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What is PECOS and How to Verify a Provider

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PECOS plays a critical role in facilitating communication and data accuracy between providers and CMS. This database powers several datasets indicating a provider’s status and CMS standing.

In this post, we provide a quick overview of the PECOS portal and the related datasets that help you answer important eligibility questions about providers in your networks.

What is PECOS?

PECOS stands for Provider, Enrollment, Chain, and Ownership System. It is the online Medicare enrollment management system that allows individuals and entities to enroll as Medicare providers or suppliers. This system also allows you to renew your enrollment, withdraw from the Medicare program, keep your information up to date, report any changes to your enrollment record, and electronically sign and submit all your information. CMS developed PECOS as a result of the Patient Protection and Affordable Care Act.

The PECOS system is managed and maintained by the Centers for Medicare & Medicaid Services (CMS). The PECOS applications are processed electronically, allowing for an efficient and data-protected process.

Who must register in PECOS?

  • Physicians and Specialists
  • Registered Nurses
  • Physician Assistants
  • Certified Clinical Nurse Specialists
  • Nurse Practitioners
  • Clinical Psychologists
  • Certified Nurse-Midwives
  • Clinical Social Workers
  • Physicians employed by the Department of Veterans Affairs, the Public Health Service, or the Department of Defense/Tricare (must use CMS FORM 855O)

What will happen if a provider doesn’t register in PECOS?

Any claims for items or services that a provider has prescribed will be denied if they are not in the PECOS system. This applies to Medicare claims only. Not having current and active enrollment with CMS will make it difficult for patients to receive the items they need and will prevent or delay claims processing.

Can a provider’s PECOS status change over time?

Yes, a provider’s status can change over time. Providers are required to validate their information again upon renewal. If a provider misses their renewal date or their information changes and supporting documentation is not provided, participation in the Medicare program will no longer be active. A provider’s status with CMS can also be affected by appearing on the Preclusion List or an exclusion source.

What is the role of Medicare Administrative Contractors?

Medicare Administrative Contractors manage Medicare operations for provider enrollment. They are assigned by state or jurisdiction. They can answer enrollment questions and process enrollment applications.

How to Search for a Provider using PECOS

The PECOS system is a database of providers who have registered with CMS. A National Provider Identifier (NPI) is necessary to register in PECOS. Use that identifier to search for the provider in the database.

If you don’t know the provider’s NPI number, you can search for their information in the NPI registry. To quickly screen a provider’s NPI and get additional insight into the provider, use our free NPI Lookup tool.

How to Verify if a Provider is Enrolled in Medicare

To find a provider that is enrolled in Medicare, you can search directly through the CMS system. You can also use the Physician Compare Tool provided by Medicare. A provider is required to enroll in the PECOS system and keep their information accurate to continue practicing within the Medicare program.

The the PECOS database is updated on a weekly basis. Confirm the enrolled status of providers via the Medical Provider and Supplier file. It is also important to monitor providers’ NPI status and the Preclusion List.

What is Medicare Opt-Out?

If a physician or provider decides to opt-out of the Medicare program, they must submit an affidavit to the Centers for Medicare and Medicaid Services (CMS). Information on these providers is published through the Provider Enrollment, Chain, and Ownership System (PECOS) from CMS and is updated monthly.

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