November 2009 Newsletter
CMS Expands Editing for Ordering/Referring Providers
CMS is expanding claim editing to meet the Social Security Act requirements for ordering and referring providers. The new claim edits will verify that the ordering/referring provider on a claim is eligible to order/refer and is enrolled in Medicare. The claim editing expansion will be divided into two phases.
Claims that are the result of an order or a referral must contain the National Provider Identifier (NPI) and the name of the ordering/referring provider. All ordering/ referring providers must be enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) or in the Medicare carrier’s or Part B MAC’s claim system, and must be identified as a specialty that can order/refer.
Phase 1 (October 5, 2009-January 3, 2010):
PECOS will send the Multi-Carrier System (MCS) a national file of physicians who are of the specialty eligible to order or refer under the Medicare program. Nightly, MCS will receive a national PECOS file of the newly added or updated physician and non-physician practitioners.
When a claim is received, MCS will determine if the ordering/referring provider is required for the billed service.
- If the billed service requires an ordering/referring provider and the ordering/referring provider is not on the claim, the claim will not be paid.
- If the ordering/referring provider is on the claim, MCS will verify that the ordering/referring provider is on the national PECOS file.
- If the ordering/referring provider is not on the national PECOS file, MCS will search the MAC’s claims system next for the ordering/referring provider.
- If the ordering/referring provider is not on the national PECOS file and is not in the claims system, the claim will continue to process and the Part B provider will receive a warning message on the Remittance Advice.
- If the ordering/referring provider is in PECOS or the claims system, but is not of the specialty eligible to order or refer, the claim will continue to process and the Part B provider will receive a warning message on the Remittance Advice.
Phase 2 (January 4, 2010 and thereafter):
- If the billed service requires an ordering/referring provider and the ordering/referring provider is not on the claim, the claim will not be paid.
- If the ordering/referring provider is on the claim, MCS will verify that the ordering/referring provider is on the national PECOS file.
- If the ordering/referring provider is not on the national PECOS file, MCS will search the MAC’s claims system next for the ordering/referring provider.
- If the ordering/referring provider is not on the national PECOS file and is not in the claims system, the claim will not be paid and will be rejected.
- If the ordering/referring provider is in PECOS or the claims system but is not of the specialty to order or refer, the claim will not be paid and will be rejected.
The full article can be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R572OTN.pdf