CMS is expanding their current scope of editing for Ordering/Referring Providers for claims processed by Medicare Carriers and Part B Medicare Administrative Contractors (MACs). Effective January 12, 2011, if the ordering/referring provider is not in the PECOS database, the provider submitting a claim will be denied by Medicare and other government payors until this is completed.
The providers who can order/refer are:
- Doctor of Medicine or Osteopathy
- Dental Medicine or Dental Surgery
- Podiatric Medicine
- Chiropractic Medicine
- Physician Assistant
- Certified Clinical Nurse Specialist
- Nurse Practitioner
- Clinical Psychologist
- Certified Nurse Midwife
- Clinical Social Worker
Claims that are the result of an order or a referral must contain the National Provider Identifier (NPI) and the name of the ordering/referring provider. The ordering/referring provider must be in Provider Enrollment, Chain and Ownership System (PECOS) database with one of the above types/specialties.
To continue to order or refer to Medicare beneficiaries, you will need to ensure that your provider information is loaded in the PECOS database. If you are not listed, you will have to enroll in the Medicare program or “revalidate” your Medicare enrollment information. If you are Banner employed/contracted and Banner is billing for those services, revalidation has been done on your behalf by Banner Certification Credentialing Licensing. If you are not Banner employed/contracted and you are billing for your own services you need toonfirm if you have a current enrollment record in Medicare and in the PECOS database by contacting your local Medicare carrier, as follows:
- Noridian (Alaska, Arizona, Wyoming) at 1-888-608-8816
If the local Medicare carrier confirms you are listed in the PECOS database, you do not need to do anything further. If the local Medicare carrier confirms you are not listed in the PECOS database, you will need to submit a current 855I.
If using Internet-based PECOS, be sure to mail the signed and dated Certification Statement to the carrier or A/B MAC immediately after submitting the applicationhttps://pecos.cms.hhs.gov/pecos/login.do,or fill out the appropriate Medicare provider enrollment application(s) and mail it, along with any required information, to the local Medical carrier or A/B MAC. They will enter your information into PECOS and process your enrollment application. For additional information regarding PECOS refer to: www.cms.hhs.gov/MedicareProviderSupEnroll.