The Center for Medical Services has expanded their claims editing process for durable medical equipment Medicare area contractors to include defense against claims containing missing, improper or fraudulent physician orders. Legitimate claims could be rejected if their referral sources are not properly registered with PECOS. Providers are required verify whether a claim’s ordering physician/practitioner is actively enrolled in the Medicare program by comparing the NPI on the claim to a national list of NPIs (National Provider Identifiers) in the PECOS database to ensure that medical equipment is ordered only by those individuals authorized to do so. But with registration in PECOS only recently becoming a requirement, the database is incomplete. An unintended consequence is that providers now risk having legitimate claims rejected if their referral sources are not properly registered with PECOS.

This internet based approach had been voluntary until recently, so many physicians never setup an online PECOS account. Currently the PECOS database is separate from, the carrier maintained file of approved physicians. Local Medicare contractors have been internally updating the PECOS database when paper applications were received with physician enrollments and changes, but that process only goes back to November 2003. So, physicians who have been enrolled in the Medicare program in excess of five years and who haven’t made recent updates or changes to their enrollment are not likely to be in the PECOS system. 

The Center for Medical Services is holding firm to use this developmental, online database to determine if claims should be processed. So, Effective January 4, 2011, claims will be rejected if the ordering physician/practitioner’s NPI is not provided on the claim, not found in the PECOS list, or found to be inactive. Also effective January 4, 2011, providers will no longer be permitted to utilize their own NPI in place of an ordering physician/practitioner’s NPI. If a claim is eventually rejected, providers will receive a C200, C201 or C202 error code with a “Referring Provider Not Authorized” rejection message on their GenResponse report (for electronic claims) or Remittance Advice (for paper claims). Most providers are already receiving these error codes on their GenResponse reports, but do not know what to do with them.

Tips to Prevent Rejections:

The first step to preventing rejections is to ensure that you are monitoring your GenResponse Reports and capturing all instances where referral sources are rejecting as not registered in the PECOS system. 

Unfortunately, the PECOS database is not accessible to durable medical equipment POS providers in a downloadable format at this time, but the PECOS database is used to populate the “Find A Physician” search tool on www.medicare.gov. However, there are several steps you can take:

1. Identify all physicians with NPIs resulting in warning messages (visit the Stark Vista Group to download a free tool to help parse out this data).
2. Make sure the physician information contained in your billing software reflects the same NPI and spelling of the physician’s name as reported on the publicly available NPPES system. Claims must be billed using the physician’s legal name (i.e. Robert, instead of Bob) and individual billing number, not the NPI for the group practice, and must be reported in all CAPS.
3. Once your software record is verified to be accurate, contact those physicians and practitioners for which you are receiving rejection warnings, and:

a. Refer them to MedLearn Matters publication SE0194 (page 3) for insight on how to enroll in PECOS and the documentation needed to get started.

b. Provide them with contact information for the CMS External User Services (EUS) Help Desk for general questions about accessing and using the PECOS enrollment system. The Help Desk’s toll-free number is 1-866-484-8049 and their e-mail address is eussupport@cgi.com.

c. Ask them to enroll in PECOS using the same user ID and password established with NPPES (the NPI contractor).

d. Provide the NPI Enumerator’s phone number and e-mail address for questions about their NPPES user ID and password. The NPI Enumerator may be reached, at 1-800-465-3203 or via email

Reasons providers should submit to PECOS

• To ensure that claims for durable medical equipment will be processed
• To show up on www.medicare.gov for patients to find them

How ECP can help?

• ECP is set up to accept and transmit DMERC (Durable Medical Equipment Regional Carrier) claims for all regions for Medicare.
• When providers send their claims to ECP they are put through extensive preliminary edits. Catching potentials problems as stated in this article and much more before it is ever sent to the payer.  ECP will hold a practices claim if it is missing required information. Practices will receive a report within 2 hours of their submission letting them know their status and if any additional information is need to process the claim with the payer.