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Medicare Compliance & Reimbursement

Industry Notes:

CMS to Start Denying Claims That Don't Meet Ordering/Referring Edits 'Soon'

Published on Thu Aug 16, 2012

If a new CMS news release is any indication, the agency might soon follow through on its longstanding threat to deny claims that fail the ordering/referring provider edits. Although CMS has had this on the horizon for several years now, the agency has never actually formalized a date when the denials would start. However, a July 26 news release indicates that CMS "will soon begin denying Part B, DME, and Part A HHA claims that fail the ordering/referring provider edits." Although CMS has still not set a date, it warns providers that once it does, it will only offer a 60-day notice before the edits are turned on, so you should prepare now. Background: Currently, if you submit claims for services or items ordered/referred and the ordering or referring physician's information is not in the MAC's claims system or in PECOS, your practice will get an informational message letting you [...]
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