CMS Delays Referring Physicians’ PECOS Enrollment Requirement

(WASHINGTON, DC) -- The Centers for Medicare and Medicaid Services (CMS) announced through a listserv message that the Medicare enrollment requirement for referring or ordering physicians is delayed until April 5, 2010. This rule requires ordering or referring physicians to enroll in the Medicare program by registering in the Provider Enrollment Chain and Ownership System (PECOS), which was initially planned to be implemented on Dec. 31, 2009. CMS believes that the delay would provide enough time for providers to enroll or establish current enrollment records in the PECOS.

Medicare claims will be marked for nonpayment because physicians and other health care practitioners ordering or referring services are not enrolled in Medicare, which poses the risk of reimbursement interruption for legitimate providers. For example, if an ordering or referring physician is not in the CMS PECOS database then the radiologist who furnishes the ordered service will not be paid for their service.

For those providers who are already enrolled in the Medicare program, it is recommended that they check to see that their information in PECOS is current. CMS plans to make the names and National Provider Identifiers (NPIs) of the Medicare physicians and non-physician practitioners who are eligible to order or refer in the Medicare program publicly available on the Internet prior to implementing the enrollment requirement.

CMS noted that further guidance will be provided addressing many different circumstances such as issues involving enrollment requirements of providers who occasionally order or refer services for Medicare beneficiaries, for instance, dentists and pediatricians.

CMS also stated that they will be issuing MLN article to further educate providers about the enrollment requirement.

CMS provided the following instruction for providers:

If you are not enrolled in the Medicare program, or 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 not have an enrollment record in PECOS. In order to continue to order or refer items or services for Medicare beneficiaries, you will have to submit an initial enrollment application. You may do so either by (1) using Internet-based PECOS (which transmits your enrollment application to the Medicare carrier or A/B MAC via the Internet—be sure to mail the signed and dated Certification Statement to the carrier or A/B MAC immediately after submitting the application), or (2) 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 at www.cms.hhs.gov/MedicareProviderSupEnroll

If you are already enrolled in Medicare, make sure you have a current enrollment record. You can find out if you have an enrollment record in PECOS by calling your designated carrier or A/B MAC or by going on-line, using Internet-based PECOS, to view your enrollment record. We will be posting information to the Medicare provider/supplier enrollment web site that will guide you through this process. Information about Internet-based PECOS and a link to Internet-based PECOS can be found on the Medicare provider/supplier enrollment web site. Before using Internet-based PECOS, we recommend that you read the information that is posted there and that is available in the downloadable documents section.

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.

For further information, visit the CMS Web site.

The copy of transmittal 572 may be obtained from the CMS Web site.