Medicare Enrollment Deadline: Will Your Practice Be Impaired?– April 29, 2013

UPDATE to the below notice: Due to technical issues, CMS has temporarily DELAYED the May 1, 2013, implementation of ordering and referring denials due to absent or inaccurate provider information. Until CMS sets a new implementation deadline, informational messages will continue to be sent for claims that would have been denied had the edits been in place.


The Patient Protection and Affordable Care Act (PPACA) required that all providers who order or refer items or services to Medicare patients be enrolled in the Medicare program, consistent with prior CMS initiatives instituted in 2007. As a referring or ordering provider, you must enroll or update your information online via the Provider Enrollment, Chain and Ownership System (PECOS) by May 1 — whether you choose “opt out,” “non-participating” or “participating” status in the Medicare program. If you are already enrolled in Medicare, all information in PECOS must be accurate by the May 1 deadline.

Paralyzing Consequences
What happens if you don’t register through PECOS, even if only to opt out of Medicare, or if all of your provider information is not accurate and up to date in the system? Claims from your ancillary providers will be denied. When you write a prescription or order a lab, x-rays, therapy, DME or home health services for a Medicare patient, the claims of those providers of goods and services will not be paid. Those providers will either require cash from your patient, or they may refuse to treat the patients/provide the items altogether.

Something as simple as entering or confirming your basic practice information could essentially shut down your ability to effectively treat patients, lowering your standard of care.

Impending Deadlines
The denial of claims due to absent or inaccurate information will occur using a phased approach. Claim denials for diagnostic and therapeutic services and durable medical equipment will begin May 1, 2013; claim denials for home health services claims will begin June 26, 2013. The effort for data integrity continues through 2015, with other re-validation deadlines to come. Stay tuned via AAPP for relevant information and dates.

Common Claim Denial Triggers
Certain pieces of fundamental information, if not provided or updated by the May 1 or June 26, 2013 deadlines, could generate claim denials:

  • Provider is not enrolled in PECOS because he or she opted out of Medicare before 2007 and didn’t think he or she had to keep PECOS information current.
  • Information contains misspelled names.
  • Information contains nicknames, instead of proper/legal names.
  • Credentials have not been added to the system.
  • Information contains incorrect practice information.
  • The National Provider ID number (NPI) entered in PECOS is an entity NPI and not an individual provider NPI.

Considerations & Next Steps for Opt-out Docs
Even if you are a private/concierge physician who has opted out of Medicare altogether, you must register via PECOS and all information must be accurate if you wish to continue providing a high level quality of care to Medicare patients. Consider the following:

  • If you opted out of Medicare before 2007, you may not currently be in the PECOS database at all, but need to be by May 1.
  • Regardless of what you may have heard, opt-out providers DO have access to PECOS and are valid referring/ordering providers.
  • You cannot use another provider’s NPI as an alternative to enrolling.

If you are a private/concierge physician who has opted out of Medicare altogether, you should confirm the accuracy of the information located in the following areas:

  • Medicare Ordering and Referring file, as of April 25, 2013, provided by AAPP (use your NPI or name)
  • National Plan and Provider Enumeration System (NPPES)

Below is a checklist of information to have available when updating your profile in PECOS.

Personal Information:

  • Legal name
  • Date of birth
  • Social Security Number

Schooling Information:

  • School name
  • Graduation year

License Information:

  • Medical license number with effective / renewal date(s)
  • State(s) issued

Certification Information:

  • Certification number with effective / renewal date(s)
  • State(s) issued

Drug Enforcement Agency (DEA) Information:

  • DEA number and effective date – ensure it’s current

Adverse Action Information:

  • If applicable, need final outcomes

Practice Location Information:

  • All Physical location(s) of practice
  • Physical location(s) of medical records & storage
  • Billing company information (if applicable)

Electronic Funds Transfer (EFT) Information:

If you’re participating ONLY (not non-participating or Opt Out) will need:

  • Bank ABA routing number
  • Account number
  • Cancelled check

For assistance with login issues, contact:

National Plan and Provider
Enumeration System (NPPES)


Provider Enrollment, Chain and
Ownership System (PECOS)


For assistance with provider status, contact:

Maria Shinn Bouck, CPC, CPMA, CHC
Cohen Healthcare Consulting, Ltd.

Sonda Kunzi, CPC, CPMA, CPC-I
Associate Director
Cohen Healthcare Consulting, Ltd.