Expect Further Part B Claims Editing Process Scrutiny
October 19th, 2009
Physicians, non-physician practioners (NPPs), and other Part B providers and suppliers submitting claims to carriers or Part B Medicare Administrative Contractors (B/MACs) for ordered or referred items or services can expect further scrutiny during the claims editing process.
Beginning Oct. 5, carriers and B/MACs expanded claims editing to include validation of the ordering/referring provider’s national provider identifier (NPI) and name reported on the claim against Medicare’s provider enrollment records.
Implementation phases
During phase 1 (Oct. 5 through Jan. 3, 2010), ordering/referring providers will receive a warning message on the remittance advice if their provider information is:
- not in the Provider Enrollment, Chain and Ownership System (PECOS) and not in the claims system, or
- in PECOS or the claims system but is not of the specialty to order or refer.
During phase 2 (Jan. 4, 2010 and thereafter), the service will be rejected (not processed) if their provider information is:
- not in PECOS and not in the claims system, or
- in PECOS or the claims system but is not of the specialty to order or refer.
Providers who are eligible to order/refer are:
- Doctor of medicine or osteopathy
- Dental medicine
- Dental surgery
- Podiatric medicine
- Optometry
- Chiropractic medicine
- Physician assistant
- Certified clinical nurse specialist
- Nurse practitioner
- Clinical psychologist
- Certified nurse midwife
-
Clinical social worker
Tip: For paper claims, be sure not to use periods or commas within the name of the ordering/referring provider. Hyphenated names are allowed.
The Centers for Medicare & Medicaid Services (CMS) issued MLN Matters article MM6417 to relay this information to providers.
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