Embracing Value-Based Care: A Shift Towards Patient-Centered Health Systems

James Smith
04 Apr, 2024 updated

In healthcare where accuracy and communication are paramount, PECOS (Provider Enrollment, Chain, and Ownership System) emerges as a crucial bridge between providers and the Centers for Medicare & Medicaid Services (CMS).


This system is pivotal in ensuring precise data relay and managing a provider's standing with CMS. Here’s a deep dive into what PECOS entails, its importance, and how to seamlessly navigate it for provider verification.

What is PECOS?

PECOS is the online platform designated for Medicare enrollment of individuals and entities as providers or suppliers. Through PECOS, you can renew enrollment, update information, report changes to your enrollment record, withdraw from the Medicare program, and electronically sign and submit all necessary documentation.

The PECOS system is managed and maintained by the Centers for Medicare & Medicaid Services (CMS). The PECOS applications are processed electronically, allowing for an efficient and data-protected process.

The significance of PECOS is underscored by the CMS regulation mandating physicians to be either enrolled in or opted out of Medicare to order or refer patients for Medicare-covered home health services and DME supplies. The CMS verifies physician status using PECOS; without an approved enrollment record in PECOS, Medicare will not cover home health services provided to that physician's patients.

Who must register in PECOS?

With the advent of the Patient Protection and Affordable Care Act (PPACA), all practitioners ordering or referring healthcare services or supplies must enroll in Medicare or officially opt out. This includes:

  • Physicians and Specialists
  • Registered Nurses
  • Physician Assistants
  • Certified Clinical Nurse Specialists
  • Nurse Practitioners
  • Clinical Psychologists
  • Certified Nurse-Midwives
  • Clinical Social Workers
  • Physicians employed by the Department of Veterans Affairs, the Public Health Service, or the Department of Defense/Tricare (must use CMS FORM 855O)

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What will happen if a provider doesn’t register in PECOS?

Failure to register in PECOS could result in the denial of claims for items or services prescribed by a provider, affecting Medicare claims specifically. This lapse could hinder patients from receiving essential items and potentially delay claim processing.

It's crucial to validate information upon renewal as any missed renewal dates or changes in information without supporting documentation could inactivate participation in the Medicare program.

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Medicare Provider Enrollment

Enrollment with Medicare can be achieved either by completing the appropriate paper applications or through PECOS. To use PECOS, setting up a user account in the CMS Identity & Access Management System (I&A System) is essential. This account facilitates login to PECOS for enrollment application processing, managing NPI numbers in the NPPES system, entering incentive payment information, and setting up surrogate users for your organization or an individual provider record.

Before proceeding with PECOS, ensure you have the following:

  • An active National Provider Identifier (NPI)
  • Personal Identifying Information
  • Schooling Information
  • Professional License Information
  • Certification Information
  • Specialty/secondary specialty Information
  • Drug Enforcement Agency (DEA) number
  • Final adverse actions Information (if applicable)
  • Practice location Information
  • Federal, State, and/or local business licenses, certifications, and/or registrations
  • Electronic Funds Transfer documentation

Once logged into PECOS, a step-by-step guide aids in selecting the correct application and entering your information. An initial enrollment with Medicare via PECOS could take an hour or more, necessitating the upload of all relevant supporting documents.

After submitting your application via PECOS, you can check the status of your application online directly with the MAC through their website or via the PECOS application status check page.

What is the role of Medicare Administrative Contractors?

Post submission, your application reaches the Medicare Administrative Contractor (MAC) for your state. Although most MACs process applications within 60 days, there's no standard turnaround time, and the completion solely depends on the MAC's processing capabilities.

Medicare Administrative Contractors manage Medicare operations for provider enrollment. They are assigned by state or jurisdiction. A Medicare Administrative Contractor (MAC) is a private healthcare insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.

CMS relies on a network of MACs to serve as the primary operational contact between the Medicare FFS program and the health care providers enrolled in the program.

How to Verify a Provider's Medicare Enrollment

Ensuring a provider's enrollment in Medicare is a pivotal step in healthcare compliance. You can ascertain this by navigating through the CMS system or utilizing Medicare's Physician Compare Tool. A provider must be enrolled in the PECOS system and maintain accurate information to continue practicing within the Medicare program.

PECOS houses a database of registered providers with CMS. Utilizing the National Provider Identifier (NPI), you can search for a provider in the database. If the NPI is unknown, the NPI registry can be used for the search.

The PECOS database is refreshed weekly, making it a reliable source for checking a provider's enrollment status. It's advisable to also monitor providers' NPI status and the Preclusion List for comprehensive verification.

1. Utilize PECOS for a Search

  • Access the Centers for Medicare & Medicaid Services (CMS) website.
  • Select the 'Search and Referring' option.
  • A list of Medicare physicians and non-physician practitioners with current PECOS enrollment records will appear.
  • This list, which can be sorted alphabetically or numerically, showcases the National Provider Identifiers (NPI) and legal names of providers.

Please note, name suffixes are not displayed, and there are no duplicate records. Deceased practitioners are excluded from this list.

The CMS updates this list bi-weekly for accuracy and completeness.

2. Log In to PECOS

  • You can view a provider's status and specialty type in PECOS, following instructions available on the CMS website.
  • An active user ID and password are required to log into PECOS, obtainable through the National Plan & Provider Enumeration System (NPPES) or PECOS Identification and Authentication System (I&A).

In case you possess more than one NPPES ID, ensure to log in with all IDs to determine if a PECOS enrollment record exists.

  • Post login, you can browse PECOS to see your Medicare enrollment information if it exists, and also view, print, and update your Medicare information.

If you are not yet enrolled in Medicare, the portal facilitates the enrollment process post-sign in.

3. Examine the List of Pending Applications

In scenarios where an enrollment application is believed to have been submitted, but no enrollment record exists in PECOS, a search can be conducted for pending applications.

  • Navigate to the 'Initial Physician Applications Pending Contractor Review' or the 'Initial Non-Physician Applications Pending Contractor Review' section.
  • These applications haven't been fully processed and are awaiting review.
  • Similar to the previous search, this list contains the physicians’ NPIs and their legal names, all of which can be sorted for ease of review.

If a physician or provider decides to opt out of the Medicare program, they must submit an affidavit to the Centers for Medicare and Medicaid Services (CMS). Information on these providers is published through the Provider Enrollment, Chain, and Ownership System (PECOS) from CMS and is updated monthly.

Conclusion

Navigating PECOS is an essential undertaking for healthcare decision-makers, ensuring seamless communication with CMS and accurate provider verification. Understanding the intricacies of PECOS, staying updated with enrollment procedures, and ensuring timely renewals are steps toward fostering a compliant and efficient healthcare practice. The journey through PECOS, although intricate, is a cornerstone in aligning with Medicare’s operational framework, ultimately enhancing the healthcare delivery system for better patient outcomes.

What is PECOS and why is it crucial for healthcare providers?

PECOS, or Provider Enrollment, Chain, and Ownership System, is an online platform operated by the Centers for Medicare & Medicaid Services (CMS) for enrolling individuals and entities as Medicare providers or suppliers. It's pivotal for ensuring accurate provider verification, compliance with CMS regulations, and facilitating seamless communication between healthcare providers and CMS.

Who is required to register in PECOS?

All practitioners who order or refer healthcare services or supplies need to enroll in Medicare or officially opt out via PECOS, according to the Patient Protection and Affordable Care Act (PPACA). This encompasses physicians, specialists, registered nurses, and other healthcare professionals.

What are the repercussions of not registering in PECOS?

Failure to register in PECOS can lead to denial of claims for items or services prescribed, affecting Medicare claims. This can impede patients from receiving essential items and potentially delay claim processing.

How do Medicare Administrative Contractors (MACs) interact with PECOS?

MACs are private healthcare insurers designated by geographic jurisdictions to process Medicare Part A and Part B medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries. They manage Medicare operations for provider enrollment and are a key component in the provider verification process through PECOS.

How can a provider’s Medicare enrollment be verified within PECOS?

Provider enrollment in Medicare can be verified by checking within the PECOS system using the provider’s National Provider Identifier (NPI). It's a reliable source for confirming a provider's enrollment status, as the PECOS database is refreshed weekly.

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