PECOS edits set to start next week

Thursday, January 2, 2014

BALTIMORE – It looks like the PECOS edits are still scheduled to go into effect next week.

Noridian Administrative Services, the DME MAC for Jurisdiction D, reminded providers in a Jan. 2 bulletin that Medicare plans to implement Phase 2 denial edits on Monday, Jan. 6.

Once the edits take effect, contractors will verify that the ordering/referring physician or healthcare provider on the claim is in the Physician Enrollment, Chain and Ownership System (PECOS), and is eligible to order/refer in Medicare. Ordering/referring physicians must be enrolled in PECOS or the billing provider will not be paid for items and services that physicians prescribed.

Contractors will continue to process claims for which the ordering/referring physician or healthcare provider is enrolled in PECOS but is not of the correct type or specialty to order/refer. If the physician is not enrolled in PECOS, or if the name on the claim does not match the name in the system, suppliers will receive an N544 alert, according to the bulletin.

The N544 alert will say: Although this was paid, you have billed with an ordering/referring provider that does not match our system record. Unless corrected, this will not be paid in the future.

Previously, CMS said the PECOS edits would start May 1, 2013, but the rollout was delayed due to technical glitches.