Non-PECOS physician claims will be processed before Jan. 1

This is a PECOS update from TAHC

PECOS Update

The Centers for Medicare & Medicaid Services (CMS) has issued Transmittal 765 regarding expansion of claims editing to meet the July, 6 PECOS requirement. The transmittal states that the claims editing will be implemented in two phases. The initial phase begins October 1, 2010, and the second phase is set to begin on or after January 1, 2011.  These edits are being put into place to begin verification of physician’s name and NPI number as they appear on the “Medicare Ordering Referring File.” Agencies that bill the Medicare program must ensure that claims contain accurate information from the “Medicare Ordering Referring File.” The following describes the two phases and if you wish to read Transmittal 765, please click here.

Phase 1 (October 1, 2010 –December 31, 2010) – When a claim is received, CMS will determine if the attending physician is required for the billed service. If the attending physician’s NPI is on the claim, Medicare will verify that the attending physician is on the national PECOS file. If the attending physician NPI is not on the national PECOS file during Phase 1, the claim will continue to process but a message will be included on the remittance advice notifying the billing provider that claims may not be paid in the future if the attending physician is not enrolled in Medicare or if the attending physician is not of the specialty eligible to be an attending physician for HHA services.

Phase 2 (On or after January 1, 2011) – As stated above, Medicare will determine if the attending physician’s NPI is required for the billed service. If the billed service requires an attending physician and the attending physician’s NPI is not on the claim, the claim will not be paid. If the attending physician’s NPI is on the claim, Medicare will also verify that the attending physician is on the national PECOS file. If the attending physician is on the PECOS file, but not as a specialty eligible to be an attending physician, the claim, during Phase 2, will not be paid.

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