CMS implemented Phase 2 denial edits for the Provider Enrollment, Chain, and Ownership System (PECOS) on Monday of this week. The edits check specific claims to ensure they are from a valid individual National Provider Identifier (NPI), and deny the claim when this information is invalid.
The edits cover claims from:
- Clinical laboratories for ordered tests.
- Imaging centers for ordered imaging procedures.
- DMEPOS Suppliers for ordered DMEPOS.
- Part A Home Health Agencies (HHAs).
The edits will determine if the Ordering/Referring Provider (when required to be identified in Part B clinical laboratory and imaging, DME, and Part A HHA claims) has a current Medicare enrollment record and contains a valid NPI (the name and NPI must match), and is of a provider type that is eligible to order or refer for Medicare beneficiaries. Those types of providers are:
- Physicians
- Physician Assistants
- Clinical Nurse Specialists
- Nurse Practitioners
- Clinical Psychologists
- Interns, Residents, and Fellows
- Certified Nurse Midwives
- Clinical Social Workers.
The PECOS implementation has been taking place over a phased process during the past several years. Phase 1 began Oct. 5, 2009, and alerted billing providers that the identification of the ordering/referring provider had to have a valid NPI in the PECOS system.
In Phase 2, which went live Jan. 6, if the ordering/referring provider does not pass the edits, the claim will be denied. This means that the billing provider will not be paid for the items or services that were furnished based on the order or referral.
Complete details of Phase 2 are in CMS’s MLN Matters #SE1305, which can be downloaded at:
Providers that order or refer items or services for Medicare beneficiaries, and do not have a Medicare enrollment record, need to submit an enrollment application to Medicare. They can do this using the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) or by completing the paper enrollment application (CMS-855O). PECOS enrollment instructions and resources are available at:
