C-14-121 Physician/NPP PECOS Verification


👤 RESPONSIBLE POSITION  |  ROLE

Medical Records Specialist

🎯 PURPOSE

The PROCESS PECOS VERIFICATION task will generate if Non-PECOS Physician or Non-Physician Practitioner (NPP) is selected on a Plan of Care, Verbal Order, or Client Referral. The task generates to workflow for the Medical Records Specialist responsible position.

This task is a showstopper for scheduling; it is important these are processed timely to avoid scheduling delays.

🔄 PROCESS

  1. Within HCHB Workflow, open the PHYSICIAN PECOS VERIFICATION task.
  2. First, review the names of the physicians to identify which physicians are listed as “NOT VERIFIED” under the Enrollment Status Column.

    1. If the physican named “ZZZTemporary” is listed as “NOT VERIFIED” but all other physicians listed have a “VERIFIED” status, no further steps are needed and the task can be stage-completed.

    2. HOWEVER: If any physician listed (other than “ZZZTemporary”) has a status other than “VERFIED”, such as “NOT VERIFIED”, continue following this process.

  3. Within the task, select View/Update Physician PECOS Status. A pop-up window will open.            

  4. Type physician name in search field. Review Enrollment Status:

  5. If there is a Legal Name Mismatch Status (this is likely due to a name change or a typo), select Set Physician Name to PECOS Legal Name to update MD in database:

  6. If Enrollment Status indicates NOT VERIFIED and there is no information listed, use Link to CMS PECOS Physician List to cross reference with CMS PECOS verification website (data.cms.gov). Selecting the link will open the web browser to the website:

  7. On the CMS website, scroll down and select Order and Referring.


  8. Select View Data.

  9. Enter the physician/NPP's NPI or last name and search. If PECOS is verified for home health agencies, there should be a Y under the HHA column. If this is the case, connect with the Medical Records Supervisor to determine next steps.

  10.  If the physician/NPP is not PECOS verified (with a N under the HHA column) as in the example below, determine the client’s payer by looking at the task as listed in your HCHB workflow.

    1. If the payer listed is “VA-OPTUM CCN – P – EPISODIC”, you may proceed to stage-complete the task, as PECOS verification is not required for this payer.

    2. If the payer listed is a MDCR/MDCR Advantage plan, the provider MUST be PECOS Verified.

If provider is NOT VERIFIED, then follow up must occur to determine if provider is correct or if an additional PECOS verified provider can sign orders. Coordinate with the Medical Records Supervisor for guidance on next steps and do not stage complete until the situation is resolved or directed to do so.

  1. Once all issues are resolved and you are cleared to proceed, stage complete the task by selecting Stage Completed.

  2. In cases that we are leaving a non-PECOS provider in the chart after following the steps above, a pop-up window like in the example below will open. Select Yes. This will leave the provider as Not Verified.


📅 Effective: 11.04.2024 | 🛠️ Revised: 05.27.2026 |  ✅ Approved: JFJ

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