MACs are ready for PECOS related claim denials!

CMS has received notification from the Medicare administrative contractors (MACs) that they are prepared to begin
denying home health claims when referring physicians are not listed by national provider identifier (NPI)
in CMS’ provider enrollment system (PECOS).   According to the announcement made in the November 6, 2013
MLN Matters article, this edit will begin on January 6, 2104.

Just for some perspective:

Palmetto (MAC for home health and hospice for 16 southern states) reported that about 40% of agencies
billing the MAC would have been hit with at least one denial in January or February if the edit were on.

CGS (MAC for 15 Midwestern and Eastern states and DC) reported that 3 or 4 agencies wound have seen at
least one denial from September 2012 to February 2013.

Both of the MACs based this analysis on claims with remark code N272-physician’s information is either
invalid or incomplete based on CMS’ ordering/referring file.

If you do not have a process in place to verify physician information, now is the time to get it done!

The full announcement can be found in the November 6, 2013 MLN matters.

If you have any questions or would like more information regarding QIRT, please contact us.

Until next time,

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