Effective May 1st, CMS will deny home health claims where the physician on the claim does not have an enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS).
CMS released MLN Matters-SE1305, on March 1st, detailing information regarding this new “phase 2” edit. Phase 2 is part of CMS’s implementation of Section 6450 of the Affordable Care Act, which requires physicians or other eligible professionals to be enrolled in the Medicare Program to order or refer items or services for Medicare beneficiaries, even if those physicians do not directly bill Medicare for any services.
Home Health claims will be denied with one of two reason codes, according to the March 1st MLN Matters article:
- 37236: The statement “from” date is on or after May 1, the type of bill is “32” or “33” and the attending physician’s national provider identifier (NPI) is not present in PECOS. The claim could also be denied if the NPI is present in PECOS but the name given on the claim doesn’t match the one on the physician’s enrollment record.
- 37237: Same as above, but this denial reason code will be assigned only when the type of bill frequency code is “7,” which indicates an adjustment, or “F-P.”
Check your referring physicians’ status in PECOS; agencies may be forced to hold billing the claim for physicians who are not enrolled.
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