PECOS Tips as Edits Draw Near

May 1, 2013 is the date for activation of the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) edits that will result in denial of home health claims if the ordering physician is not enrolled in PECOS or officially opted-out of Medicare. In order to protect against non-payment by Medicare, home health agencies must verify enrollment of all ordering physicians.

Beneficiary Notification

The Centers for Medicare & Medicaid Services (CMS) has not issued final guidance about beneficiary notices and liability. However, home health agencies should begin to notify both physicians who are not enrolled in PECOS and their patients who will be affected by nonpayment by Medicare as a result of the activation of edits. For beneficiaries who are unable to identify a PECOS-enrolled physician to assume ordering responsibilities for episodes of care beginning on and after May 1, discharge planning should begin immediately in accord with State regulations and agency policy.

PECOS Verification Tips

Below are several important tips about PECOS operational consideration:

  1. Physicians approved to order home health services are limited to doctors of medicine, osteopathy, and podiatry.
  2. The NPI must be that of the individual physician, not a group or organization.
  3. Home health agencies must report the name of the physician who ordered services on the RAPs and claims – i.e. the physician who signs the plan of care.
  4. The first name, last name, and NPI number of physician must appear on home health RAPs and claims exactly as they appear in PECOS.
  5. Information such as middle initial, nicknames, credentials, or titles may be included on electronic claims as long as they do not appear in first or last name fields on the claims, and must never appear on paper claims.
  6. If the PECOS information differs from that in NPES or licensure files, agencies should verify and document that identity was confirmed but only use PECOS information on claims.
  7. Enrollment status should be verified upon referral – at the start of care – and on the date of all subsequent episodes.
  8. Retain documentation of verified PECOS enrollment. For denied RAPS, $0 payment, verify the physician information. If erroneous cancel, correct and submit a new RAP. If you have a claim denied due to the Ordering/Referring provider edits, you must file an appeal. An adjustment cannot be submitted. Note: We are seeking information as to whether the claim can be cancelled and resubmitted.
  9. Check each physician’s enrollment status individually in the CMS Medicare Ordering Referring File download available here.

Impact of Edits on Payment

In response to home health agencies’ questions about the dates of service and application of PECOS edits to claims, we have learned from CMS that:

  • Edits are based on date of service, not the date of billing.
  • If the “from” date of a claim is prior to May 1, then it will not hit the denial edits and the episode will be paid in full.
  • Claims will always be paid in full if the ordering physician is enrolled in PECOS as if the “from” date of claims – i.e. the start of episode – even if the physician dis-enrolls prior to the end of the episode.

How do CMS contractors determine physicians’ “date of enrollment” (i.e. is it the date that they are approved, or the date that the physician’s name is entered into PECOS, or some other date)? The effective date of enrollment in PECOS for physicians is determined by CMS by the later of the two following criteria:

  • The date the physician filed an enrollment application that was subsequently approved. For PECOS applications, this is the date that the contractor received an electronic version of the enrollment application and a signed certification statement submitted via paper or electronically.


  • The date the physician first began furnishing services at a new practice location.

Additional information will be provided as it is received.

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