Physicians (or other qualified practitioners) who order or refer patients for Part B services must be enrolled in Medicare in order for the Part B supplier that performs the services to be paid. The Centers for Medicare & Medicaid Services (CMS) previously announced that, effective January 3, 2011, the ordering/referring physician shown on a claim form must have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) in order for the claim to be paid. Services affected by this requirement include, for example, laboratory tests, imaging services, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), and claims from specialists for referred services. Many physicians who are enrolled in Medicare are nevertheless not enrolled in PECOS (e.g., because they have not changed their information in recent years), so suppliers of Part B services were facing denial of claims where their referring physicians had not yet enrolled in PECOS.
CMS has now announced it will not adhere to its January 3, 2011, deadline for denying claims for certain Part B billed items and services that include the names of ordering/referring providers who are not enrolled in PECOS. CMS confirmed it is working diligently to resolve enrollment backlogs and other system issues, and will provide “ample advanced notice” to providers before implementing automatic nonpayment actions.