AANEM News Express

AANEM News Express

Referring and Ordering Denial Edits to be Implemented January

11/8/2013
 
Paperwork

The Centers for Medicare and Medicaid Services (CMS) has instructed Medicare Administrative Contractors (MACs) to turn on an edit to deny claims without a valid referring or ordering National Provider Identifier (NPI) for dates of service on or after January 6, 2014. This new edit will check the following claims for a valid NPI and deny the claim when the information is missing:

  • Claims from clinical laboratories for ordered tests
  • Claims from imaging centers for ordered imaging services
  • Claims from suppliers of durable medical equipment, prosthetics, orthotics, and supplies
  • Claims from Medicare Part A home health agencies (HHAs)

If you order any of the above services, you will need a valid NPI number, or a valid opt-out affidavit for the Medicare program. If you bill for any of the above services, you will need to ensure that those providers from whom you accept orders and referrals have current Medicare enrollment records and are eligible to order or refer in the Medicare program. Medical bills denied by Medicare due to missing or incorrect ordering/referring information cannot be collected from a Medicare beneficiary. 


Members not sure of the status of referral providers can check the Ordering Referring Report, an alphabetical list of the names of physicians who have current enrollment records on file with CMS. To access the report, visit this page on the CMS website.


Related News

CMS Denial Process Set for May 1 is Delayed

4/26/2013
Previously, AANEM reported that starting May 1, 2013, claims without a valid National Provider Identifier (NPI) number would be denied by Medicare and Medicaid contractors, and providers would not be paid for the items or services that were furnished when claims with incorrect or incomplete information are submitted. However, recently the Center for Medicare and Medicaid Services (CMS) has indicated that implementation of edits to deny claims without a valid NPI number will be delayed until a future date. CMS will advise providers of the new implementation date in the near future. 
 
The AANEM will keep its members informed as this NPI process is launched.


New Denials Go Into Effect May 1

3/22/2013
Starting May 1, 2013, claims without a valid National Provider Identifier (NPI) number will be denied by Medicare and Medicaid contractors. Billing providers will not be paid for the items or services that were furnished when claims with incorrect or incomplete information are submitted.

The Affordable Care Act requires physicians to be enrolled in the Medicare program in order to refer items for Medicare beneficiaries. In 2009 the Centers for Medicare & Medicaid Services (CMS) implemented edits to alert the billing provider if the NPI of the ordering physician is missing from a Medicare claim. However, until now, those claims were not denied.

If you are a physician that has opted out of Medicare, you can still order items or services for Medicare beneficiaries by submitting an opt-out affidavit to a Medicare contractor within your specific jurisdiction. Claims that include the name and NPI of a referring physician who has not completed the opt-out form will be denied. CMS also has a special, shorter enrollment form—known as the 855-0—for use by physicians and other health professionals who just refer and order services but do not bill Medicare directly.

“I encourage AANEM members to review the steps their practice uses to verify that the physicians from whom they accept orders and referrals have the appropriate paperwork on file with CMS,” states Catherine French, AANEM senior  analyst of medical economics. “Claims that do not pass these edits can be appealed if an honest mistake has occurred, but any amounts not paid cannot be billed to the Medicare beneficiary.”   

Members not sure of the status of referral providers can check the Ordering Referring Report, an alphabetical list of the names of physicians who have current enrollment records on file with CMS. To access the report, visit this page on the CMS website.


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