Complete Story
03/18/2010
Reimbursement Update - Enrollment
By, Joy Newby, LPN, CPC, Newby Consulting, Inc.
All Physicians - Update on Supplier Claims Processing for Ordering/Referring Providers
The Centers for Medicare & Medicaid Services (CMS) will delay until January 3, 2011, the implementation of Phase 2 the Expansion of the Current Scope of Editing for Ordering/Referring Providers for Claims Processed by Medicare Carriers and Part B Medicare Administrative Contractors [MACs]) and Expansion of the Current Scope of Editing for Ordering/Referring Providers for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies [DMEPOS] Supplier Claims Processed by Durable Medical Equipment Medicare Administrative Contractors [DME MACs]).
In Phase 2 if the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and eligible to order and refer. If the 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. Initially Phase 2 was to begin April 4, 2010. As stated previously, CMS is delaying implementation until January 3, 2011.
This delay will give physicians and nonphysician practitioners who order items or services for Medicare beneficiaries or who refer Medicare beneficiaries to other Medicare providers or suppliers sufficient time to enroll in Medicare or take the action necessary to establish a current enrollment record in Medicare prior to phase 2 implementation.
Although enrolled in Medicare, many physicians and nonphysician practitioners who are eligible to order items or services or refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in Medicare. A current enrollment record is one that is in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and contains the National Provider Identifier (NPI). Under phase 2, a physician or nonphysician practitioner who orders or refers and who does not have a current enrollment record that contains the NPI will cause the claim submitted by the Part B provider/supplier who furnished the ordered or referred item or service to be rejected.
CMS continues to urge physicians and nonphysician practitioners who are enrolled in Medicare but who have not updated their Medicare enrollment record since November 2003 to update their enrollment record now. If these physicians and nonphysician practitioners have no changes to their enrollment data, they need to submit an initial enrollment application which will establish a current enrollment record in PECOS. CMS posted 02/23/2010
Fee-For-Service Provider Enrollment Reporting Responsibilities for Individual Physicians Enrolled in the Medicare Program
Reportable Physician Changes
After enrolling in the Medicare Program, all physicians are responsible for maintaining and reporting changes in their Medicare enrollment information to their designated Medicare contractor. By reporting changes as soon as possible, physicians will help to ensure that their claims are processed correctly.
The reportable events listed below may affect claims processing, a payment amount, or a physician's eligibility to participate in the Medicare Program. Physicians are required to report the following reportable events as soon as possible, but no later than 30 days after the reportable event.
- Change in Practice Location occurs when a physician establishes a new practice location, moves an existing practice location, closes an existing practice location, or changes any portion of an existing practice location address where Medicare information is sent.
- Change in Final Adverse Action occurs when a physician is debarred or excluded by any Federal or State health care program, has his or her medical license suspended or revoked by a State licensing authority, was convicted of a felony within the last 10 years, has his or her Medicare billing privileges revoked by a Medicare contractor, or has a revocation or suspension by an accreditation organization.
Physicians are required to report the following reportable events as soon as possible, but no later than 90 days after the reportable event.
- Change of Business Structure occurs when a physician changes his or her business structure (e.g., sole proprietorship to sole incorporated owner or vice versa).
- Change in Organization Legal Business Name/Tax Identification Number occurs when a business owner changes the organization's legal business name and/or Taxpayer Identification Number with the Internal Revenue Service.
- Change in Practice Status occurs when a physician decides to retire or voluntarily withdraw from the Medicare Program. This type of change is referred to as a voluntary withdrawal.
Other Reportable Changes Include
- Change in Reassignment of Benefits occurs when a physician adds or voluntarily withdraws his or her reassignment of Medicare benefits. Physicians must report this type of change on the CMS-855R.
- Change in Banking Arrangements or any Payment Information occurs when a physician changes his or her bank or bank account or makes other payment information changes. This type of change should be reported immediately to the Medicare contractor. A physician can update his or her electronic funds transfer information by submitting the Electronic Funds Transfer Authorization Agreement (CMS-588) to his or her Medicare contractor.
Additional Information
Physicians can apply for enrollment in the Medicare Program or make a change in their enrollment information using either:
- The Internet-based Provider Enrollment, Chain and Ownership System (PECOS) or
- The paper enrollment application process (e.g., CMS-855I).
There are three basic steps to completing an enrollment action using Internet-based PECOS. Physicians and non-physician practitioners must:
1. Have a National Plan and Provider Enumeration System (NPPES) User ID and password to use Internet-based PECOS.
- For security reasons, passwords should be changed periodically, at least once a year.
- For information on how to change a password, go to the NPPES Application Help page available at https://nppes.cms.hhs.gov/NPPES/Welcome.do and select the "Reset Password Page" on the NPPES Application Help page.
2. Go to PECOS at https://pecos.cms.hhs.gov to complete, review, and submit the electronic enrollment application via PECOS.
3. Print, sign, and date the two-page Certification Statement and mail it with all supporting paper documentation to the Medicare contractor within seven days of the electronic submission.
NOTE: A Medicare contractor will not process an Internet enrollment application without the signed and dated two-page Certification Statement and the required supporting documentation. In addition, the effective date of filing an enrollment application is the date the Medicare contractor receives the signed two-page Certification Statement that is associated with the Internet submission.
Physicians who are enrolled in the Medicare Program, but have not submitted the CMS-855I since 2003, are required to submit a Medicare enrollment application (i.e., Internet-based PECOS or the CMS-855I) as an initial application when reporting a change for the first time.
If a physician has any questions about reporting a change, the physician should contact his or her designated Medicare contractor in advance of submitting the CMS-855I.
For additional information regarding the Medicare enrollment process, including Internet-based PECOS, go to http://www.cms.hhs.gov/MedicareProviderSupEnroll on the CMS website.
