CarePrecise merges healthcare provider data from multiple sources, giving you a reference data file keyed on the NPI.
CarePrecise, PECOS and the NPI registry
The Provider, Enrollment, Chain and Ownership System (PECOS) Medicare Ordering and Referring Report does not include much information about the listed providers, and is of limited usefulness to its intended audience. In particular, DME (Durable Medical Equipment) suppliers use the ordering and referring report in the normal course of business, and require some additional data on ordering and referring physicians.
PROVIDERS: 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
- Physician assistant (PA)
- Certified clinical nurse specialist
- Nurse practitioner
- Nurse midwife
- Clinical psychologist
- Clinical social worker
The CarePrecise 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 comprehensive CarePrecise 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.
CarePrecise Complete 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.
Implementation of Changes in Medicare Submissions
CMS has not yet decided when it will begin to reject claims if an ordering/referring provider does not have a Provider Enrollment, Chain and Ownership System (PECOS) record. CMS will give providers ample notice before claim rejections begin.
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, email@example.com