Phase 2 Enrollment Implementation Delayed

Ordering and referring physicians and nonphysician practitioners (NPPs) have a bit more time to comply with new Medicare enrollment requirements. Phase 2 of the claims editing expansion will now begin April 5, 2010, rather than Jan. 4.

The Centers for Medicare & Medicaid Services (CMS) recently delayed the Phase 2 implementation to give physicians and NPPs who order items or services for Medicare beneficiaries, or who refer Medicare beneficiaries to other Medicare providers or suppliers, sufficient time to enroll in Medicare or take the action necessary to establish a current enrollment record in Medicare.

Phase 2 instructs Medicare carriers to reject claims:

  • If the item or service you bill requires an ordering/referring provider and that information is not provided on the claim.
  • If the ordering/referring provider is not in Provider Enrollment, Chain and Ownership System (PECOS) and is not in the claims system.
  • If the ordering/referring provider is not of the specialty being ordered/referred.

During Phase 1 implementation (which began Oct. 5), if the claim does not pass the edits described above, Medicare will continue to process the claim and will include a remark message (M68 – missing/incomplete/invalid attending, ordering, rendering, supervising, or referring physician identification) on the remittance advice.

Once Phase 2 begins, if the ordering/referring provider is on the claim, Medicare will verify the ordering/referring provider’s National Provider Identifier (NPI) and name reported on the claim against Medicare’s provider enrollment records to ensure the ordering/referring provider is enrolled in Medicare and is a specialty eligible to order or refer.

Enrolled ordering/referring providers who have not updated their Medicare enrollment record since November 2003 should do so at once. If there are no changes in information, providers should submit an initial enrollment application to establish a current enrollment record in PECOS.

Further guidance can be found in a notice titled, “Tuesday, November 17, 2009 Physicians ODF Follow Up Notice,” which CMS released as a follow-up to an Open Door Forum conducted Nov. 17.

Providers who order or refer can verify their enrollment in PECOS by accessing Internet-based PECOS.


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