PECOS Ordering & Referring Data | CarePrecise
Update released    
February 17, 2020    
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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



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NPPES and PECOS Ordering and Referring Report Data

SUMMARY: CarePrecise publishes the PECOS enrollment status with each provider's NPI record.

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

CarePrecise, PECOS and the NPI registry

The 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.

CarePrecise obtains data from multiple sources and merges them using advanced record-linkage technology to bring it all together into a single master database.

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



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

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.



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The data contained in CarePrecise® products and services is compiled and processed on an ongoing basis, with monthly update releases, from public and proprietary sources, including the complete National Plan & Provider Enumeration System (NPPES) data submitted by the providers themselves, Medicare Provider Enrollment Chain and Ownership System (PECOS), List of Excluded Individuals/Entities (LEIE), Medicare claims data, and other US federal sources obtainable under the Freedom of Information Act (FOIA) and provided monthly by the U.S. Department of Health and Human Services Services and Office of Inspector General of the U.S. Department of Health and Human Services, and from the U.S. Census Bureau, a division of the U.S. Department of Commerce, agencies of the U.S. federal government, and the United States Postal Service (USPS). Neither CarePrecise nor its shareholders, 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 Federal NPI regulation to provide their information to the NPI Registry, a federal database of healthcare providers, and to update their records within thirty days of any change in that information. Data is provided "as is" and in accordance with the Freedom of Information Act (FOIA) and e-FOIA ammendments, and relevant data dissemination notices. While these sources are considered among the most reliable available, no warranty is expressed or implied as to the accuracy, completeness, timeliness, fitness for any purpose, or absence of processing errors of the information presented here or in any CarePrecise product or service, 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. Nothing in the product descriptions, in writing or verbal, may be construed as a warranty, guarantee, or representation of deliverability, save the deliverability guarantee on email addresses. All data ages between updates, and it is reasonable to expect that a portion of records will contain contact information that is incorrect or for other reasons undeliverable. Not all fields are populated with data for every record except where indicated; some fields are not populated due to restrictions imposed by a data supplier even though a field may be present for later use. Where percent of records populated is quoted, the percent quoted is subject to slight differences upon delivery as data is continuously updated. To determine a provider's eligibility to practice and/or to bill Medicare or other health plans and carriers, or to in any other way perform professional activities, users should not rely solely on data included in CarePrecise datasets, particularly regarding alleged fraudulent or infraction activity given as reason for listing in data on excluded providers (records carrying "sanction", "desanction", "warning" and/or "exclusion" identifiers or flags). Data which has been in-matched using algorithmic rather than direct means will include a percentage of error; such data is labeled as such in the documentation. Algorithmic in-matching logic and processes are proprietary trade secrets. Subscriptions are fullfilled with quarterly or monthly releases containing the most recently released data from all pertinent sources. CarePrecise is a registered trademark, and CarePrecise Access, CarePrecise Select, CarePrecise Gold, CarePrecise Platinum, CP ListMaker, CP ChangeMaker, SharpMail, Authoritative Physician Database, and Authoritative Hospital Database are trademarks of CarePrecise LLC. All CarePrecise products including data, data structures, code, and related materials are the property of CarePrecise LLC and protected by U.S. and international copyright. Other trademarks and copyrights are the property of their respective owners. CarePrecise reserves the right to cease services and/or communication with parties that abuse its services or its personnel, or fail to comply with its terms of service. For additional information on CarePrecise policies see the Policies page. Purchase of a CarePrecise product affirms understanding and acceptance of these policies and this information, and affirms that use will conform to the product's license agreement. Pricing for CarePrecise products published on its website are licensed for a single user. Any form of dissemination, sharing, making public, distribution, or derivative product, whether or not for profit, is strictly forbidden without an alternative licensing arrangement; such licensing arrangements are available - please contact CarePrecise Sales for terms and pricing.

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