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What is PECOS?

PECOS supports the Medicare provider and supplier enrollment process by capturing provider/supplier information from the CMS-855 family of forms. The system manages, tracks, and validates enrollment data collected in both paper form and electronically via the Internet.

 

 

CMS - Medicare PECOS Ruling May Affect Payments by Medicare

By: Michele Redmond - Solutions Medical Billing Inc

 

CMS originally had a deadline of July 6, 2010 for all ordering and referring providers to be enrolled in the PECOS system, or the Provider Enrollment, Chain and Ownership System but in the June 30th news release they announced that they will not be making the changes that will automatically reject claims based on ordering or referring providers who have not yet had their PECOS applications approved. What does all of this mean?

Well it's actually good news for any providers who order services or refer patients enrolled in Medicare, and have not enrolled yet in PECOS. Basically if a provider has not enrolled in Medicare or submitted changes or updates to their Medicare Information in the past 6 years, then they probably are not enrolled in PECOS. If a provider has enrolled or submitted changes/updates in the last 6 years, then they should be already enrolled in PECOS. The Medicare contractor would have automatically input the application into the PECOS system, even if they submitted a paper application.

So if the provider has been enrolled in Medicare longer than 6 years and has not submitted any updates or changes, then they still need to enroll in PECOS. The PECOS system can be accessed at the Medicare website. They should use their NPI login username and password to access the system.

CMS has been encouraging providers to use the PECOS system to enroll in Medicare or submit any updates or changes to their Medicare information for quite a while. Now they are mandating the use of PECOS by denying any claims for services that were ordered or referred by a Medicare provider who is not enrolled in the PECOS system. This makes things tough because the provider submitting the claim cannot control if the ordering or referring provider has enrolled in PECOS. This may be why they announced that they would not make the changes that would result in the denial of claims that were ordered or referred by providers not enrolled in PECOS.

At some point, this mandate probably will be implemented so it really is in a provider's best interest to make sure they are compliant. If you do not know if you or your provider is enrolled in PECOS then you should check. There is a national list available. It has the names and NPI numbers of all providers in the US who are enrolled in the PECOS system. You can check that list to see if you or your provider is enrolled. You can also call the local Medicare carrier provider enrollment line and ask if you or your provider is already enrolled.

If you or your provider is not enrolled you will either need to enroll by completing the application online thru the PECOS website, or by submitting a paper enrollment application re-validating the information, even if nothing has changed. I would suggest that you don't wait until claims do start to get denied. If you are a billing service you should check the list for all of the providers you bill for and advise them if they are or are not all set. If they are not, you should advise them what needs to be done.

 

PECOS Update from CMS for VA Physicians and Others

 

CMS has finally addressed Medicare Enrollment Guidance for VA physicians, physicians employed by the DOD Tricare program and several other groups that infrequently receive Medicare reimbursements. A streamlined process is now available for the VA docs, but they can't complete their enrollment online – only paper-based enrollment is available.

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 dentists, physicians working at the Veterans Administration, Department of Defense, or the Public Health Service, physicians in a fellowship, and physicians working at an RHC, FQHC or CAH.

For Physicians – How can I verify whether I am already enrolled in PECOS?

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.

 

Frequently Asked Questions

 

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 CMS has 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;”

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 13 – Contact Person

Section 15 – Certification Statement (must be signed and dated—blue ink recommended)

• Include a cover letter with the application form stating the physician is enrolling for the sole purpose of ordering and referring items or services for a Medicare beneficiary to other providers and suppliers and cannot be reimbursed for services performed, and

• Mail the completed form to the designated Medicare enrollment contractor

(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. 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.

CMS has developed specific instructional materials for residents and physicians on a fellowship. Click here to access this material.

 

Frequently Asked Questions (for Internet-Based PECOS)

 

Q1. Is Internet-based PECOS available to provider and supplier organizations in all States and the District of Columbia?

Yes. However, suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) will not be able to use Internet-based PECOS until a later date.

 

Q2. What are the advantages of Internet-based PECOS?

The primary advantages of Internet-based PECOS are to:
• Reduce the time necessary for provider and supplier organizations to enroll or make a change in their Medicare enrollment information;
• Streamline the Medicare enrollment process for provider and supplier organizations;
• Allow provider and supplier organizations to view their Medicare enrollment information to ensure that it is accurate; and

 

Q3. What information will a provider or supplier organization need before beginning to complete the enrollment via Internet-based PECOS?

The list below shows the type of information needed in order to complete an initial enrollment application for a provider or supplier organization using Internet-based PECOS. This information is similar to the information needed to complete a paper Medicare enrollment application.
• The provider or supplier organization's active National Provider Identifier (NPI);
• Other identifying information, to include the Legal Business Name and the Taxpayer Identification Number of the provider or supplier organization;
• Bank account information;
• Practice location address(es);
• Business license(s); and, if applicable
• Information about any final adverse actions.

 

Q4. Are provider and supplier organizations required to complete and submit enrollment applications via Internet-based PECOS?

No. They continue to have the option of completing and mailing paper Medicare enrollment applications to Medicare contractors.

 

Q5. My skilled nursing facility has been enrolled in Medicare for many years. But when I access Internet-based PECOS to view its enrollment record, I can't find the facility. Is this an error?

Even though a provider or supplier organization may be enrolled in Medicare, its enrollment record might not be in PECOS. If the provider or supplier organization enrolled in Medicare more than 5 years ago and has not reported any changes or updates to its enrollment record in the past 5 years, the provider or supplier organization probably does not have an enrollment record in PECOS. A provider or supplier organization that does not have an enrollment record in PECOS will have to submit an initial Medicare enrollment application, either via Internet-based PECOS or by using the paper application process.

 

Frequently Asked Questions (for Internet-Based PECOS)

 

Q6. Who do I call if I am unable to access Internet-based PECOS even though I have a PECOS User ID and password?

You should contact the Centers for Medicare & Medicaid Services (CMS) External User Services (EUS) Help Desk at 1-866-484-8049 or EUSSupport@cgi.com.

 

Q7. Who do I call if I have a general provider enrollment question?

Medicare contractors (fiscal intermediaries, carriers, or A/B MACs) answer general enrollment questions.

 

Q8. Are there any processing limitations for Internet-based PECOS?

Yes. While Internet-based PECOS supports most enrollment scenarios for provider and supplier organizations, there are some limitations that will not be available until a future date. For example, changes of ownership, consolidations/acquisitions, and mergers cannot be accommodated in Internet-based PECOS at this time.

 

Q9. What types of enrollment applications can provider and supplier organizations do by using Internet-based PECOS?

Provider and supplier organizations can do the following types of enrollment applications using
Internet-based PECOS:
• Establish a new enrollment record – This occurs when the provider or supplier organization does not have an existing enrollment record in PECOS.
• Make a change to information in an existing enrollment record – This occurs when the provider or supplier organization has at least one existing enrollment record in PECOS and is reporting a change of information to that record.
• Reactivate enrollment – This occurs when a provider or supplier organization reactivates an existing enrollment record that had been deactivated in PECOS.
• Voluntarily withdraw from Medicare – This occurs when a provider or supplier organization takes the action to withdraw from the Medicare program.

 

Q10. If a Medicare contractor requests that my hospital revalidate its Medicare enrollment information, can the hospital use Internet-based PECOS to do this?

Yes.

 

Frequently Asked Questions (for Internet-Based PECOS)

 

Q11. My facility's information has changed. Must that information be updated?

Yes. Following initial enrollment, a provider or supplier organization is required to report certain changes in the enrollment record. For more information about reporting changes, review the applicable reporting Responsibility Fact Sheet.

 

Q12. What is a "reportable event"?

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 or supplier organization's eligibility to participate in the Medicare program.

 

Q13. What days and times will Internet-based PECOS be available?

We expect that Internet-based PECOS will be available from 5:00 a.m. to 1:00 a.m. Eastern Time, Monday through Saturday.

 

Q14. What is the Certification Statement?

The 2-page Certification Statement lists additional requirements that provider and supplier organizations must meet and maintain in order to bill the Medicare program. This is similar to the information in Section 14 of the CMS-855A. Read these requirements carefully. By signing and dating the Certification Statement, the Authorized Official of the provider or supplier
organization is attesting to having read the requirements and understanding them.

 

Q15. Is there additional information that provider or supplier organization needs to send to the Medicare contractor other than the electronically submitted application?

Yes. The signed and dated 2-page Certification Statement must be mailed to the Medicare contractor. In addition, a provider or supplier organization may need to submit certain supporting documentation, such as a copy of the CP-575 that was issued by the Internal Revenue Service. When the user submits the Medicare enrollment application for the provider or supplier organization, he or she will see the "Mailing Instructions, Print/Save Materials" page. This page lists the Certification Statement and the supporting documentation required to be mailed to the Medicare contractor in order to complete the enrollment action. Note: The signed and dated 2- page Certification Statement must be mailed to the Medicare contractor immediately, but no
later than 7 days after submitting the application over the Internet. The Medicare contractor will not process an application submitted using Internet-based PECOS until it receives the signed and dated Certification Statement. The effective date of filing of an Internet-based PECOS enrollment application is the date the signed and dated Certification Statement is received by the Medicare contractor for an enrollment application that has been successfully submitted to the Medicare contractor via Internet-based PECOS. The signature must be an original signature (not copied or stamped); we recommend that blue ink be used.

 

Steps to Enrolling with PECOS

 

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

 

Steps to Enroll

 

Physicians and non-physician practitioners must:

1. Have an NPPES User ID and password to use Internet-based PECOS.

For security reasons, physicians and non-physician practitioners should change passwords periodically, at least once a year. For information on how to change a password, go to the NPPES Application Help page available at https://nppes.cms.hhs.gov/NPPES/Welcome.do and select the “Reset Password Page” under the NPPES Application help page.

 

2. Complete and submit the following forms:

     - CMS 460

     - CMS 588

     - CMS 855i

For a list of locations to submit the forms, click here.

 

3. Go to Internet-based PECOS and complete the sign up process.

4. Print, sign and date the 2-page Certification Statement and mail the 2-page Certification.

Statement and all supporting paper documentation to the Medicare contractor within 7 days of the electronic submission.

Note: A Medicare contractor will not process an Internet enrollment application without the signed and dated 2-page Certification Statement and the required supporting documentation.
In addition, the effective date of filing an enrollment application is the date the Medicare contractor receives the signed 2-page Certification Statement that is associated with the internet submission.

The 2-page Certification Statement must be signed by the physician or non-physician practitioner 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.

 

PECOS ENROLLMENT HELP REQUEST

 

If you are still having difficulties signing up with PECOS, please provide the following information. We are willing to help you complete your enrollment and will contact you shortly after we receive your information.


Note: To begin the PECOS enrollment process you will need an NPI number. If you have an NPI number, you already have an NPI user ID and password. We need this information to access PECOS and will contact you to get your permission to acquire it. If you do not know your NPI user ID and password, please call 1-866-484-8040 to acquire it.

 

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