CMS Announces Delay In
Edit for the Ordering/Referring Provider on Medicare Claims
The
Centers for Medicare & Medicaid Services (CMS) has delayed the
implementation of Phase 2 of CMS CR 6421 for Part B providers until January 3,
2011.
Originally radiology
providers could have faced denials of claims starting April 1st if
the ordering physician/healthcare provider was not in the Medicare database. We
have reprinted below the majority of the recent CMS advisory.
The delay in
implementing Phase 2 of these CRs will give physicians and non-physician
practitioners who order or refer items or services for Medicare beneficiaries
to other Medicare providers/suppliers sufficient time to enroll in Medicare or
take the action necessary to establish a current enrollment record in Medicare
prior to Phase 2 implementation.
As part of Phase 1 for
CR 6421, CEDI implemented warning errors/edits to be returned on the CEDI
GenResponse Report (GENRPT) if the referring/ordering provider submitted on the
claim was not enrolled in PECOS and/or not eligible to order or refer services.
Should a provider
receive one of these warning errors/edits on a claim, CEDI recommends the
following:
Contact the
Ordering/Referring Provider to verify their eligibility with PECOS.
Contact the Ordering/Referring Provider
to verify how their name is listed with their PECOS enrollment and ensure the
name submitted on the claim matches the PECOS record.
CMS has made available a
file that contains the National Provider Identifier (NPI) and the name (last
name, first name) of all physicians and non-physician practitioners who are of
a type/specialty that is eligible to order and refer in the Medicare program
and who have current enrollment records in Medicare (i.e., they have enrollment
records in PECOS that contain an NPI). This file is downloadable from the
Medicare provider/supplier enrollment Web
site www.cms.hhs.gov/MedicareProviderSupEnroll,
click on "Ordering Referring Report" on the
left-hand side. This .pdf file contains approximately 800,000 records. Due
to the large size of this .pdf file CEDI suggests you right click and select
"Save as" before attempting to open this file.
Verify the Type I (individual
physician's) NPI and name of the Ordering/Referring Provider is submitted on
the claim. If the Type II (physician's group) NPI and name is submitted, a
match will not be found on the PECOS file.
CMS
continues to urge physicians and non-physician practitioners who are enrolled
in Medicare but who have not updated their Medicare enrollment record since
November 2003 to update their enrollment record now. If these physicians
and non-physician practitioners have no changes to their enrollment data, they
need to submit an initial enrollment application which will establish a current
enrollment record in PECOS.
