CMS/PECOS REQUIREMENTS FOR ALL DME MACs

This article was revised on September 14, 2009, to add clarifying language to emphasize that billed services requiring an ordering/referring provider on the claim must contain the ordering/referring provider under both phases of this change or the claim will not be paid.

This article is based on change request which requires Medicare implementation of system edits to assure that DMEPOS suppliers bill for items or services only when those items or services are ordered or referred by physician and non-physician practitioners who are eligible to order/refer such services.Physician and non-physician practitioners must be enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and of the type/specialty eligible to order/refer services for Medicare beneficiaries. Be sure billing staff are aware of these changes that will impact DMEPOS claims received and processed on or after October 5, 2009.


The two phases are list below:

During Phase 1 (October 5, 2009-January 3, 2010):
If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and is eligible to order/refer in Medicare. If the ordering/referring provider is not in PECOS or is in PECOS but is not of the type/specialty to order or refer, the claim will continue to process.

1. If the DMEPOS supplier claim is an ANSI X12N 837P standard
electronic claim, the DMEPOS supplier will receive a warning
message on the Common Electronic Data Interchange (CEDI)
GenResponse Report.
2. If the DMEPOS supplier claim is a paper CMS-1500 claim, the
DMEPOS supplier will not receive a warning and will not know that
the claim did not pass these edits.



During Phase 2, (January 4, 2010 and thereafter):
If the ordering/referring provider is not on the claim, the claim will not be paid. If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and eligible to order and refer. If the ordering/referring provider is not in PECOS or is in PECOS but is not of the specialty to order or refer, the claim will not be paid. It will be rejected.

Below is a link found that might help in checking if a physician is enrolled in PECOS? it looks like this is a list of providers who accept assignment. Please play around with it and see what you find.
We suggest that you select a few with the green symbol beside them and personally call and ask if they are PECOS enrolled. Please let us know your feedback and the results from your phone calls. CLICK HERE TO FIND OUT IF YOUR PHYSICIANS IS ENROLLED IN PECOS