Medicare: New Regulation May Impact Eligibility Verification

Medicare: New Regulation May Impact Eligibility Verification

Medicare: New Regulation May Impact Eligibility Verification

A new CMS regulation effective April 1, 2019, will require Medicare Part A providers checking beneficiary eligibility to have a registered a valid National Provider Identifier (NPI) in the Medicare Provider Enrollment and Chain/Ownership System (PECOS) database.


When providers submit a Medicare HIQA/HIQH search request for beneficiary eligibility, the NPI will now be verified against information in the PECOS database. The Common Working File (CWF) will reject eligibility requests when the NPI is either not present or is not active in PECOS.

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CMS suggests providers review the PECOS status for any NPIs your organization uses to check eligibility. If your NPIs are not registered in PECOS, you will not be able to query eligibility after April 1, 2019.