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How to determine if a Physician or Non-Physician who is Eligible to Order or Refer Services has a Current PECOS Enrollment Record

Although enrolled in Medicare, many physicians and non-physician practitioners who are eligible to order items or services or refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in the Provider Enrollment, Chain and Ownership System (PECOS). A current enrollment record is one that is in the PECOS and also contains the National Provider Identifier (NPI). The lack of a current enrollment record in the PECOS is a result of not having submitted any enrollment information updates since November 2003. The purpose of this article is to provide guidance to assist physicians and non-physician practitioners in determining whether or not they have a current enrollment record in the PECOS, and if not, the necessary follow-up steps to take.

Remember: Part B claims (CR 6417) that are the result of an order or a referral, must contain the National Provider Identifier (NPI) and the legal name of the ordering/referring provider and the ordering/referring provider must be in the PECOS or in the A/B MAC’s master provider file. This means if the ordering/referring provider does not have a current record in the PECOS, but has a record in the A/B MAC’s master provider file that contains an NPI; the provider does not have to immediately establish an enrollment record in the PECOS.

Note: The CMS has postponed Phase 2 of CRs 6417 and 6421 until January 3, 2011. More information is available on the CMS website.

To determine if you have a current enrollment record in the PECOS, you can do the following:

  • Utilize the national file of Medicare physicians and non-physician practitioners who are eligible to order/refer and have current enrollment records in the PECOS. This file is made available by the Centers for Medicare & Medicaid Services’ (CMS) and contains the provider’s NPI and his/her legal name (from the PECOS enrollment record).
  • Utilize Internet-based PECOS. Instructions for establishing the status of your PECOS enrollment can be found on the CMS website. Note: If you have more than one NPPES User ID and password, log in to Internet-based PECOS using each to ascertain if a PECOS enrollment record exists.
  • Calling our Enrollment Help Line. If you are unable to verify your PECOS enrollment using either of the two methods outlined above, you can contact the HMS Enrollment Help Line at 1-866-488-0549 between the hours of 8:00 a.m. and 3:30 p.m. Monday through Friday. Please have your PTAN (i.e., your legacy identifier/Medicare provider number) and/or NPI number available to assist in expediting the call.

If you do not have a current enrollment record in the PECOS and will be ordering or referring services, particularly items of durable medical equipment (e.g., oxygen, diabetic supplies, and wheelchairs), you should take one of the following steps:

  • Use Internet-based PECOS to complete and send your enrollment application. For more information regarding submissions via Internet-based PECOS, you can refer to our Enrollment Center or the CMS website. Note: When submitting your application via Internet-based PECOS, select “New Application”. Upon receipt, we will readily determine the application is not an actual initial enrollment.
  • Fill out the paper CMS-855I Medicare provider enrollment application and mail the application, along with any required additional supplemental documentation to us. To obtain the CMS-855I application, as well as our mailing address and other helpful enrollment information, please refer to our Enrollment Center.

INDUSTRY NEWS TAGS: Highmark Medicare MAC


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