Wednesday, December 4, 2013

Home Health Ordering/Referring Edits Effective, January 6, 2014

The Centers for Medicare & Medicaid Services (CMS) issued a revision to the Medicare Learning Network (MLN) Matters® article SE1305, which is available in this bulletin, announcing that effective, January 6, 2014, the Fiscal Intermediary Standard System (FISS) will implement the ordering/referring physician edits.  Billing transactions and adjustments for home health services with the “FROM” date of service on or after January 6, 2014, will be denied if the attending physician National Provider Identifier (NPI) and name do not exactly match the NPI and name that is on the Provider Enrollment, Chain and Ownership System (PECOS) file. 

NOTE: The edits will compare the first four letters of the last name.  When submitting home health billing transactions and adjustments, include the first and last name as it appears on the ordering and referring file found at on the CMS website.  Middle names (initials) and suffixes (such as MD, RPNA, etc.) should not be listed in the ordering/referring fields.

Please review the following to learn how Requests for Anticipated Payment (RAPs), final claims, and adjustments will process in the Fiscal Intermediary Standard System (FISS) and how to prevent denials for this reason. 

Requests for Anticipated Payment (RAPs)
If the attending physician NPI and name submitted on the RAP does not match the NPI and name in PECOS, the RAP will process with zero payment.  If this occurs, you may either:
  • Cancel the RAP and resubmit a new RAP with the correct attending physician NPI and name to receive the RAP payment; OR
  • Submit the final claim with the correct attending physician NPI and name to receive the full episode payment. 
Final Claims and Adjustments
Final claims and adjustments will deny when the “FROM” date is on or after January 6, 2014, AND:
  • The attending physician National Provider Identifier (NPI) is not found in the eligible attending physician file from PECOS; or
  • The attending physician NPI is found in the eligible attending physician file from PECOS but the name on the claim/adjustment does not match the name in the PECOS file; or
  • The specialty code is not a valid eligible code to order and refer.
Appeal Process
If the final claim or adjustment is denied, to receive Medicare payment, you must follow the appeal process by submitting a redetermination.  To avoid administrative costs that providers experience with filing an appeal, take action now to develop an internal process to prevent such denials. 

How to Prevent Denials
  • Review the “Ordering Referring File” to ensure the information that you submit exactlymatches the information as it appears in the file. 
  • Review your billing transaction before submitting to Medicare, to ensure there are no typos. 
Please note the following clarifications.
Medicare Learning Network (MLN) Matters® Articles
Obtained from:


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