New Deadline (Sigh) Set for Medicare Claim Denial If Ordering/Referring Providers Not in PECOS

NOTE April 2011: CMS recently announced that July 5, 2011 will not be the date that claim editing will begin.


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;
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 carrier’s or Part B MAC’s 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 contractor’s 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.

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