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.
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 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.
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.
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.
I’ve noticed that a lot of people in healthcare seem unusually tired and even, if I dare say so, somewhat cranky. This includes me. I’ve decided we’re all suffering from healthcare fatigue – fatigue from dealing on a daily basis with so much change, uncertainty, and financial stress. Here’s my top ten list of healthcare management stressors accompanied by posts I’ve written that discuss the topic or suggest resources for the challenge.
10. Red Flags Rules – on again, off again, patients don’t want to have their pictures taken or let you copy their driver’s licenses.
9. HIPAA – don’t be fooled, HIPAA is not something we handled years ago and it’s taken care of; there are new requirements and penalties associated with HIPAA breaches. HIPAA is a biggie and something that now infiltrates almost every facet of healthcare.
8. Employment Uncertainty – both for you and your staff – the aftermath of layoffs can be even more demoralizing to those who didn’t lose their jobs. Also, many healthcare entities are still freezing raises. If I hear one more time “we’ll just have to do more with less” I might just scream.
7. Unrealistic Workloads – directly related to #9, most staff and managers have much more work to do than they did just two years ago. Couple that with the ability for managers to be available and work by computer, phone, text message, email or Skype 24/7 and you have fatique that you understand only when you truly, truly stop and wind down for more than three days at a time.
6. Hospitals Buying Practices – this could be a good thing or a bad thing, but as you and I know, change is completely unnerving to most people. Hospitals have very different cultures than private practices and trying to marry the two takes skill, patience and excellent leadership.
5. Stimulus Money for Using EMRs – it’s a big decision and many practices are very nervous about purchasing an EMR. Many think that meaningful use components are unrealistic and even more are fearful of the inevitable productivity drop when the EMR is implemented and for months afterwards.
4. Unhappy Patients – lots of patients are also trying to do more with less (argghhh!) and are avoiding coming to the doctor whenever possible. The front desk staff and the phone staff in particular are getting a lot more heat when they inform patients they’ll have to make an appointment.
2. Medicare Reimbursement – this year has been as exhausting as watching a single point of ping pong played for hours – there will be cuts, there won’t be cuts, there will be cuts, there won’t be cuts. Gird your loins as the November 30 deadline looms for the next potential cuts.
1. The Bottom Line – we have RAC audits, more pre-certification and pre-authorization and pre-notification requirements, more denials, high deductible plans, formularies and 50 other things that are making it difficult to know which hoop to jump through to get paid. Expenses continue to go up, reimbursement continues to go down, and the healthcare world spins faster and harder, making us all wonder when it will, or if it ever will slow down.
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.
[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].
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.
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 firstname.lastname@example.org.
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
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
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.
Reference Conference ID 61448973
Read my post on the date change for PECOS enrollment that relates to CMS-6010-IFC here.
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:
Providers with a National Provider Identifier (NPI) must include it on their Medicare and Medicaid enrollment applications and claims.
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.
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.
Claims that do not meet these requirements will be rejected by Medicare contractors.
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.
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
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.**
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.
As of April 5, 2010As 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:
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.
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:
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.
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
Public Health/Welfare Agency
Physical/Occupational Therapy Group in Private Practice
Independent Clinical Laboratory
Independent Diagnostic Testing Facility (site visit or state survey typically required)
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)
Certified Nurse Midwife
Certified Nurse Specialist
Certified Register Nurse Anesthetist
Clinical Social Worker
Mass immunization, roster biller (individual only)
Occupational Therapist in private practice
Physical Therapist in private practice
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.
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:
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 email@example.com.
Go to Internet-based PECOS by clicking on this link and complete, review, and submit the electronic enrollment application via Internet-based PECOS.
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.
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.
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 firstname.lastname@example.org. 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!