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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:

1. 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.
2. If not enrolled, you can get your provider enrolled by paper or electronically. The Internet-based PECOS application is here.
3. 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.

Related posts:

1. Due to PECOS Backlog, CMS Announces Delay of January 3, 2011 Automated Edits & Claims Denial
2. Forget January 3, 2011! PECOS Date Moved 6 Months Closer for Referring & Supplying Providers New Date is July 6, 2010
3. Providers Without a PECOS Record Will Receive a Letter From Their Medicare Administrative Contractor (MAC)
4. May 19, 2010 Centers for Medicare & Medicaid Services Special Open Door Forum: Medicare Provider & Supplier Enrollment
5. CMS to Hold Open Door Forum on Medicare Provider and Supplier Enrollment via PECOS