Expect Denials For Claims That Don’t Meet Ordering/Referring Edits ‘Soon’, CMS Says
Posted on 12. Aug, 2012 by dchandhok in Provider News
If a new CMS news release is any indication, the agency might soon follow through on its longstanding threat to deny claims that fail the ordering/referring provider edits. Although CMS has had this on the horizon for several years now, the agency has never actually formalized a date when the denials would start.
However, a July 26 news release indicates that CMS “will soon begin denying Part B, DME, and Part A HHA claims that fail the ordering/referring provider edits.” Although CMS has still not set a date, it warns providers that once it does, it will only offer a 60-day notice before the edits are turned on, so you should prepare now.
Background: Currently, if you submit claims for services or items ordered/referred and the ordering or referring physician’s information is not in the MAC’s claims system or in PECOS, your practice will get an informational message letting you know that the practitioner’s information is missing from the system.
Part B reminder: In Part B, MACs will take two steps before denying your claims. First, the carrier will check whether the ordering/referring physician is in PECOS. If not, the MAC will try to find the provider in the Claims Processing System Master Provider File. If the physician is in neither system, the claim will be rejected once the edits are turned on.
Resource: For more on the edits, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1221.pdf.
If a new CMS news release is any indication, the agency might soon follow through on its longstanding threat to deny claims that fail the ordering/referring provider edits. Although CMS has had this on the horizon for several years now, the agency has never actually formalized a date
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