Questions? Call now: (877) 782-2294         CarePrecise Access is: the complete NPI registry, the complete listing of U.S. physicians the complete listing of hospitals and all other healthcare providers in the U.S. the complete federal healthcare provider database (NPPES), plus additional valuable data, the PECOS enrollments of providers eligible to bill Medicare, and LEIE listing of providers barred from Medicare fully normalized data, linked by NPI number addresses, phones, faxes and contact names for all U.S. HIPAA covered entities EXPLORE:

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PECOS/NPI Linked Data

NPI restored to PECOS Ordering and Referring Report Data

SUMMARY: Despite the decision by CMS to redact a portion of the NPI number in the PECOS Ordering and Referring Report, CarePrecise continues to publish the PECOS enrollment status with each provider's NPI record. Our advanced record-linkage system makes this possible. Read our press release on this issue...

CarePrecise merges healthcare provider data from multiple sources, giving you a master data file keyed on the NPI.

CarePrecise, PECOS and NPI

With the January, 2012 release of the PECOS Ordering and Referring Report, CMS began redacting a portion of the NPI (National Provider Identifier) number, listing only the last four digits of the NPI, first name and last name of PECOS-enrolled providers.

This has caused significant problems for organizations who need to pull that data into their in-house systems for validation of providers' eligibility to order on a patient's behalf for billing to Medicare. In particular, DME (Durable Medical Equipment) suppliers use the ordering and referring report in the normal course of business.

Because CarePrecise obtains data from multiple sources, using advanced record-linkage technology to bring it all together into a single master database, the action of CMS has not changed the CarePrecise Access Complete healthcare provider dataset; CarePrecise continues to publish the PECOS enrollment status of eligible providers in each monthly update.

The dataset can be ordered for a single state, or for the entire U.S.

About PECOS

PROVIDERS INCLUDED: The following healthcare providers can order and refer Medicare beneficiary services once they have enrolled and have been accepted in the PECOS system:

• Physician (MD or DO)
• Dental practitioner
• Dental surgeon
• Podiatric practitioner
• Optometrist
• Physician assistant (PA)
• Certified clinical nurse specialist
• Nurse practitioner
• Nurse midwife
• Clinical psychologist
• Clinical social worker

The CarePrecise Access Complete dataset contains complete information on the above provider specialties, as well as all other HIPAA-covered U.S. healthcare provider specialties, organizations and facilities. PECOS enrollment status is only one of the hundreds of data fields in the master dataset; if a provider has been barred from billing Medicare by the HHS Office of Inspector Genera (OIG), a Warning field is flagged and reason is provided. This feature was not part of the PECOS Ordering and Referring Report.

The CarePrecise Access Complete dataset also includes practice and mailing addresses, phone and fax numbers, all taxonomy codes (specialties, subspecialties and facility types), state license numbers, business entity information, provider gender, complete names and credentials, alternate names, and much more.

Review details on the fields included in the dataset and additional documentation...

Implementation of Changes in Medicare Submissions

Change Request (CR) 6421 implements system edits to ensure that suppliers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) only bill for items or services when ordered or referred by eligible physicians and non-physician practitioners who are enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS). These changes impact DMEPOS claims received and processed on or after October 5, 2009.

Phase 1 (Implementation effective October 5, 2009)

• If an ordering/referring provider is present on the claim, Medicare will verify that the ordering/referring provider is in PECOS and is eligible to order/refer Medicare services.
• If an ordering/referring provider is not in PECOS or is in PECOS but is not of the type/specialty to order or refer, the claim will continue to process.
• If a DMEPOS supplier claim is an ANSI X12N 837P standard electronic claim, the DMEPOS supplier will receive a warning message on the Common Electronic Data Interchange (CEDI) GenResponse Report.
• If a DMEPOS supplier claim is a paper CMS-1500 claim, the DMEPOS supplier will not receive a warning and will not know that the claim did not pass these edits.

Phase 2 ( Date TBA)

• If an ordering/referring provider is not present on the claim, the claim will not be paid.
• If an ordering/referring provider is present on the claim, Medicare will verify that the ordering/referring provider is in PECOS and eligible to order/refer.
• If an ordering/referring provider is not in PECOS or is in PECOS but is not of the specialty to order or refer, the claim will not be paid. It will be rejected.
• If the DMEPOS supplier claim is an ANSI X12N 837P standard electronic claim, the DMEPOS supplier will receive a rejection message on the CEDI GenResponse Report.
• If the DMEPOS supplier claim is a paper CMS-1500 claim, the DMEPOS supplier will see the rejection indicated on the Remittance Advice (RA).

In both phases, Medicare will verify the National Provider Identifier (NPI) and the name of the ordering/referring provider reported on the ANSI X12N 837P standard electronic claim against PECOS. Providers who order or refer are encouraged to verify their enrollment in PECOS.

MORE INFORMATION: Contact CarePrecise Sales at (877) 782-2294, sales@careprecise.com

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The data contained in CarePrecise products is compiled and processed on an ongoing basis, with monthly update releases, from free and fee-based sources, including the National Plan & Provider Enumeration System (NPPES), Medicare Provider Enrollment, Chain, and Ownership System (PECOS), List of Excluded Individuals/Entities (LEIE) and other US federal sources obtainable under the Freedom of Information Act (FOIA) and provided monthly by the Centers for Medicare and Medicaid Services (CMS) and Office of Inspector General, divisions of the US Department of Health and Human Services (HHS), and from the US Census Bureau, a division of the US Department of Commerce, agencies of the US federal government, and the United States Postal Service (USPS). Neither CarePrecise nor its investors, partners and affiliates are responsible for data maintained by these or other source providers. All HIPAA covered entity healthcare providers in the U.S. are required under the NPI Final Rule to provide their information to a federal database of healthcare providers and to update when their information changes. No warranty is expressed or implied as to the accuracy, completeness or timeliness of the information presented here, nor that the data structure will not be changed in the future as necessitated by source data, beyond the diligent effort to include all released data. To determine a provider's eligibility to practice and/or to bill Medicare, users should not rely solely on data included in the CarePrecise dataset, particularly regarding alleged criminal and/or fraudulent activity given as reason for listing in data on excluded providers. Data which has been in-matched using algorithmic rather than direct means may include a percentage of error; affected data is labled as such in the documentation. CarePrecise, CarePrecise Access, CarePrecise Select, CarePrecise Gold, CP ListMaker and SharpMail are trademarks of CarePrecise Technology. Other trademarks are the property of their respective owners.