Provider Enrollment Chain and Ownership System
Why is PECOS important?
The Centers for Medicare & Medicaid Services issued regulations stating that physicians who have not either enrolled in, or opted out of, Medicare participation, will not be permitted to order or refer patients for Medicare covered home health services and DME supplies. CMS is verifying physicians’ status by using its provider enrollment dataabase known as PECOS. In other words, if a physician does not have an approved enrollment record in PECOS, Medicare will not pay for home health services provided to that physician’s patients. Physicians who have validly opted out of Medicare participation (which requires filing a valid affidavit on file with CMS) should already have a PECOS record on file.
How do I confirm my PECOS status?
The latest version of the PECOS database released by CMS contains information updated each week. A physician may confirm his/her own status by reviewing the Ordering and Referring file found at the following link on the Medicare Provider and Supplier website: http:// www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html
What if I have already opted out of Medicare?
Physicians who have validly opted out of Medicare may order items or services for Medicare beneficiaries. Their opt-out information must be current (an affidavit must be completed every two years, and the NPI is required on the affidavit). Opt-out practitioners whose affidavits are current should have enrollment records in PECOS that contain their NPIs.
What if I am an intern or resident?
Interns are not eligible to enroll in Medicare because they do not have medical licenses. Unless a resident (with a medical license) has an enrollment record in PECOS, he/she may not be identified in a Medicare claim as the Ordering/Referring Provider. The teaching, admitting, or supervising physician is considered the Ordering/Referring Provider when interns and residents order and refer, and that physician’s name and NPI would be reported on the claim as the Ordering/Referring Provider.
What if I am employed by the Department of Veterans Affairs, the Public Health Service or the Department of Defense/Tricare?
These physicians will need to enroll in Medicare using a new CMS 855O Form to continue to order or refer items or services for Medicare beneficiaries. The CMS 855O Form is an an abbreviated enrollment process, which includes the following:
- Completion of the CMS FORM 855O
- Submission of the completed form along with a cover letter stating that the physician is enrolling for the sole purpose of ordering and referring items or services for a Medicare beneficiary to other provider and suppliers and cannot be reimbursed for services performed.
Upon completion, the physician should mail the cover letter and the completed form to the physician’s designated Medicare enrollment contractor. Additional instructional materials can be found at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certifi- cation/MedicareProviderSupEnroll/index.html
What if I am in a fellowship program?
If the physician is in a fellowship and licensed by the applicable state, he/she 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,” the physician is only required to complete the CMS 855O abbreviated enrollment application form in the same way as other physicians employed by the Department of Veterans Affairs, the Public Health Service, or the Department of Defense/Tricare (see above). If the physician elects to enroll to order and refer only, he/she would not be enrolled in Medicare for the purpose of providing Medicare services to Medicare beneficiaries. To provide covered services
to Medicare beneficiaries, a physician in a fellowship program would need to complete the full enrollment application. Additional instructional materials can be found at the following link: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/EnrollmentApplications
How to Complete Enrollment
Complete your enrollment online at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index. Select “Internet-based PECOS” located in the left navigation menu to access instructions and a link to the online enrollment form. We’ve enclosed a step-by-step guide titled Enrollment Example for your reference.
You’ll need your individual National Provider Identifier (NPI) to complete PECOS enrollment. If you don’t know your NPI, contact the NPI Enumerator at https://nppes.cms.hhs.gov/, or call 1.800.465.3203.
Official CMS Provider Enrollment site: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html
For guidance on Medicare billing issues and PECOS enrollment, visit the American Medical Association website at www.ama-assn.org. Enter “PECOS” in the search field, then click “What’s new with Medicare enrollment?”
Members of the Medical Group Management Association can access a PECOS toolkit at www.mgma.com/.
If you have any questions, call the Provider Enrollment Department of your Medicare Administrative Contractor.