CMS to Provide File for PECOS Verification

BALTIMORE — While the agency is so far standing firm on
its Jan. 4 date — when claims will begin to reject if
referring physicians are not registered in the Provider Enrollment,
Chain and Ownership System, or PECOS — an Oct. 30 message
seems to indicate that CMS is aware of the issues surrounding the
controversial deadline.

The problem, according to HME providers, is that many physicians
are not registered in the system, and others don’t even know about
it. That’s something they only found out, they said, when they
began receiving warnings that their claims would reject come
January because the names and NPI numbers of the ordering
physicians or non-physician practitioners were not on the PECOS
list.

Another problem brought up by HME providers on a recent Open
Door Forum call: They don’t have access to any information to
verify whether physicians are listed in the PECOS. (See Providers Add PECOS to the Worry
Pile, Oct. 23.)

According to the listserv notice, CMS will address that issue by
making available a national file of Medicare physicians and
non-physician practitioners who are eligible to order/refer.

In addition, CMS said, because many DMEPOS providers are
receiving warnings with their claims, the agency is taking the
following actions:

• CMS will systematically add the NPIs to the PECOS enrollment
  records of all physicians and non-physician practitioners whose
  PECOS records do not contain their NPIs, resulting in the addition
  of many more physicians and non-physician practitioners to the
  PECOS List.

• CMS will make publicly available on the Internet a national file
  of Medicare physicians and non-physician practitioners who are
  eligible to order/refer. The file will contain the NPI and the
  legal name (from the Medicare PECOS enrollment record). This will
  allow DMEPOS suppliers to determine if the ordering/referring
  provider has a current Medicare enrollment record and is eligible
  to order or refer.

• CMS will issue instructions that will assist Medicare
  contractors in enrolling licensed residents, Department of Veterans
  Affairs physicians and Public Health Service physicians. These
  physicians continue to order DMEPOS but have not enrolled in
  Medicare because they are not eligible for payments from
  Medicare.

• An MLN Matters article (MM6421) about CR 6421 is
  available on the CMS Web site. To supplement that article, CMS will
  be preparing a Special Edition Medicare Learning Network (MLN)
  Matters article about CR 6421.

• CMS’ Medicare contractors have also initiated a revalidation
  effort (via CR 6574, Transmittal 557) which is designed to update
  the Medicare enrollment record for 2,500 physicians and
  non-physician practitioners (50 practitioners per state). “We
  expect that this revalidation effort will be complete or nearing
  completion by [Jan. 4],” the notice said.

The CMS notice also offered these “points to remember”:

• As of Jan. 4, only accept and fill orders from eligible Medicare
  providers.

• If you submit electronic claims, ensure that the
  ordering/referring provider name is reported in all uppercase
  letters.

• Do not report a nickname in the ordering/referring provider
  name. For example, a reported first name of “BOB” will result in a
  non-match to the first name of “ROBERT” (editing includes the
  comparison of the first initial of the first name), causing the
  claim to fail the two new edits.

• Do not use commas, periods or apostrophes within the
  ordering/referring provider’s name. For example, “O’CONNELL” should
  be reported as “OCONNELL.”

• Ensure that names are reported correctly. For example, do not
  include credentials in a name field in the name segment for the
  ordering/referring provider (e.g., do not report a first name as
  “DR JOHN”).

• Use of the Advance Beneficiary Notice of Noncoverage (ABN) is
  not appropriate on a rejected claim. An ABN is appropriate only
  when a provider/supplier expects Medicare to deny coverage
  for an item or service under the Limitation on Liability provisions
  of Section 1879 of the Social Security Act.

• Even though a DMEPOS claim may identify an ordering/referring
  provider who has a current enrollment record (i.e., in PECOS with
  the NPI in the record), the date of service could precede the date
  the ordering/referring provider’s information was effective in
  PECOS. Such a claim would pass the two new edits — Medicare
  is not comparing the date of service on the claim to the date the
  ordering/referring provider was effective in PECOS. The claim would
  not be rejected.