Effective May 1, 2013, Medicare will begin denying claims with physicians that are not enrolled OR do not have an “Opt out” status in PECOS.
Physician Enrollment and Chain/Ownership System – PECOS
The Affordable Care Act requires physicians or other eligible Non-Physician Practitioners (NPPs) to enroll in the Medicare Program to order/refer items or services for Medicare beneficiaries, including those physicians and other eligible NPPs who do not and will not send claims to a Medicare Contractor for the services they furnish. The Centers for Medicare & Medicaid Services (CMS) permits such physicians and other eligible NPPs to enroll for the sole purpose of ordering/referring items or services for Medicare beneficiaries.
There are three basic requirements for ordering/referring:
- The physician or NPP must enroll in Medicare, either in an approved or an opt-out status.
- The ordering/referring National Provider Identifier (NPI) must be for an individual physician or NPP (not an organizational NPI).
- The physician or NPP must be of a specialty type that is eligible to order and refer.
Who May Order and Refer for Medicare Part A Home Health Agency (HHA) Beneficiary Services?
- Doctors of Medicine or Osteopathy, and
- Doctors of Podiatric Medicine
How do I know if my physician has enrolled or opted out of PECOS?
- Check status in E-Solutions – located on Girling Intranet – HH Links
- Review monthly report sent from HHQ of physicians that are in Horizon, but do not show an enrolled or opted out status.
If you have questions, please contact Home Health Quality at 1-800-447-5464
Article submitted by: Terry Greene, Director of Home Health Quality