On November 26, 2010, CMS announced that Medicare contractors will not implement (on January 3, 2011) system wide edits that would automatically deny certain part B billed items and services requiring ordering / referring providers, when the ordering/ referring provider is not listed on the claim, and/or not of a profession that is permitted to refer/ order, or does not have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS). Learn more
The Centers for Medicare and Medicaid Services (CMS) plans to implement system wide edits (in two phases) that would enable the Medicare Administrative Contractors (MACs) and Medicare carriers to automatically deny claims when the ordering or referring provider is not eligible under the Medicare program to order or refer and is not enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS). These new guidelines are delineated in Change Requests 6417 and 6421.
In the Medicare program, ordering or referring providers must indicate their names and National Provider Identifiers (NPIs) on their claims and must be listed in PECOS or the Medicare carrier or Part B MAC claims systems. Under the Medicare program, the providers who are eligible to order or refer are:
Phase 1 (effective from October 5, 2009 – January 2, 2011)
If an ordering or referring provider submits a claim during this phase, Medicare will verify whether he or she has privileges to refer or order under the Medicare program and is listed in PECOS. If the provider is not entered in PECOS, the Medicare contractor will search its claims system to determine if the provider is listed there. If the provider is not listed there, the Medicare contractor will process the claim and send a notification via the Remittance Advice (RA) informing the provider of this discrepancy. Consequently, if the provider in question is in PECOS but does not have a specialty or type that is eligible to order or refer, the Medicare contractor will process the claim and send a warning notification to the provider via the RA.
Phase 2 (effective from January 3, 2011)
If the claim originates from a referring or ordering provider who is not listed on the claim, the Part B MAC or carrier will automatically reject it. If the provider is listed on the claim but is not in PECOS, the Medicare contractor will check if he or she is in the Medicare claims system and will reject the claim if he or she isn’t listed there. If the ordering provider is in PECOS or in the claims systems but is not eligible to order or refer under the Medicare program, the claim will also be rejected.
What you need to do to prevent rejections when you order or refer under the Medicare program?
The CMS urges providers who have not updated their enrollment records since November 2003 to do so now. If you fall under this category and you haven’t made any changes to your enrollment data (such as changes in practice location etc.) you will need to submit an initial enrollment application, which will establish a current enrollment record in PECOS.
If you’re unsure about the last time you updated your enrollment record, you can check a report that CMS just released which contains the first and last names of providers who are eligible to order or refer in the Medicare program and who have enrollment records in PECOS. If your name is not on this list, we encourage you to follow up with your Medicare contractor and / or submit an enrollment application.
Please contact Healthpolicy@entnet.org if you have questions.
Updated on December 7, 2010
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