decisionhealth Newsletters, Coder Pink Sheets - 2009 Issue 12 (December)
DME to be denied if ordering provider is not in PECOS
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Article Overview
This article covers a CMS policy update affecting claims for supplies and durable medical equipment when the ordering or referring provider is not properly reflected in PECOS. It is relevant to DME suppliers, physicians, billing staff, and practices that submit or support claims tied to ordering and referral requirements. The article focuses on the transition from warning notices to claim denials and highlights the operational impact of the enrollment file review process.
Why This Topic Matters
The policy change can directly affect whether claims are paid, so suppliers and practices need to understand the enrollment-file requirement and its timing. It is especially important for organizations that bill Medicare-related DME and supply claims and rely on ordering or referring providers.
What You Will Learn
- How a CMS enrollment database affects claims for supplies and durable medical equipment.
- Which types of providers and billing workflows may be impacted by the policy change.
- Why supplier claim processing may change from notice-based handling to denial-based handling.
- What role PECOS plays in CMS verification of ordering or referring providers.
Who Should Read This
- DME suppliers
- Medical billing specialists
- Practice managers
- Physician offices
- Medicare billing staff
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