Trailblazer REPORTS HERE on the PECOS update:  

"On May 5, 2010, CMS published CMS-6010-IFC (Interim Final Rule with Comment Period) in the Federal Register. The rule is titled, “Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements.” Based on the IFC, provisions contained in the rule will be effective July 6, 2010. Providers are interpreting the IFC rule to mean that all referring/ordering providers must be enrolled in the Provider Enrollment, Chain and Ownership System (PECOS) by July 6, 2010, which in their view contradicts the January 3, 2011, date currently in effect based on directives issued in Change Request (CR) 6417.

To clarify the required dates for the ordering/referring provider to be enrolled in Medicare, please consider the following information.

When new regulations or changes to current regulations affect the Medicare program, CMS publishes the regulations in the Federal Register in the form of Final Rules. Although regulations are published in the Federal Register, Medicare contractors do not perform any action to implement the provisions contained in those rules until CMS issues official directives in the form of CRs. CRs are developed by CMS with specific instructions to contractors on how and when Medicare requirements must be implemented. At this time, TrailBlazer has not received a CR from CMS directing us to perform any action in relation to the provisions addressed in CMS-6010-IFC.

TrailBlazer continues to comply with the directives CMS issued in CR 6417, which established claims processing editing to verify the referring/ordering provider submitted on a claim is of the type to order/refer the service billed and is enrolled in Medicare as recorded in the national PECOS files or the contractor's master provider files. The effective dates outlined in CR 6417 are provided below for further clarification.

Important Dates

October 5, 2009, through January 2, 2011 – For claims received during this period for services/items requiring a referring/ordering provider, claims processing editing will verify the ordering/referring provider submitted on the claim is of the specialty eligible to order/refer and is either enrolled in PECOS or on the contractor's master provider file. If either of those requirements is not met, the billing provider receives an informational message explaining that the claim failed the ordering/referring provider edits. The claim will continue processing during this time period.

January 3, 2011 – For claims received on or after this date for services/items requiring a referring/ordering provider, claims processing editing will verify the ordering/referring provider submitted on the claim is of the specialty eligible to order/refer and is either enrolled in PECOS or the contractor's master provider file. If either of those requirements is not met, the billing provider will not receive payment for the ordered/referred services/items billed.

Enroll at the PECOS web site HERE.

References

• CR 6417:
  http://www.cms.gov/transmittals/downloads/R642OTN.pdf.
• MLN Matters^® Article for CR 6417:
  http://www.cms.gov/MLNMattersArticles/downloads/MM6417.pdf.
• CMS-6010-IFC:
  http://edocket.access.gpo.gov/2010/2010-10505.htm.