Resolving Denials for PECOS Errors

One of the top denials suppliers receive each month is for PECOS Edits. These edits ensure that the ordering or referring provider is enrolled in the Provider Enrollment, Chain, and Ownership System (PECOS) and the ordering or referring provider is eligible to order the DMEPOS

The ordering/referring provider name, entered in line item 17 and the NPI number that is entered in line item 17b, on the claim must match the information in PECOS.

  • During the claims process, Medicare will verify that the NPI is in PECOS and provider is eligible to order and refer
  • If the ordering/referring provider is not in PECOS, or is in PECOS but is not a valid specialty to order or refer, the claim will be denied
  • If the name submitted on the claim does not match the provider's name in PECOS, the claim will be denied

The remittance advice will display the following remark codes when claims are denied due to an error in the ordering physician's NPI:

N265-Missing/incomplete/invalid ordering provider primary identifier

N276-Missing/incomplete/invalid other payer referring provider identifier

Next Step in Resolving Denials

  • Verify that the ordering physician NPI is on the list of physicians and other non-physician practitioners enrolled in PECOS. Even if a provider has an individual NPI, it does not mean that their enrollment record is in PECOS and/or is active. Verification of enrollment in PECOS can be done by:
    • Checking the CMS ordering/referring provider downloadable report containing the NPI, first name, and last name of providers enrolled in PECOS.
      • Be sure the name and NPI entered for the ordering provider belong to a physician or non-physician practitioner. A group NPI cannot be used as an ordering NPI on a Medicare claim. In addition, be sure the qualifier in the electronic claim (2310A NM102 loop) is 1 (person). Organizations (qualifier 2) cannot order and refer.
  • Resubmit the claim with a valid ordering physician NPI registered in PECOS.

Please refer to the PECOS Edits page for more information on the CMS ordering/referring provider downloadable report and what information is included in the report.

Top Ordering/Referring Submission Errors

  • Supplier is interchanging the first and last name of the referring physician
  • Supplier submitting the organizational NPI of the referring physician
  • Nurse practitioners and interns not enrolled in Medicare are listed as the referring physician
  • The supplier submitted a last name that did not match PECOS
Last Updated Jun 26 , 2024