Is Your Doctor Enrolled in Medicare? PECOS and Ordering/Referring Status Explained

What Medicare enrollment is

Having an NPI does not make a clinician part of Medicare. To bill Medicare, a clinician enrolls through PECOS, the Provider Enrollment, Chain and Ownership System. CMS's provider enrollment page calls PECOS the Medicare enrollment system and points physicians, practitioners, suppliers and institutional organizations to it both to become a Medicare provider and to revalidate, that is, renew, their enrollment.

CMS publishes enrollment data: the Medicare Fee-For-Service Public Provider Enrollment dataset lists providers with an approved Medicare enrollment, and the Order and Referring dataset lists clinicians eligible to order and refer. Both describe enrollment in Original Medicare (fee-for-service).

Enrolled, opted out or not enrolled

Enrolled

An enrolled clinician can bill Medicare for covered services. Enrollment alone does not say how they bill: Medicare.gov's assignment page explains that a provider may accept assignment, charging you only the deductible and coinsurance, or be non-participating and in many cases charge up to 15% above the Medicare-approved amount. Our assignment guide covers the details.

Opted out

Medicare.gov's assignment page says that doctors who do not want to work with the Medicare program may opt out, that Medicare does not pay for items or services from them except in emergencies, and that providers opt out for at least 2 years. You may need to pay under a private contract. CMS publishes a list of opt-out affidavits.

Not enrolled

Some clinicians have an NPI but no Medicare enrollment, for example because they do not see Medicare patients or have not enrolled yet. If you have Original Medicare and a clinician is not enrolled, ask the office how your visit would be billed before you go.

Ordering and referring: why it matters for tests and equipment

Some Medicare services are ordered by one clinician and provided by another: a lab test is ordered by your doctor and run by a laboratory, a wheelchair is prescribed by your doctor and supplied by a medical equipment company. For these, Medicare checks the ordering clinician too.

The regulation at 42 CFR 424.507 sets the conditions: for Medicare to pay for ordered imaging, clinical laboratory services and durable medical equipment, prosthetics, orthotics and supplies, the claim must name the physician or eligible professional who ordered them by legal name and NPI, and that clinician must be enrolled in Medicare in an approved status or have validly opted out. Home health services have similar rules.

CMS's ordering and certifying page explains who can qualify: a clinician with an individual NPI, enrolled in an approved or opt-out status, and of an eligible type. The eligible types include physicians (MD and DO), dentists, podiatrists, optometrists (for certain items only), physician assistants, nurse practitioners, clinical nurse specialists, clinical psychologists, certified nurse midwives, clinical social workers, marriage and family therapists, mental health counselors, and interns, residents and fellows. Organizational NPIs cannot order. A clinician who does not want to bill Medicare can still order by opting out or enrolling only to order and certify.

What this means for you

If a clinician who is not eligible orders your lab work, imaging, equipment or home health care, Medicare may deny the claim from the lab or supplier. If you are about to get ordered services, especially medical equipment, it is reasonable to ask the ordering office whether it is enrolled in Medicare or eligible to order.

Revalidation and deactivation

Enrollment has to be renewed. CMS's revalidation page says that, in general, providers and suppliers revalidate every five years, and medical equipment suppliers every three years, and that CMS can also request off-cycle revalidations. Failing to revalidate on time can lead to a hold on Medicare payments or deactivation of Medicare billing privileges, and Medicare does not pay for services during a period of deactivation. The grounds for deactivating billing privileges are set out in 42 CFR 424.540.

Medicare deactivation is different from NPI deactivation in NPPES, which is covered in our deactivated NPI guide. A clinician can have an active NPI and an inactive Medicare enrollment.

How enrollment appears on T-MedInfo profiles

When a clinician appears in the CMS enrollment dataset, the profile shows an "Enrolled in Medicare (PECOS)" card, which explains that PECOS is the CMS system clinicians use to enroll so they can bill Medicare or order services for people with Medicare. When the clinician appears in the Order and Referring dataset, a "Can order Medicare-covered services" card lists what CMS says they are eligible to order or refer, such as clinical laboratory and imaging services, durable medical equipment or home health services.

Next to both cards we state what they do not show: enrollment does not tell you whether the clinician accepts assignment, is in your plan's network or is taking new patients, and eligibility to order does not mean the clinician provides those services directly. The data come from CMS releases we have loaded, so a recent change may not appear yet; our methodology page shows which release is loaded.

If there is no enrollment card, the clinician was not in the CMS file we loaded. That can mean they are not enrolled, have opted out, or enrolled after that release.

Questions to ask

• Are you enrolled in Medicare, and do you accept assignment?
• If you order tests or equipment for me, will Medicare accept your order?
• Which lab, imaging center or equipment supplier do you use, and do they bill Medicare?

For questions about a specific claim, call 1-800-MEDICARE (1-800-633-4227).