3 Days left! 50% off + FREE Books on select certification training ends 8/31 |  Save Now

Expect Further Part B Claims Editing Process Scrutiny

  • By
  • In CMS
  • October 19, 2009
  • Comments Off on Expect Further Part B Claims Editing Process Scrutiny

Physicians, non-physician practioners (NPPs), and other Part B providers and suppliers submitting claims to carriers or Part B Medicare Administrative Contractors (B/MACs) for ordered or referred items or services can expect further scrutiny during the claims editing process.

Beginning Oct. 5, carriers and B/MACs expanded claims editing to include validation of the ordering/referring provider’s national provider identifier (NPI) and name reported on the claim against Medicare’s provider enrollment records.

Implementation phases

During phase 1 (Oct. 5 through Jan. 3, 2010), ordering/referring providers will receive a warning message on the remittance advice if their provider information is:

  • not in the Provider Enrollment, Chain and Ownership System (PECOS) and not in the claims system, or
  • in PECOS or the claims system but is not of the specialty to order or refer.

During phase 2 (Jan. 4, 2010 and thereafter), the service will be rejected (not processed) if their provider information is:

  • not in PECOS and not in the claims system, or
  • in PECOS or the claims system but is not of the specialty to order or refer.

Providers who are eligible to order/refer are:

  • Doctor of medicine or osteopathy
  • Dental medicine
  • Dental surgery
  • Podiatric medicine
  • Optometry
  • Chiropractic medicine
  • Physician assistant
  • Certified clinical nurse specialist
  • Nurse practitioner
  • Clinical psychologist
  • Certified nurse midwife
  • Clinical social worker

Tip: For paper claims, be sure not to use periods or commas within the name of the ordering/referring provider. Hyphenated names are allowed.

The Centers for Medicare & Medicaid Services (CMS) issued MLN Matters article MM6417 to relay this information to providers.

CPB : Online Medical Billing Course

admin aapc
Latest posts by admin aapc (see all)

No Responses to “Expect Further Part B Claims Editing Process Scrutiny”

  1. pat schneider says:

    When i first started think of going back to school it first started in 1984, with hey i never completed high school.I then went after the idea of getting my depiloment.Well almost ten yrs later i finally got it,but i got it in 1990.Then well almost 20 yrs later i got sick and i started wondering what all the numbers were for, and what they all meant! however i was a foster parnet,in 1990 yeap started in 1986, lasted til 1996, had lots of babys drug babys lots of doctors lots of different hospitals, lots more of those nuumber codes, and inbetween my younger daughter became pharmacy tech, and now 2009 my first daughter is seek to become a nurse.I now am more eager to become a medical billing and coding mom, hoping to get my ba before i turn 90 ahah.Lots a work a head and move at a faster pace then the younger ones.

  2. Cory Roths says:

    I have a question. I work for a optometrist and we are debating this issue. If the doctor has a patient come in for routine exam and at the end of the exam he notices a change in pressures etc., then he decides to refer this patient to a cataract specialist based on his finding. Can the doctor keep this visit as routine without any repercussions from insurance companies or does he have to change it to medical? I’m thinking he needs to change the dx but everyone here is telling me that he can keep it routine and still refer the patient out to a surgeon. Will you help me with this please?