring provider is not in the claim, is not of a profession that is permitted to order/refer, or does not have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS), the claim will not be paid. The automated edits will not be turned on effective January 3, 2011. We are working diligently to resolve enrollment backlogs and other system issues and will provide ample advanced notice to the provider and beneficiary communities before we begin any automatic nonpayment actions.
Previous posts on enrolling physicians in PECOS are here and here.
Image by Squash713 via Flickr
NOTE: The date has been changed to July 5, 2011 has been delayed indefinitely.
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Many managers have told me they know their providers are in PECOS but they’re not on the list OR they never enrolled their providers but they are on the list OR they’ve sent their paperwork and have not heard back for 2, 4, 6 weeks – should they be worried? The CMS website says “It is possible that it could take 45-60 days, sometimes longer, for Medicare enrollment contractors to process enrollment applications,” so I guess we all need to chill out a little.
The massive undertaking of qualifying every single healthcare professional who refers/orders or provides medical services to Medicare patients in order to sift out those who would lie about providing goods and services is fraught with confusion, miscommunication and misunderstanding. That’s okay, though, because CMS says no checks for services or goods will be withheld due to providers not being listed in PECOS, at this time. They know it’s a mess and it will take quite a while to get everyone straightened out, on the list and able to get checks from CMS if and only if their name is on the list.
Below is the CMS fact sheet published last week.

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Medicare Enrollment Guidance for Physicians that Infrequently Receive Reimbursement from the Medicare Program
Traditionally, most physicians have enrolled in the Medicare program to furnish covered services to Medicare beneficiaries. However, with the implementation of Section 6405 of the Affordable Care Act, some physicians will need to enroll in the Medicare program for the sole purpose of certifying or ordering services for Medicare beneficiaries. These physicians do not send claims to a Medicare contractor for the services they furnish.
In the process of implementing the provisions contained in the Affordable Care Act, we have become aware of several unique enrollment issues for certain types of physicians or practitioners. Specifically, we have modified the process of enrollment to accommodate the special circumstances of the following individual physicians and practitioners:
- Physicians employed by the Department of Veterans Affairs
- Physicians employed by the Public Health Service
- Physicians employed by the Department of Defense Tricare program
- Physicians employed by Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) or Critical Access Hospitals (CAHs)
- Physicians in a Fellowship
- Dentists, including oral surgeons
This document provides guidance to those practitioners.
Q: How can I verify whether I am already enrolled in PECOS?
A: If a physician is concerned or uncertain about whether s/he is actually enrolled in the Provider Enrollment, Chain and Ownership System (PECOS), s/he can review the Ordering and Referring file found in the download section of the “OrderingReferringReport tab (click here) on the Medicare Provider and Supplier Web Site.
Providers and suppliers can check with the ordering or referring physician to see if the physician is currently seeing Medicare patients and the physicians claims are being paid. Until we advise otherwise, your orders and referrals will not be rejected due to the lack of an approved enrollment record in PECOS.
Q: I am a physician employed by the Department of Veterans Affairs, Department of Defense Tricare program, by the Public Health Service, an FQHC, an RHC, or a CAH. Do I need to enroll in PECOS to order and refer items or services for Medicare beneficiaries?
A: Yes, but we have abbreviated the enrollment process and documents for physicians employed by the Department of Veterans Affairs, the Public Health Service, the Department of Defense Tricare program, an FQHC, an RHC, or a CAH. However, because this is a unique solution to enrollment for a specific set of physicians, our systems will not accommodate the abbreviated forms on-line. Therefore, any physician employed by the Department of Veterans Affairs, the Public Health Service, the Department of Defense Tricare program, an FQHC, an RHC, or a CAH, who is not already enrolled in PECOS, must use the paper enrollment application process
and do the following:
Complete the following sections of the paper CMS-855I, Medicare Enrollment Application for Physicians and Non-Physician Practitioners and mail the completed form to the designated Medicare enrollment contractor:
- Section 1 Basic Information (they would be a new enrollee)
- Section 2 Identifying Information (section 2A, 2B, 2D and if appropriate 2H and 2K)
- Section 3 Final Adverse Actions/Convictions
- Section 4C/4E Practice Location Information (same as section 2B)
- Section 13 Contact Person
- Section 15 Certification Statement (must be signed and datedblue ink recommended)
- Section 17 Supporting Documentation (cover letter stating the provider is only enrolling to order and refer services to a beneficiary)
Note: Physicians who are employed by the Department of Veterans Affairs, the Public Health Service, the Department of Defense Tricare program, an RHC, FQHC, or CAH are not required to include the Electronic Funds Authorization Agreement (CMS-588) or the Medicare Physician and Supplier Agreement (CMS-460) with the enrollment form.
Q: I am a physician in a fellowship program. Do I need to enroll in PECOS?
A: If you are a physician in a fellowship, and licensed in the State, you can enroll in Medicare for the sole purpose of ordering or referring items or services for Medicare beneficiaries. To enroll as a referring and ordering physician-only you would need to complete the abbreviated enrollment application form in the same way as other physicians (VA, DoD, PHS, FQHC, RHC CAH) who are enrolling to order and refer only (see previous question.) If you elect to enroll to order and refer only, you would not be enrolled in Medicare for the purpose of providing Medicare services to Medicare beneficiaries. In order to provide covered services to Medicare beneficiaries, a physician would need to complete the full enrollment application either on-line or in hard copy.
Q: I am an Oral Surgeon or Dentist. How do I Enroll in PECOS?
A: Dentists, including oral surgeons, must enroll in the Medicare program to receive reimbursement for services furnished to Medicare beneficiaries or to order covered items or services for Medicare beneficiaries. Oral surgeons would complete the same paper forms, or on-line application, as any other practitioner enrolling in PECOS.
If you elect to enroll as a referring and ordering physician-only, you would need to complete the abbreviated enrollment application form in the same way as other physicians (VA, DoD, PHS, FQHC, RHC CAH) who are enrolling to order and refer only (see previous two questions.) If you elect to enroll to order and refer only, you would not be enrolled in Medicare for the purpose of providing Medicare services to Medicare beneficiaries.
In order to provide covered services to Medicare beneficiaries, a dentist, including oral surgeons, would need to complete the full enrollment application either on-line or in hard copy.
Note: In completing the enrollment application portion dealing with specialty, oral surgeons would check the oral surgery (dentist only) box found in section 2 of the Medicare enrollment application and any other dentist would check the box titled, Undefined Physician Type and specify that they are a dentist in the space provided. In the near future, we will revise the Medicare enrollment application to add Dentist as a physician specialty.
Internet-based PECOS
Physicians and practitioners who are employed by the Department of Veterans Affairs, the Defense Department, the Public Health Service, an RHC, FQHC, or CAH must complete the paper enrollment application that has been modified and shortened to accommodate the special situation of these professionals. All other physicians and practitioners who furnish services to Medicare beneficiaries must enroll in the Medicare program to receive reimbursement and order/refer in the Medicare program. For those physicians and practitioners using the on-line process, we have developed a document that will help you through the PECOS enrollment process. It will be easier to complete the process if you review this document before you begin the enrollment process.
- The document titled, Internet-based PECOS — Getting Started Guide for Physicians and Non-Physician Practitioners can be found here.
- Although you are permitted to complete your enrollment application in hard copy, it will be easier and quicker if you use the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) to complete the Medicare enrollment process. The Internet-based PECOS application is completed via the web here.
- After submitting an enrollment application via Internet-based PECOS, you must:
- Print, sign and date (blue ink recommend) the Certification Statement(s), and
- Mail the Certification Statement(s) and applicable supporting documentation to the designated Medicare contractor (no later than 7 days after you complete the online portion.)
- NOTE: The Medicare contractor will not be able to begin to process your enrollment application until it receives a signed and dated Certification Statement.
Additional Medicare Enrollment Information
To ask a provider enrollment question, contact the Medicare contractor for your State. Medicare provider enrollment contact information for each State can be found here.
To report Internet-based PECOS navigation, access, or printing problem with Internet-based PECOS, contact the EUS Help Desk at 1-866-484-8049 or send an e-mail to the EUS Help Desk to EUSSupport@cgi.com
For additional information regarding the Medicare enrollment process, visit the website here. Of course, if you have any additional questions about the Medicare enrollment process, you can contact the designated Medicare contractor for your state.
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If you haven’t started yet but plan to use the online process to enroll your providers or yourself, here’s a really excellent SlideShare presentation by David Zetter that steps you through the enrollment process by showing screen shots of each step. You can contact David Zetter here.
Note: MLN Matters published this link on June 9th that was inadvertently left out of the June 8th notice: http://www.cms.gov/MLNMattersArticles/downloads/MM6842.pdf
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On May 28, 2010, CMS in Change Request 6842 notified Medicare Part A & B Administrative Contractors (A/B MACs) of their responsibility to facilitate a “One-Time Mailing” to all physicians and non-physicians who are currently enrolled in Medicare but who do not have an enrollment record in PECOS.

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This mailing is to take place no later than 30 days after the date of the issuance (May 28th), therefore no later than June 28, 2010, leaving only six business days before the July 6 date for PECOS enrollment.
Additionally, the Change Request states:
A provider education article related to this instruction will be available at http://www.cms.hhs.gov/MLNMattersArticles/ shortly after this CR is released. You will receive notification of the article release via the established “MLN Matters” listserv. Contractors shall post this article, or a direct link to this article, on their Web site and include information about it in a listserv message within one week of the availability of the provider education article. In addition, the provider education article shall be included in your next regularly scheduled bulletin. Contractors are free to supplement MLN Matters articles with localized information that would benefit their provider community in maintaining Medicare provider enrollment data correctly.
As of Tuesday evening when I posted this article, the MLN Matters article referred to had not been published.
Interestingly, there is no mention of the July 6, 2010 date that is the so-called compliance date for all providers to have an enrollment record in PECOS. As of the last CMS open door forum (my notes here) there was a lack of clarity surrounding the July 6, 2010 date versus the original January 1, 2011 date. The speaker would not definitively say that providers without a PECOS enrollment record as of July 6, 2010 would not receive Medicare payments. Given the short time frame between the MAC letters and the July 6 date, one would assume providers will have a grace period before CMS shuts off reimbursement for services rendered and/or refuses stimulus money for meaningful use of an EMR.
More information on the Stimulus Money here:
FAQ on HITECH, Meaningful Use, Eligible Providers, and the Stimulus Money
If you are not enrolled in PECOS,
this is what your letter will look like:
[DATE]
[Physician/Non-Physician Practitioner Name and Correspondence Address]
Dear Physician/Non-Physician Practitioner:
Our records indicate that you do not have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) because you enrolled in Medicare prior to the implementation of PECOS and you have not submitted any updates to your Medicare enrollment information in the past 6 (or more) years. PECOS is the enrollment system for Medicare providers and suppliers.
There are three important reasons why you should take the necessary action to establish an enrollment record in PECOS as soon as possible. First, updating your Medicare enrollment record will assist us in ensuring payment accuracy for the services you furnish to Medicare beneficiaries. Second, you will need an approved enrollment record in PECOS to continue to order or refer items or services for Medicare beneficiaries. Finally, in accordance with the American Recovery and Reinvestment Act of 2009, Title XIII, known as the HITECH Act, incentive payments may be made by Medicare and Medicaid to enrolled eligible professionals and certain hospitals that meet the HITECH requirements. More information on Medicare HITECH incentive payments can be found at http://www.cms.hhs.gov/Recovery/11_HealthIT.asp under Related Links Outside CMS on the CMS web site. The Centers for Medicare & Medicaid Services (CMS) will use the PECOS enrollment records to verify Medicare enrollment for HITECH incentive payments. Therefore, you will not be eligible to receive incentive payments from Medicare for meaningful use of certified electronic health records if your enrollment information is not maintained in PECOS by CMS.
Since you do not have a current Medicare enrollment record, it is imperative that you immediately begin the process to establish your enrollment record in PECOS. CMS expects you to do this as soon as possible after receiving this letter. If you have already submitted an enrollment application within the last 60 days, and your enrollment application has been accepted for processing by the carrier or A/B MAC, you need not take any additional actions based on this letter.
You can submit your enrollment application in one of two ways:
(1) Use Internet-based PECOS
Step 1. Before you begin, be sure you have a National Provider Identifier (NPI) and have created a User ID and password in the National Plan and Provider Enumeration System (NPPES). You will need the NPPES User ID and password in order to access Internet-based PECOS. If you need help creating an NPPES User ID and password, or if you are not sure you ever created them or cannot remember what they are, you may contact the NPI Enumerator for assistance at 1-800-465-3203.
Step 2. Read the documents that are available about Internet-based PECOS on the CMS Provider/Supplier Enrollment web page www.cms.hhs.gov/MedicareProviderSupEnroll/
Step 3. Once you have completed and submitted your enrollment application using Internet-based PECOS, be sure to print the Certification Statement, sign and date it, and mail it, along with any required supporting documentation, to the carrier or A/B MAC whose name and mailing address will be displayed to you by the system.
Note: If you reassign some or all of your Medicare benefits to a group practice, there will be two Certification Statements to print, sign and date, and one of them will also need to be signed and dated by an Authorized Official of the group practice. The carrier or A/B MAC cannot process your web-submitted enrollment application without having the signed and dated Certification Statement(s) in hand.
(2) Complete the paper Medicare enrollment application (CMS-855I) as an initial application.
Step 1. Complete the CMS-855I (if you reassign benefits to a clinic or group practice other than your own, complete a CMS-855R as well), sign and date (blue ink recommended) and mail the application(s), along with any required additional supporting documentation, to the Medicare carrier or A/B MAC. These forms are downloadable from the CMS Provider/Supplier Enrollment web page (shown above) or the CMS forms page www.cms.hhs.gov/cmsforms or you may request the necessary forms from the carrier or A/B MAC.
Step 2. Once the paper application has been received by the carrier or A/B MAC, the carrier or A/B MAC will begin to process your enrollment application. If additional information is needed by the carrier or A/B MAC to complete the processing of your enrollment application, they will contact you.
You are strongly urged not to delay in establishing your Medicare enrollment record within PECOS, especially if you plan on applying for incentive payments under the HITECH program. The carriers and A/B MACs are expected to process your enrollment application within 60 days as long as you submit your enrollment application before September 1, 2010.
If you need information about Medicare enrollment or how to use Internet-based PECOS, visit the
CMS Provider/Supplier Enrollment web page at: www.cms.hhs.gov/MedicareProviderSupEnroll/
If you need assistance with your NPPES User ID and password, contact the NPI Enumerator at 1-800-465-3203.
If you have questions about this letter, contact [carrier or A/B MAC phone number/contact person].
Sincerely,
[Name of carrier or A/B MAC]
CMS held a two-hour Open Door Forum today and there was so much good information shared that I thought I’d pass my notes from the call along to you.
New EFT Form
The revised EFT (Electronic Funds Transfer) authorization form 588 is available here (pdf.) The old form will still work for a few months longer before it becomes invalid.
Changes to the Medicare Program Integrity Manual
The Program Integrity Manual (publication 100-80) will have revisions related to the changes in provider enrollment. The online-only manual here will have content moved from Chapter 10 to Chapter 15 and the provider enrollment information will be easier to understand.
The Question on Everyone’s Lips
How do I know if I’m listed in PECOS (Provider Enrollment and Chain/Ownership System) and how do I know if others are listed in PECOS? A new downloadable file is now available here (12,000 pages!) and everyone listed in this Ordering/Referring file has approved enrollment status. Anyone not appearing on this list is not in approved status, or has opted completely out of the Medicare program.
Advanced Diagnostic Imaging
Beginning in January 2012, all diagnostic magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine imaging such as positron emission tomography (PET) must be performed in a facility accredited by the American College of Radiology (ACR), The Joint Commission (TJC) or the Intersocietal Accreditation Commission (IAC) for the technical component of the test to be reimbursed by Medicare. This rule does not apply to x-rays, ultrasound, fluoroscopy, mammography or DEXA scans and does not apply to any professional component.
Hospital Revalidations
Hospitals not enrolled in PECOS or not receiving EFT (Electronic Funds Transfer) will be contacted by CMS in an attempt to get all hospitals revalidated.
PECOS (pronounced “pay-cose”)
CMS recommends that anyone with questions or just getting started in PECOS read the “Getting Started Guide”, of which there are two versions, both available here in pdf form. One is for providers and one is for suppliers of DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.) You need to know your corporate structure before getting started because the business must enroll before the providers can assign benefits to the business. The 855I is for individual/solos providers and the 855B is for non-individuals (multiple owners) billing Medicare Part B and assigning benefits to a legal entity/corporation. Dentists and pediatricians who order or refer services for Medicare patients are required to have an enrollment record in the PECOS. Residents and interns are exempt from the enrollment requirement, but an attending physician needs to be identified on the claim when a service is ordered or referred. The main page for enrollment is https://www.cms.gov/MedicareProviderSupEnroll/
Two Ways to Get Into PECOS
One is to complete the paper form in BLUE INK (and if time is of the essence CMS suggests that you use the paper form) and let the MAC enter it into PECOS for you. The other is to use the internet-PECOS system directly, and sign, date and mail the certification statement to complete the process. Submit the participation form or EFT form if required. The certification form for the paper process is NOT the same as the certification from for the internet-PECOS process.
What is the 30-day rule?
The 30-day rule states that you can bill for services provided to Medicare patients up to 30 days prior to your filing date. The filing date is the date your enrollment is accepted, not the date you mailed it. Online it will say “Status Approved”, and you will receive an email, and then a letter confirming it. You will appear on the Ordering/Referring file on the CMS website.
What happens to payments for patients that were referred by a provider not enrolled on PECOS?
Even though you are enrolled, if the referring physician is not enrolled, you will not be paid for that patient’s services. However, if that referrer becomes enrolled, you can resubmit the claim and it will be paid.
What happens on July 6, 2010? When does this happen?
July 6, 2010 The compliance date for Part A providers (hospitals, skilled nursing homes and home health agencies) and Part B providers (physicians, ambulance) must be enrolled in PECOS as ordering/referring physicians for payments to be made has been delayed indefinitely!
What happens on July 13, 2010?
DMEPOS (pronounced “demmy-pos”) providers must be enrolled in PECOS to receive Medicare payments.
What should be done if a provider leaves a group?
The provider or his Authorized Official (CEO, CFO, Manager) should file a 855R or make the change in PECOS as soon as possible.
Why do provider offices still request UPINs from our office?
Unclear. UPINs were no longer required as of May 23, 2008. The NPI is the only number accepted on Medicare claims.
Should the information submitted on a 855 be the same information in PECOS?
Yes, if it isn’t, contact the Help Desk. Their toll-free number is 1-866-484-8049 and their e-mail address is eussupport@cgi.com.
For more information on the nuts and bolts of PECOS, see my post here.
The Centers for Medicare & Medicaid Services (CMS) will hold a Special Open Door Forum (ODF) to discuss Medicare provider enrollment issues. During this call, CMS staff will discuss:
- The May 5, 2010 provider enrollment regulation titled, “Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements (CMS-6010-IFC)”
- Medicare ordering and referring issues, including physician notification
- Documentation requirements
- Internet-based Provider Enrollment, Chain and Ownership System (PECOS)
- Physician, non-physician practitioner, provider and supplier organizations
- Upcoming availability of Internet-based PECOS for DMEPOS suppliers
- Pharmacy accreditation issues
- Advanced diagnostic imaging accreditation
- Provider and supplier reporting responsibilities
- Revalidation efforts
Afterwards, there will be an opportunity for the public to ask questions.
May 19, 2010
3:00PM – 5:00PM ET
2:00 PM – 4:00 PM CT
Open Door Forum Instructions:
Capacity is limited so dial in early. You may begin dialing into this forum as early as 2:45 PM ET.
Dial: 1-800-603-1774
Reference Conference ID 61448973
Read my post on the date change for PECOS enrollment that relates to CMS-6010-IFC here.





