PECOS Enrollment

If the physician is not on the ordering and referring physicians list, the invoice will not bill.  We check when physician is added to the system and then before billing.  This is a free service.

PECOS Enrollment Verification Process

PECOS is the online Medicare enrollment management system which allows you to enroll as a Medicare provider, renew your enrollment or withdraw from the Medicare program.   Any physicians that refer Medicare patients and signs orders for Medicare patients must be actively enrolled in PECOS.   If not enrolled, you cannot use this physician to accept referrals, sign orders and bill Medicare for services you provide.

Careficient obtains a CMS Referral file knowns as PECOS) every Friday that has the latest physician enrollment information.   The Careficient application checks PECOS as follows:

  1. Entering a new physician that includes the NPI
  2. Billing Edits check Physician enrollment in PECOS for every invoice if the non-Medicare payer requires the Physician to be enrolled

Adding New Physician with NPI

When you enter a Physician that includes the NPI, the Careficient application automatically checks the Physician’s NPI against the CMS Referral file (known as PECOS).   If the Physician is not actively enrolled, you will receive a “warning” message indicating that the NPI you entered does not appear in the CMS Referral file.  You can still add the Physician but you will not be able to use this Physician for Medicare referrals/physician orders/billing for services.

Billing Edits for PECOS Enrollment  

For non-Medicare payers, you have a payer rule that you can activate if that payment source requires physicians to be enrolled in PECOS.  Typically this will be for Medicaid, and other government payers such as the Veterans Administration.   If any of your non-Medicare payers require physicians to be PECOS enrolled, you must activate this rule as follows:

  1. Resources menu
  2. Organization Payers option
  3. Find/Select the Payer that requires this rule to be active
  4. Select the Rules tab
  5. Select the “Add Payer Rule” icon for the rule that reads “Check Physician NPI against CMS Ordering and Referring File” (Add Payer Rule pop-up displays)
  6. Enter the date you want to start using this rule.
  7. Select the Save button.

After you activate this rule, you will see invoices edit/errors indicating that the Physician is not PECOS enrolled.  You must correct this information before you can bill for the services.