CMS extends cease fire on referring/ordering edits

This posting is in follow-up to "CMS issues a temporary cease fire," a posting from last December. I am happy to announce that the Centers for Medicare and Medicaid Services (CMS) has extended the delay in implementation of new rules that give Medicare the authority to reject claims for services or supplies when the ordering physician or health care professional is not enrolled in the Medicare Provider Enrollment, Chain, and Ownership System, or PECOS. The agency is delaying implementation of the new policy until Jan. 3, 2011.

As of this new date, Medicare will reject claims if the ordering or referring provider does not have an active enrollment record in Medicare’s PECOS or is not of the correct type/specialty to order or refer services to Medicare beneficiaries. Currently, physicians who submit electronic claims receive a warning message if the ordering/referring provider is not in PECOS or is in PECOS but is not the correct type/specialty to order or refer services. Despite the warning, the claims hitting these edits will continue to process. However, such claims will be rejected starting Jan. 3, 2011.

CMS recently posted on its web site the Ordering/Referring Report, a list of physician and non-physician providers who are eligible to order or refer items or services for Medicare beneficiaries because they have an active enrollment record in PECOS and are of a right specialty or type to order or refer items or services. Physicians and non-physician providers are encouraged to check this list to make sure that they are on it. If not, they need to submit an 855I Provider Enrollment form to their local Medicare contractor and update their enrollment information to have an active enrollment record. This can be done through the on-line, Internet-based PECOS or by mailing a paper application to the local Medicare contractor.

Please see MLN (Medicare Learning Network) Matters article MM6417 for additional information on this initiative as well as for a complete list of types of practitioners who can order or refer Medicare beneficiaries for items or services.

Posted on Mar 17, 2010 by Kent Moore