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 http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html 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

• Check the “Ordering Referring File” at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html to ensure that the physicians and non-physician practitioners from whom you accept orders and referrals have current Medicare enrollment records, and are of a type/specialty that is eligible to order or refer in the Medicare program.

• 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.

• HHAs should not use the NPPES web site at https://npiregistry.cms.hhs.gov/NPPESRegistry/NPIRegistryHome.do to verify the physician’s information

• HHAs should use the “Medicare Ordering and Referring File” at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html to verify the physician’s NPI, last name and first name reported on the home health billing transaction.  Once again, the attending physician NPI and name that you submit must exactly match the NPI and name that is on the PECOS file and displays in the “Medicare Ordering and Referring File.”

• The CGS Home Health & Hospice Customer Service Representatives cannot assist with physician enrollment issues, since we do not process their enrollment applications.  If it appears that your referring physician is not enrolled in PECOS, please ask the physician to contact his or her Medicare Administrative Contractor regarding the appropriate steps to follow.  Refer to the CMS interactive map at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html for Medicare contractor contact information. 

Medicare Learning Network (MLN) Matters® Articles

• SE1305 - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf
• MM6856 - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM6856.pdf  

Obtained from: http://cgsmedicare.com/hhh/pubs/mb_hhh/2013/12_2013/index.html#001