Physician Re-Validation Sandy Sage RN Wednesday January 27, 2016

Provider Enrollment, Chain and Ownership System (PECOS): Electronic Medicare enrollment system through which providers and suppliers can submit Medicare enrollment applications. https://pecos.cms.hhs.gov/pecos/help-main/faq.jsp

PECOS Why is PECOS important? CMS issued regulations stating that physicians who have not enrolled in or opted out of Medicare participation, will not be able to provide services or refer patients for services such as Home Health and DME. CMS is using PECOS to verify the physician’s status.

How do physician’s confirm their status? PECOS How do physician’s confirm their status? Review status by reviewing the Ordering and Referring file found at this link: https://data.cms.gov/Medicare/Order- and-Referring/qcn7-gc3g This will tell you if the NPI is valid.

Re-Validation Initiative Providers will be required to re-validate their Medicare enrollment using form CMS-855 They will receive a request from their MAC Florida – First Coast Service Options Do not revalidate until this notice is received This will apply to all providers who were Medicare providers prior to March 25, 2011

Re-Validation Initiative You have 60 days, after you receive a letter from the MAC, to send your re-validation information in for processing. If you do not respond your provider number will be deactivated Once your provider number is deactivated you have 120 days from the date of the first notice to re- validate. CMS will make 2 phone calls to remind you that your provider number will be deactivated

OOPS!!! If you have missed the deadlines and have had your Medicare/Medicaid privileges revoked, you have 3 options: File a formal appeal within 60 days of notice File a corrective action plan within 30 days of notice File a formal written appeal with a corrective action plan within 30 days of notice.

IMPORTANT!!! If physicians do not pursue one of these options in a timely manner, they waive all their rights to further administrative review. In the event a physician’s Medicare billing privileges are revoked, the revocation is effective 30 days from date of the postmark on the envelope containing the notice that has been mailed

CAH Hospitals Method II billing All claims submitted to Medicare must have an attending or rendering physician who has a valid NPI number and is enrolled in Medicare. Failure to list a valid physician NPI will result in the rejection of the CAH Method II claim!! Rejection Codes: N253 and N290 Missing provider identifier

CAH Hospitals When submitting the CMS-1500 or the UB-04, please only include the first and last name as it appears on the attending and rendering file available at https://data.cms.gov on the CMS website. Middle names (initials) and suffixes (such as MD, RPNA etc.) should not be listed in the attending/rendering fields.

Education for Physicians Medicare Enrollment Guidelines for Physicians https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/MedEnroll_Orde rReferProv_FactSheet_ICN906223.pdf

Contact Information Sandy Sage RN SandySageRN@Gmail.com