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.

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 physician’s 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 dated””blue 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.

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.