The Centers for Medicare & Medicaid Services (CMS) recently implemented new editing requirements to ensure that ordering/referring physicians and non-physician practitioners (NPPs) reported on claims are eligible to order/refer services for Medicare patients. The edits in place verify that the provider’s specialty is one listed as a specialty that can order/refer services. This verification process also ensures that the provider is correctly enrolled in the Medicare program in one of two systems: the Medicare Provider Enrollment, Chain and Ownership System (PECOS) or Palmetto GBA’s claims processing system. These verification edits will be implemented in two phases.
Phase 1
For claims processed October 5, 2009, through April 4, 2010, if the ordering/referring provider information submitted on the claim does not meet the CMS specialty requirements or is not present in either system noted above, the billing provider’s claims will still be processed as usual. The remittance advice (RA) sent to the billing provider, however, will include a message code informing them that the name (N264) or provider identifier (N265) of the ordering/referring provider reported on their claim was missing, incomplete or invalid.
As a proactive measure, Palmetto GBA is contacting providers who are currently not enrolled in PECOS and asking that they update their enrollment information. If you receive remark codes N264 or N265 on a remittance notice, we suggest that you contact the ordering/referring provider for that service and ask him or her to update their enrollment with Palmetto GBA.
Phase 2
Beginning April 5, 2010, claims submitted with ordering/referring provider NPIs that do not meet CMS specialty requirements or that are not enrolled in PECOS or Palmetto GBA’s claims processing system will be ‘returned as unprocessable’ (rejected) with remark codes N264 or N265. These claims do not have appeal rights and must be corrected and resubmitted.
For a complete listing of provider specialties that can order/refer services for Medicare patients and additional details on the new editing process, please refer to MLN Matters article MM6417 (PDF, 78 KB) (‘Expansion of the Current Scope of Editing for Ordering/Referring Providers for claims processed by Medicare Carriers and Part B Medicare Administrative Contractors (MACs’).
The proactive efforts of Palmetto GBA and the provider community prior to April 5, 2010, will significantly help reduce the number of claim rejections.