On April 25, the Centers for Medicare & Medicaid Services (CMS) revised Medicare Learning Network MLN Matters Special Edition article SE1305, to announce that Phase 2 denial edits of the Provider Enrollment, Chain, and Ownership System (PECOS) program, which was slated to being May 1, will be temporarily delayed due to technical issues. These edits would have checked certain claims for an approved or validly opted-out physician or nonphysician who is an eligible specialty type with a valid individual National Provider Identifier (NPI). If this information were missing or incorrect, claims would be denied from laboratories for ordered tests; imaging centers for ordered imaging procedures; suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) for ordered DMEPOS; and Part A Home Health Agencies (HHAs).
Article SE1305is intended for:
- Physicians and nonphysician practitioners (including interns, residents, fellows, and those who are employed by the Department of Veterans Affairs (VA), the Department of Defense (DoD), or the Public Health Service (PHS)) who order or refer items or services for Medicare beneficiaries.
- Part B DMEPOS providers and suppliers that submit claims to carriers, Part A/B Medicare Administrative Contractors (MACs), and Durable Medical Equipment (DME) MACs for items or services that they furnished as the result of an order or a referral.
- Part A HHA services that submit claims to Regional Home Health Intermediaries (RHHIs), Fiscal Intermediaries (FIs, who still maintain an HHA workload), and Part A/B MACs.
- Optometrists may only order and refer DMEPOS products/services and laboratory and x-ray services payable under Medicare Part B.
CMS initially delayed implementation of Phase 2 because of the high number of physicians who had not enrolled in PECOS. However, CMS now estimates that less than 1 percent of physicians who order or refer DMEPOS services are not yet enrolled.
CMS has provided the following links to educational material related to Phase 2:
- MLN Matters® article #SE1305 Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME and Part A Home Health Agency (HHA) Claims.
- Medicare Enrollment Guidelines for Ordering/Referring Providers.
- The Basics of Medicare Enrollment for Physicians Who Infrequently Receive Medicare Reimbursement.
