In order to submit a claim for Medicare services, a provider not only needs an NPI (National Provider Identifier), but must also be enrolled in Provider Enrollment, Chain, and Ownership System (PECOS). This applies to physicians, physician assistants, nurse practitioners, certified clinical nurse specialists, clinical psychologists, certified nurse midwives, and clinical social workers. Although there are a number of overlapping variables, the application process for a provider to be entered into the PECOS system, to be eligible to bill Centers for Medicare and Medicaid Services (CMS) for health care services, is independent of the NPI application process through National Plan and Provider Enumeration System (NPPES).
Like the NPPES application, the PECOS application asks providers to report their name, credentialing degree, gender, date of birth, birth location, social security number, business tax identification number, business address, business phone, license number, and state where the license was issued. PECOS asks physicians to provide one primary and up to two secondary specialty codes using a taxonomy that is different than that used in NPPES (Centers for Medicare & Medicaid Services, 2008). Many, but not all, of the specialty codes in NPPES can be linked to specialty codes in PECOS, but there are a few examples where the same NPPES specialty maps to more than one PECOS category, or where there is a PECOS category without any corresponding specialty codes in NPPES. PECOS also gathers more detailed information than NPPES on the financial arrangement between an individual provider and a practice group or organization, as well as a number of other details about business ownership and history of adverse outcomes with malpractice claims. Prior to entering a provider into the PECOS system, CMS employs a similar approach as is used in NPPES to verify a social security number and that the provider’s address is valid, but not whether the provider actually works at that address. For PECOS, CMS also confirms that the reported NPI is consistent with what is recorded in NPPES and requires providers to submit a copy of their license, which CMS attempts to verify by using online tools from their states’ medical board Web sites. CMS also confirms that providers are potentially eligible to bill Medicare, by checking their inclusion on the Office of Inspector General’s Excluded Provider Listing. As is the case with NPPES, CMS does not attempt to verify in PECOS the provider’s self-reported specialty.