PECOS, or the Provider Enrollment, Chain, and Ownership System, is a centralized, web-based platform managed by the Centers for Medicare & Medicaid Services (CMS). It serves as the official database for all healthcare providers and suppliers who wish to participate in the Medicare program. Being PECOS enrolled signifies that a provider has successfully completed the rigorous application and screening process established by Medicare. This enrollment verifies a provider’s credentials, ownership, and compliance with federal standards before they can furnish services to Medicare beneficiaries.
What It Means to Be PECOS Enrolled
PECOS enrollment is a formal designation indicating that a provider or supplier has met all federal screening and quality standards necessary to participate in the Medicare program. This status is mandatory for entities that bill Medicare directly for services rendered and for certain practitioners who only order or refer services and equipment for beneficiaries. The requirement extends to a wide array of entities, including individual physicians, non-physician practitioners like nurse practitioners and physician assistants, and medical suppliers.
The governing regulation, specifically 42 CFR Part 424, Subpart P, outlines the requirements for establishing and maintaining Medicare billing privileges, which is managed through PECOS. This enrollment ensures the practitioner is an authorized provider type for Medicare purposes. Enrollment is a continuous obligation that requires providers to periodically revalidate their information and report any changes, such as new practice locations or ownership, to CMS. Failure to maintain accurate and up-to-date information can lead to a loss of enrollment status.
Mandatory Role in Medicare Billing and Payment
The PECOS enrollment status serves as the gatekeeper for nearly all financial transactions within the Medicare ecosystem. If a provider or supplier is not actively enrolled, Medicare will reject any claims submitted by that provider for services they rendered. This is the most direct financial consequence of non-enrollment. The system ensures that taxpayer dollars only go to verified, compliant healthcare entities.
The consequences of non-enrollment extend beyond the non-enrolled provider’s own claims, crucially impacting other entities. Medicare utilizes PECOS to verify the eligibility of any ordering or referring provider listed on a claim submitted by a separate party, such as a laboratory, durable medical equipment supplier, or hospital. For example, if a physician orders a diagnostic test but is not PECOS enrolled, the laboratory or imaging center that performs the test will have their claim for payment denied by Medicare.
This stringent check is a primary mechanism CMS uses to maintain program integrity and combat fraud, waste, and abuse. The system cross-references the National Provider Identifier (NPI) on the claim against the PECOS database to confirm the ordering practitioner is authorized and currently enrolled. A claim submitted with a non-PECOS enrolled ordering or referring provider will typically be denied with specific remark codes, leading to significant administrative and financial burden for the billing entity.
How to Verify Enrollment Status
Verifying a PECOS enrollment status depends on whether a provider is checking their own record or if an administrator, patient, or business partner is checking another provider’s status.
Verifying Your Own Status
Providers can check their own status by logging into the Internet-based PECOS portal using their Identity & Access Management (I&A) credentials. This secure login allows them to view their current enrollment information, status, and specialty type as recorded by CMS. If a provider has multiple National Provider Identifier (NPI) accounts, they may need to check each one to confirm a PECOS record exists.
Verifying Another Provider’s Status
For administrators, business partners, or beneficiaries looking to verify the status of another provider, CMS makes this information publicly available through specific tools and data files. One method is to search the Medicare.gov Physician Compare website, which draws its information from PECOS. Another, more direct method, is to utilize the downloadable data files published by CMS, which list the NPIs and names of physicians and non-physician practitioners who are actively enrolled in PECOS for ordering and referring purposes. These public lists are updated regularly to provide current enrollment verification data.