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If the application being reviewed has the specialty listed as Undefined Specialty that matches a current enrollable Medicare specialty, what steps am I taking?
Research documentation to see if the app needs to be sent to denial for review
If there is a matching description, an RFI can be sent to correct the specialty.
If I am looking up a provider’s license in SharePoint Quick links and it doesn’t work, what is another way to complete this task?
Specialty License Guide suggests using Health Guide USA to look for alternatives. A Google Search may also be used. If the link does not function submit a DCR to make the update. If the alternatives do not find the license, you may contact the provider. If this does not work, call the state certification board. Log any calls.
When reviewing the ADR for the reassignment, the Receiving Medicare ID or also known as the group PTAN, is missing. What steps can I take to establish what is needed or how to proceed?
Check for any Finalized Enrollments in PECOS, do this by searching for the EIN (group) or SSN (provider linked) and review OnBase for any B applications. We can call to verify the PTAN with the group, and if there is no response send an RFI.
When reviewing my application, the reassignment section lists an incorrect PTAN or PTAN with a typo. Am I required to RFI for them to update this?
An RFI is not required if the PTAN can be found through appropriate means like calling the provider or checking MCS and PECOS. Be sure to document how you found the information.
If the application is pending signatures an RFI is required. After the RFI for signatures is sent, signatures can be accepted how?
via fax, email, or uploaded to the application in PECOS. PEPSI doc page 97
Reassignment requires all PTAN to NPI combinations be selected when completing PECOS. If I have a Group where multiple group PTANs were added on the ADR, what feature can I use to narrow down results in the Linking area?
Click the checkbox for all NPIs associated with the Group PTAN(s). For larger lists, Group PTANs can be filtered using the Find field. Select the individual PTAN from the drop down next to its associated Group PTAN.
Accidents happen, what steps can I take if I accidentally tie the L&T and then realize that I needed to compete an RFI?
Email using the RFI in OnBase Email process in found in the PEPSI doc.
OPSIE! What steps can I take if I accidentally put an L&T “In Review” for a California L&T that is now in the wrong region?
Create a manual L&T for a not established record, to make the corrections then delete the incorrect one.
The provider’s application shows a prior deactivated enrollment in PECOS within the state that I am processing. What research do I need to complete to help continue to proceed with my application?
Find the cause of the deactivation through PECOS and prior applications. Reactivation with the requested effective date may apply based on the cause.
When reviewing my application, the DEA is listed but no copy of the certificate is attached. What is the proper way to complete my verification in this situation? How about if it was attached?
Send an RFI for a copy of the DEA - you can also review old applications for a copy as long as the copy of the DEA isn't expired
True or False- once you have submitted your app for review to ALA you can put your application in clock stoppage
False- Applications should not be placed into clock stoppage until you have received the email from ALA confirming that the application qualifies for clock stoppage. Be sure to print in all emails received from ALA for verification for the application.
If my application signature(s) say pending when I begin my review of the ADR, what date should I use to be able to send the RFI through PECOS since that certification date is missing?
Use the current date from Requesting Certification Statements in PEPSI.
If my application requires an RFI, how do I choose the correct method of instruction for this process?
The RFI in PECOS section of PEPSI has the basic rules for when an RFI goes through PECOS, or by email. However, Email should only be used when the information being requested cannot be completed through PECOS.
If my applicant may be telehealth/telemedicine, what areas or items do I review in the application process?
Page 63 of PEPSI.
True or False: An application can be put into clock stoppage once an RN ticket has been submitted on the PE Operations Page
False: Applications should not be placed into clock stoppage until you have received the email from EP confirming that the application qualifies for clock stoppage. Add the CS# to your tagline and print the email into your application for verification
According to the PE Policy document on the PE Operations page, how many days do you have to review and complete corrections for an application that has been MQA'd?
5 business days
The PE Representative shall correct any/all errors within 5 business days and notify their Production Team once completed. If corrections require additional development the PE Representative will notify the Team-EP and supervisor.
When ordering a site visit in PECOS, which piece of information is ALWAYS required to complete the order?
The days and hours of operation for the provider’s practice location must be entered so the site inspector can schedule the visit.
You ordered a site visit in PECOS for a 15-day requirement (Initial application). It is now day 16, and the site visit status still shows "sent to NSVC." What should you do?
Pend the application for delayed Site Visit and check back regularly for site visit to be completed
If my applicant may be telehealth/telemedicine, located in a different state than the enrollment, what state licensing does they need to hold?
The license matches the state they sit in.
If you send an approval letter before the enrollment crosses and the PTAN is not active in FISS, what risk does this create?
The provider may submit claims that reject, causing complaints and escalation, and the MAC may be out of CMS compliance for notification accuracy.
True or False: It is acceptable to send an approval letter as soon as PECOS status is set to “Approved,” even if the PTAN has not yet crossed to the claims system.
False. The provider cannot bill without the PTAN loaded in FISS/MCS, so the approval letter must not be sent until systems verify the update.
Which of the following is the primary reason letters get flagged in QA audits?
d) All the above – All are common and preventable by cross-verifying before sending.
Double check for typos and ensure People, places, and things are all in the right place.
Where do you find the official Noridian guidance for determining if a provider name with punctuation differences (e.g., periods vs. spaces) is acceptable for IRS matching?
PEPSI – “Legal Business Name and Punctuation in IRS Matching” section.
If you need to verify the signature requirements for a 855R when adding PTANs under the same group EIN, where do you check?
PEPSI → Reassignments section and the 855R Application Processing document.
If a provider sends you a SAM.gov registration and asks if it should be attached, where do you confirm whether SAM is required?
PEPSI → Supporting Document Requirements.