CMS-Announcement

Home Health PECOS Edits Finally a Reality

HEALTHCAREfirst Provides Free Verification Tool.

Effective May 1, 2013, CMS is turning on edits that will deny Part B, DME, and Part A HHA claims that fail the ordering/referring provider edits.  CMS had previously announced last summer that they would give providers at least 60 days’ notice regarding the edit activations but were recommending agencies begin verifying physicians they work with are enrolled.

HEALTHCAREfirst agencies can run reports within the software to see which physicians are listed as enrolled. To get specific details on how to run reports and any verification processes that might be available within your specific product line, HEALTHCAREfirst clients can contact the support department.

HEALTHCAREfirst’s free PECOS lookup tool is available to all providers regardless of if they use our software or not, to verify a referring physician against the most recent CMS public-use file.  Claims that fail the edits will display the following reason codes:

Reason Code 37236 will display when:

  • The statement “From” date on the claim is on or after May 1, 2013.
  • The type of bill is ’32’ or ’33’
  • Covered charges or provider reimbursement is greater than zero but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claim is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from PECOS or the specialty code is not a valid eligible code

Reason Code 37237 will display when:

  • The statement “From” date on the claim is on or after May 1, 2013.
  • The type of bill is ’32’ or ’33’
  • The type of bill frequency code is ‘7’ or ‘F-P’
  • Covered charges or provider reimbursement is greater than zero but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claims is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from PECOS or the specialty code is not a valid eligible code

These edits are currently for Home Health providers only. For those not familiar with the Provider Enrollment, Chain and Ownership System (PECOS), physicians and others who are eligible to order and refer items or services need to establish their Medicare enrollment record and must be of a specialty that is eligible to order and refer. Enrollment applications must be processed in accordance with existing Medicare instructions. It is possible that it could take 45-60 days, sometimes longer, for Medicare enrollment contractors to process enrollment applications. All enrollment applications, including those submitted over the Web, require verification of the information reported.

Full details of the PECOS edits activation can be located here.

March 1, 2013

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