Archive for PECOS

Providers Without a PECOS Record Will Receive a Letter From Their Medicare Administrative Contractor (MAC)

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

ARRA Eligible Providers: Who Is Eligible to Receive Stimulus Money and How Much is Available Per Provider?

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]

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My Notes from the CMS Open Door Forum on May 19, 2010: PECOS, DMEPOS and Blue Ink on Paper Forms

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 100-08) 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.

Posted in: Headlines, Medicare & Reimbursement, PECOS

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May 19, 2010 Centers for Medicare & Medicaid Services Special Open Door Forum: Medicare Provider & Supplier Enrollment

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.

Posted in: Medicare & Reimbursement, PECOS

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Forget January 3, 2011! PECOS Date Moved 6 Months Closer for Referring & Supplying Providers New Date is July 6, 2010

NOTE: The date has been changed to July 5, 2011. delayed indefinitely.

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Physicians and “eligible” providers received a jolt today in the May 5, 2010 Federal Register as the date for enrollment in PECOS was moved up (pending the comment period and any changes resulting from the comment period) six months for providers that order or supply durable medical equipment (DME) for Medicare patients.  Instead of the January 3, 2011 date previously announced by CMS, the Patient Protection and Affordable Care Act (Affordable Care Act or PPACA) has provisions to move the go-date to July 6, 2010, just 60 days away.

What does this mean to you? Unless something changes based on public comments, beginning July 6, 2010:

  1. Providers with a National Provider Identifier (NPI) must include it on their Medicare and Medicaid enrollment applications and claims.
  2. Providers of medical items/other items/services and suppliers that qualify for a National Provider Identifier (NPI) must include their NPI on all applications to enroll in the Medicare and Medicaid programs AND on all claims for payment submitted under the Medicare and Medicaid programs.
  3. The ordering/referring supplier must be a physician or an eligible professional with an approved enrollment record in the Provider Enrollment Chain and Ownership System (PECOS) thus changing the previously reported January 3, 2011 date given by CMS.
  4. Claims that do not meet these requirements will be rejected by Medicare contractors.

You can read the rule in its entirety here.

Want to read the comments on this interim final rule when they are published? Go here.

Posted in: Headlines, Medicare & Reimbursement, PECOS

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CMS Announces Delay in PECOS Use Until January 3, 2011

NOTE: The date has been changed to July 5, 2011.delayed indefinitely.

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A collective sigh of relief was heard across the land as it was revealed today during the CMS Open Door Forum that the requirement for providers to be enrolled in PECOS has been delayed until January 3, 2011.

Part B MACs (Medicare Administrative Contractors) will be sending revalidation letters to all providers who have not updated their Medicare enrollment since November of 2003, asking them to submit a paper enrollment form or to use the electronic enrollment system PECOS (Provider Enrollment, Chain and Ownership System.) This proactive stance on the part of CMS should help the many managers who have been desperately trying to determine if their providers are in PECOS or not.

An audio recording of today’s call will be available on the ODF website here and will be accessible for downloading on or around Monday March 1, 2010 and available for 30 days.

For automatic emails of Open Door Forum schedule updates (E-Mailing list subscriptions) and to view Frequently Asked Questions click here.

Posted in: Headlines, Medicare & Reimbursement, PECOS

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CMS to Hold Open Door Forum on Medicare Provider and Supplier Enrollment via PECOS

On February 17, 2010 from 2:00PM ”“ 3:30PM ET 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:

  • Internet-based Provider Enrollment, Chain and Ownership System (PECOS) for physicians, non-physician practitioners and provider and supplier organizations
  • Provider and supplier reporting responsibilities
  • Medicare ordering and referring issues
  • Revalidation efforts

Afterwards, there will be an opportunity for the public to ask questions.

Open Door Forum Instructions:

**Capacity is limited so dial in early. You may begin dialing into this forum as early as 1:45 PM ET.**

Dial: 1-800-837-1935
Reference Conference ID 52537484
An audio recording of this Special Forum will be posted to the Special ODF website here and will be accessible for
downloading on or around Monday March 1, 2010 and available for 30 days.

For automatic emails of Open Door Forum schedule updates (E-Mailing list subscriptions) and to
view Frequently Asked Questions click here.

Posted in: Medicare & Reimbursement, PECOS

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Is Your Practice Ready for the 60-Day PECOS Countdown?

NOTE: The date has been changed to July 5, 2011. delayed indefinitely.

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As of April 5, 2010 As of January 3, 2011, As of July 6, 2010, if the ordering/referring provider of goods and services on the CMS-1500 claim is not listed in PECOS and eligible to order/refer, the claim will not be paid.  Your patients may not be able to get the items they need, they may have problems with rented items (going three years back) and hospital discharges may be delayed.  Even if your practice doesn’t fall into any of these categories, you will fall into some Medicare category sooner or later, particularly if you need to inform CMS of any practice changes.

If your providers aren’t in the PECOS database, you should bite the bullet and GET STARTED TODAY!

Some terminology I use in this article:

AO = Authorized Official

CMS = Centers for Medicare & Medicaid Services

EUS – External User Services (for CMS PECOS) Help Desk

MAC = Medicare Administrative Contractor

NPPES = National Plan and Provider Enumeration System (the system that assigns the National Provider Identifier (NPI)

Providers = physicians and non-physician practitioners (I know physicians hate being called “providers”, but there it is.)

Type I NPI = National Provider Identifier for a physician or non-physician practitioner

Type II NPI = National Provider Identifier for a practice or organization

WHAT is PECOS?

PECOS stands for the Provider Enrollment and Chain/Ownership System. It was created by CMS as an electronic portal for Medicare enrollment of physicians, non-physician practitioners, and provider and supplier organizations.

Even though some providers are enrolled in Medicare, their enrollment records might not be in PECOS. If they have not sent in a Medicare application to report any changes to their Medicare enrollment information within the past 5 years, they probably do not have an enrollment record in PECOS. These individuals will need to submit a  Medicare enrollment application. To see if a provider is enrolled in PECOS, check here. If the name is not there, the PECOS enrollment is incomplete or missing.

PECOS is designed to electronically:

  • Enroll in the Medicare program
  • Make changes to Medicare enrollment information
  • View existing Medicare enrollment information
  • Withdraw from the Medicare program
  • Check the status of an Internet-submitted Medicare enrollment application

While PECOS supports most enrollment application actions, there are some limitations. Providers cannot use PECOS to:

  • Change his/her name or Social Security Number, or changes in Taxpayer Identification Number (TIN). These must be done using the paper enrollment application (CMS-855)
  • Change an existing business structure or changes in Legal Business Name (LBN). These must be done using the paper enrollment application (CMS-855). An example of a change to a business structure is:
    • A sole owner of an enrolled Professional Association, Professional Corporation, or Limited Liability Company cannot change the business structure to a sole proprietorship; or
    • An enrolled sole proprietorship cannot be changed to a solely-owned Professional Association, Professional Corporation, or Limited Liability Company.
  • Reassign benefits to another supplier if that supplier does not have a current Medicare enrollment record in PECOS.
  • An enrolled Medicare Part A provider or supplier organization wants to enroll with a Medicare carrier or A/B Medicare Administrative Contractor (MAC) to bill for Part B services. This must be done using the paper enrollment application (CMS-855).

WHY should I use PECOS?

Described as being 50% faster than paper, PECOS will alert the applicant when a response is inadequate or unacceptable, thereby decreasing the possibility of a rejected application.

Going forward, Medicare providers are required to notify Medicare of reportable events within a specific timeframe or risk losing their ability to bill for services provided to Medicare patients. A reportable event is any change that affects information in a Medicare enrollment record. A reportable event may affect claims processing, claims payment, or a provider’s eligibility to participate in the Medicare program.

Effective April 4, 2010, providers are required to report the following changes within 30 days of the following reportable events:

  • Change in ownership
  • Change in practice location, and
  • Final adverse action.

A final adverse action includes: (1) a Medicare imposed revocation of any Medicare billing privileges; (2) suspension or revocation of a license to provide health care by any State licensing authority; (3) revocation or suspension by an accreditation organization; (4) a conviction of a Federal or State felony offense (as defined in 42 CFR 424.535(a)(3)(i)) within the last ten years preceding enrollment, revalidation, or re-enrollment; or (5) an exclusion or debarment from participation in a Federal or State health care program.

Providers are required to report the following changes immediately, but not later than 90 days, after the reportable event:

  • Change in practice status (e.g., retirement, voluntary surrender of medical license or voluntary withdrawal from the Medicare program)
  • Change of business structure, Legal Business Name or Taxpayer Identification Number
  • Banking arrangements or payment information
  • A change in the correspondence or special payments address

Hopefully, PECOS should make this reporting easier by:

  • Reducing the time necessary for provider and supplier organizations to enroll or make a change in their Medicare enrollment information;
  • Streamlining the Medicare enrollment process for provider and supplier organizations;
  • Allowing provider and supplier organizations to view their Medicare enrollment information to ensure that it is accurate; and
  • Reducing the administrative burden associated with completing and submitting enrollment information to Medicare.

So far the above has not been the case, but let’s move on.

WHO needs to enroll in PECOS?

  • If you are not enrolled in the Medicare program and want to become enrolled,  you do.
  • If you enrolled more than 6 years ago and have not submitted any updates or changes to your enrollment information in more than 6 years, you do. If a provider who is currently enrolled in the Medicare program has not submitted a complete Medicare enrollment application (CMS-855) since November 2003, the Medicare contractor will require the individual or organization to submit a complete CMS-855 in order to update or make a change in their enrollment information.

In order to continue to order or refer items or services for Medicare beneficiaries, you will have to submit an initial enrollment application, which you may do in one of two ways:

  1. Using Internet-based PECOS (which transmits your enrollment application to the MAC) AND BE SURE to mail the signed and dated Certification Statement to the carrier or A/B MAC immediately after submitting the application.
  2. Filling out the appropriate paper Medicare provider enrollment application(s) (CMS-855I and CMS-855R , if appropriate) and mailing the application, along with any required additional supplemental documentation, to the local Medicare carrier or A/B MAC, who will enter your information into PECOS and process your enrollment application. Information on how to enroll in Medicare is found on the Medicare provider/supplier enrollment web site.

If you are already enrolled in Medicare, make sure you have a current enrollment record in PECOS.  You can find out by:

  • Calling your designated carrier or A/B MAC (recommended). Find out who your A/B MAC is here.
  • Using PECOS to view your enrollment record.
  • Going to Medicare.gov and searching for the provider

If you are a dentist or a physician with a specialty such as a pediatricians who is eligible to order or refer items or services for Medicare beneficiaries but have not enrolled in Medicare because the services you provide are not covered by Medicare or you treat few Medicare beneficiaries, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.

WHICH paper enrollment form should be used?

CMS uses five different provider and supplier enrollment applications:

  • Part A providers are required to use the CMS-855A to enroll or update their enrollment information;
  • Part B suppliers (except suppliers of Durable Medical Equipment, and Prosthetics, Orthotics, and Supplies (DMEPOS)) are required to use the CMS-855B to enroll or update their enrollment information;
  • Physicians and non-physician practitioners are required to use the CMS-855I to enroll or change their enrollment information;
  • DMEPOS suppliers are required to use the CMS-855S to enroll or update their enrollment information.
  • Individual practitioners who would like to reassign their benefits to an eligible provider or supplier or terminate an existing reassignment agreement would use the CMS-855R.

You should file a CMS-855A (pdf) with the designated MAC if you would like to enroll your organization in the Medicare program as one of the following types of providers.

  • Community Mental Health Center
  • Comprehensive Outpatient Rehabilitation Facility
  • End-Stage Renal Disease Facility
  • Federally Qualified Health Center
  • Histocompatibility Laboratory
  • Home Health Agency
  • Hospital
  • Hospice
  • Indian Health Services Facility
  • Organ Procurement Organization
  • Outpatient Physical Therapy/Occupational Therapy/Speech Pathology Services
  • Religious Non-Medical Health Care Institution
  • Rural Health Clinic
  • Skilled Nursing Facility

You should file a CMS-855B (pdf) with the designated MAC if you would like to enroll in the Medicare program as one of the following types of suppliers:

  • Ambulance Service Supplier
  • Ambulatory Surgical Center (site visit or state survey typically required)
  • Clinic and Group Practices
  • Hospital Departments
  • Multi-Specialty Clinic
  • Public Health/Welfare Agency
  • Physical/Occupational Therapy Group in Private Practice
  • Single Specialty
  • Independent Clinical Laboratory
  • Independent Diagnostic Testing Facility (site visit or state survey typically required)
  • Mammography Center
  • Mass Immunization – roster biller only
  • Portable X-ray Facility (site visit or state survey typically required)
  • Radiation Therapy Center
  • Slide Preparation Facility
  • Voluntary Healthy/Charitable Agency

You should file a CMS-855I (pdf) with the designated MAC  if you would like to enroll in the Medicare program as one of the following types of providers.

  • Physicians (all specialties)
  • Non-Physicians
    • Anesthesiology Assistant
    • Audiologist
    • Certified Nurse Midwife
    • Certified Nurse Specialist
    • Certified Register Nurse Anesthetist
    • Clinical Social Worker
    • Mass immunization, roster biller (individual only)
    • Nurse Practitioner
    • Occupational Therapist in private practice
    • Physical Therapist in private practice
    • Physician Assistant
    • Psychologist, Clinical
    • Psychologist, billing independently
    • Registered Dietitian or Nutrition Professional

NOTE!! If you are enrolled in Medicare and your NPPES record is correct, you are not re-enrolling, you are revalidating, an important distinction in terminology. The word on the street is that it seems to be easier to revalidate via paper by completing the CMS-855 and writing “REVALIDATION” in the upper margin of the first page.


WHAT information is needed for a PECOS enrollment?

Below is a list of the types of information needed to complete an initial enrollment action using PECOS. This information is similar to the information needed to complete a paper Medicare enrollment application. You may find it useful to print and review the CMS-855 paper enrollment application before initiating an Internet-based PECOS enrollment action.

  • An active National Provider Identifier (NPI).
  • The NPI of the Practice (PA, PC, or LLC)
  • National Plan and Provider Enumeration System (NPPES) User ID and password.
  • Personal identifying information. This includes legal name on file with the Social Security Administration, date of birth, Social Security Number
  • Professional license and certification information. This includes information regarding the physician’s or non-physician practitioner’s professional license, professional school degrees or certificates.
  • Practice location information. This information includes information regarding the practitioner’s medical practice location, the legal business name of a solely-owned Professional Association, Professional Corporation, or Limited Liability Company (LLC) on file with the Internal Revenue Service and appearing on the IRS CP575
  • Any Federal, State, and/or local (city/county) business licenses, certifications and/or registrations specifically required to operate as a health care facility.
  • A photocopy of the CP-575 form;
  • If applicable, information regarding any final adverse actions. A final adverse action includes: (1) a Medicare-imposed revocation of any Medicare billing privileges; (2) suspension or revocation of a license to provide health care by any State licensing authority; (3) revocation or suspension by an accreditation organization; (4) a conviction of a Federal or State felony offense (as defined in 42 CFR 424.535(a)(3)(A)(i)) within the last ten years preceding enrollment, revalidation, or re-enrollment; or (5) an exclusion or debarment from participation in a Federal or State health care program.

The following forms are routinely submitted with an enrollment application:

  • Electronic Funds Transfer (EFT) Authorization Agreement (Form CMS 588)
  • Medicare Participating Physician or Supplier Agreement (Form CMS 460)

HOW do you enroll in PECOS?

There are three basic steps to completing an enrollment action using Internet-based PECOS. Providers must:

  1. Have an active National Provider Identifier (NPI) and have a web user account (User ID/Password) established.  For security reasons, providers should change passwords periodically, at least once a year. If you/your provider needs help in changing your password, contact the NPI Enumerator at 1-800-465-3203 or send an email to customerservice@npienumerator.com.
  2. Go to Internet-based PECOS by clicking on this link and complete, review, and submit the electronic enrollment application via Internet-based PECOS.
  3. Print, sign and date the 2-page Certification Statement for each enrollment application submitted and mail the Certification Statement and all supporting paper documentation to the Medicare contractor within 7 days of electronic submission. Note: A Medicare contractor will not process an Internet enrollment application without the signed and dated Certification Statement. In addition, the effective date of filing an enrollment application is the date the Medicare contractor receives the signed Certification Statement that is associated with the Internet submission. The Certification Statement must be signed by the provider enrolling or making changes to enrollment information. Signatures must be original and in ink (blue ink recommended). Copied or stamped signatures will not be accepted.  NOTE: CMS encourages providers to print and retain a copy of the enrollment application for their records, however providers should only mail the 2-page Certification Statement and supporting documentation to the designated Medicare contractor.

HOW can managers facilitate the enrollment?

  • Look at your original Medicare application to see who is the “authorized official”. The Authorized Official (AO) may be theprovider, or may be the owner of the practice, or the CFO of the hospital, in the case of a hospital-owned practice.  The AO (in an original application) may be registered through PECOS and an approval email will be issued in 3-4 weeks. Print the screen that provides the tracking ID.  You will need to refer to it in the future.
  • If you do not have a copy of your organization’s original Medicare enrollment information and do not know who has been designated as your organization’s “authorized official”, an owner of your practice must submit a written letter on the organization’s letterhead to your Medicare contractor authorizing the release of that information.  Medicare contractors are not allowed to release such information over the telephone or in an e-mail, and neither are they allowed to release it to practice staff.
  • The organization AO goes into PECOS Identification & Authentication (I & A) and registers. As part of this process, the AO must mail a photocopy of the CP-575 to the CMS EUS Help Desk so that the Help Desk can verify the organization provider/supplier. Print the screen that provides the tracking ID.  You will need to refer to it in the future.
  • The Help Desk verifies both the organization provider/supplier and the AO, and approves the AO’s registration. The AO receives a system-generated e-mail indicating that the registration has been approved.
  • Once the AO receives this notification, the AO can let the end-user know that he/she can register in PECOS.
  • The end-user goes into PECOS I&A and registers. The registration request will be directed to the AO of the provider/supplier organization.
  • The AO must approve or reject the end-user in PECOS I&A.
  • Once the end-user has been approved in PECOS I&A by the AO for access on behalf of the organization provider/supplier, the end-user will receive a system-generated e-mail indicating that he/she has been approved.
  • The end-user then logs into PECOS and downloads the Security Consent Form. He or she fills it out, obtains the signature/date of signature of the AO, and mails the completed Security Consent Form to the CMS EUS Help Desk at P.O. Box 792750, San Antonio, TX 78216.
  • The Help Desk verifies the information on the Security Consent Form and also calls the AO to verify that the AO did, in fact, sign the Security Consent Form.
  • Once the information on the security Consent Form has been confirmed, the Help Desk approves the Security Consent Form in PECOS and an e-mail is sent to the AO notifying the AO that the end user’s organization has been approved to use Internet-based PECOS on behalf of the organization provider/supplier.
  • It is the AO’s responsibility to notify the end-user’s organization that the end-user can now use Internet-based PECOS. An e-mail is sent to the AO (step 9) because the AO is ultimately responsible for the enrollment information and who has access to that enrollment information. It is the AO’s responsibility to inform the end-user that the Security Consent Form has been approved.

TO RECAP:

  • Providers, if you search for yourself at Medicare.gov and cannot find your record, you do not have a PECOS record – it is either missing or incomplete.  Call Provider Enrollment at Medicare or your MAC for help.
  • If you do not have a PECOS record, send in a paper enrollment or complete the online (PECOS) enrollment.
  • The prerequisite for getting a PECOS record is to have a NPPES record.  Make sure you have your NPPES login and password and that your record (Type I NPI) is correct.  Your organization also needs an NPPES record (Type II NPI), and make sure your organization name on the NPPES record matches the name on your IRS letter.

RESOURCES

Read about PECOS in downloadable documents section: Downloads for PECOS

The AMA and MGMA have published an absolutely excellent resource:  “The Medicare Provider Enrollment Toolkit” available here for MGMA members. Enter “Medicare Enrollment” in the search box.

The CMS External User Services (EUS) Help Desk contact information for providers and suppliers using PECOS can be found here (pdf) on the CMS website. The Help Desk hours of operation are Monday ”“ Friday, from 6 a.m. to 6 p.m. Central Standard Time. The Help Desk toll-free number is 1-866-484-8049 and their e-mail address is eussupport@cgi.com. Questions about accessing and using PECOS should be directed to the CMS EUS Help Desk, although I have heard lots of complaints about long wait times and conflicting advice.

Readers: Please share any clarifying information or tips from your enrollment experiences with everyone.  Leave a comment and share the wealth!

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