HH-Claim-Denials

Home Health PECOS Edits on the Horizon

HEALTHCAREfirst Offers Free PECOS Verification Tool.

Home Health Claim Denials for Services Referred by Non-Enrolled Physicians are Expected to Begin Soon.  CMS has said they will give providers at least 60 days’ notice prior to turning the edits on, but agencies should verify now that physicians they work with are enrolled.

HEALTHCAREfirst agencies can run reports within the software to verify if physicians are enrolled. Agencies not using HEALTHCAREfirst software can use our PECOS lookup tool  to verify your referring physician against the most recent CMS public-use file.

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.

Once Edits are activated, reason Code 37236 will display when:

  • The statement “From” date on the claim is on or after the date the phase 2 edits are turned on.
  • 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

Once Edits are activated, reason Code 37237 will display when:

  • The statement “From” date on the claim is on or after the date the phase 2 edits are turned on.
  • 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

HEALTHCAREfirst will send out additional details once a timeline for the edits has been determined.

June 26, 2012

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