What You Need to Know about Enrolling and Ordering/Referring in the Medicare Program

On May 5, 2010, the Centers for Medicare and Medicaid Services (CMS) released the interim final rule, “Medicare and Medicaid Program; Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements,” which will implement provisions included in the Patient Protection and Affordable Care Act (PPACA). The effective date is July 6, 2010 and will apply to fee for service (FFS), Home Health and Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) claims.

CMS has not finalized the rule and is waiting to receive comments from interested parties. The Academy as well as other medical societies sent a comment letter to CMS addressing our concerns about the grave challenges that the July 6, 2010 compliance date would pose to physicians. As a result, CMS has indicated that the Medicare contractors will not automatically reject claims submitted by referring or ordering providers who do not have enrollment records (by July 6, 2010) in the Provider Enrollment, Chain and Ownership System (PECOS). The rule requires that:

  • Any provider who qualifies for a National Provider Identifier (NPI) include his or her NPI on all Medicare and Medicaid enrollment applications and on all claims he or she submits to these programs
  • Any eligible provider who orders and refers Medicare beneficiaries for services or items in Medicare be enrolled in it
  • All Medicare providers, physicians and other suppliers provide documentation on the referrals they make to programs at “high risk of waste, abuse, to include durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), home health services, and other items or services specified by the Secretary.”

What Do You Need to Do?

  • If you enrolled in Medicare before getting an NPI, you will need to obtain an NPI and update your enrollment record in the Provider, Enrollment, Chain, and Ownership System (PECOS) which is a national repository of enrolled Medicare FFS providers and suppliers (except DMEPOS suppliers, who will be added to PECOS later in 2010). You can update your enrollment records in PECOS by completing the appropriate enrollment application form or accessing the PECOS on-line. (Before accessing the internet based PECOS, you will need to obtain a National Plan and Provider Enumeration System (NPPES) user ID and password. You may read CMS’ guide to getting started with internet based PECOS here).
  • Providers will no longer be able to submit surrogate Unique Physician Identification Numbers (UPINs) on any Medicare claims because they no longer exist. CMS initially created surrogate UPINs to temporarily identify providers serving in the military, the Veteran Affairs, Public Health Services (including the Indian Health Service), interns, residents, and fellows, and retired physicians without established enrollment records in PECOS. The regulation instructs that when residents or interns order or refer or perform services in the Medicare program, only the teaching physician should be identified in the claim as the ordering and/or referring provider.
  • Medicare requires that the treating physician or eligible non-physician practitioner (NPP) be identified by his or her legal name and NPI on claims. Failure to do so would result in the Medicare contractor rejecting his or her claims. Physicians or NPPs without enrollment records in PECOS would be given the same penalty.
  • Physicians who have been enrolled in Medicare for more than six years and never updated their enrollment records in PECOS need to do so by completing the appropriate enrollment paper application or completing the process on the internet version of PECOS.
  • Remember that you will need to keep and provide access to documentation on any written orders or requests for payment for durable medical equipment, certifications for home health services, or referrals for other items or services ordered in the Medicare program for seven years. The penalty for not adhering to this would be a revocation of your Medicare enrollment for up to one year. 
  • Physicians who have validly opted out of Medicare will not need to complete a Medicare enrollment application. If you have questions, contact Healthpolicy@entnet.org

Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and Referring and Documentation Requirements; and Changes in Provider Agreements [CMS-600-IFC]. Accessed at http://edocket.access.gpo.gov/2010/2010-10505.htm on June 16, 2010
Medicare Program; Payment Policies under the Physician Fee Schedule and other Revisions to Part B for CY2010. Accessed at http://www.federalregister.gov/OFRUpload/OFRData/2009-26502_PI.pdf on November 3, 2009


Updated July 8, 2010

Posted June 17, 2010

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