Claim Denials for Non-PECOS Enrolled Ordering/Referring Providers

Good Morning MFS Bloggers, I hope you each had a very happy thanksgiving. CMS recently posted a new article regarding the PECOS enrollment requirements for all referring physician’s. It is imperative for the sustainability of your cash-flow that you confirm your referral sources are PECOS enrolled.

Providers who order or refer items or services for Medical beneficiaries and who are not enrolled in the Provider Enrollment, Chain and Ownership System (PECOS), must submit an enrollment application to Medicare. This can be done using internet-based PECOS or by completing the paper enrollment application. If you reassign your Medicare benefits to a group or clinic, you will also need to complete the CMS-855R.

Phase 1 of the claim editing initiative began on October 5th, 2009, and is scheduled to end on January 2, 2011. During phase 1, if the ordering/referring provider does not pass the edits, the claim will be processed and paid (assuming there are no other problems with the claim); however, the billing provider (the provider who furnished the item or service that was ordered or referred) will receive an informational message from Medicare in the remittance advice.

Scheduled to begin January 3, 2011, these messages will no longer be informational. They will be denial messages and the billing provider will not be paid for the items or services that were furnished based on the order or referral of the physician not enrolled in PECOS.

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