January 6, 2014 is the date for activation of the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) edits that will result in denial of home health claims if the ordering physician is not enrolled in PECOS or officially opted-out of Medicare. In order to protect against non-payment by Medicare, home health agencies must verify enrollment of all ordering physicians.
Beneficiary Notification
The Centers for Medicare & Medicaid Services (CMS) clarified in their most recent communication (MLN Matters Article SE 1305) that claims denied because they failed the ordering/referring edit will not expose a Medicare beneficiary to liability. Therefore, an Advance Beneficiary Notice is not appropriate in this situation. CMS also informed HCAF and the National Association for Home Care & Hospice (NAHC) that since the beneficiary cannot be held liable for services ordered by a provider who is not registered in PECOS, no notice is to be given because the beneficiary can not be charged.
CMS’ position would prohibit the beneficiary from choosing to privately pay for services even if informed of Medicare non-payment in advance of the initiation of care. HCAF advises that home health agencies should not initiate services for beneficiaries who are unable to identify a PECOS-enrolled physician to assume ordering responsibilities for episodes of care beginning on and after January 6.
PECOS Verification Tips
1. Physicians approved to order home health services are limited to doctors of medicine, osteopathy, and podiatry.
2. The NPI must be that of the individual physician, not a group or organization.
3. Home health agencies must report the name of the physician who ordered services on the RAPs and claims – i.e. the physician who signs the plan of care.
4. The edit will compare the physicians NPI and the first four letters of the last name as they appear in PECOS.
5. Information such as middle initial, nicknames, credentials, or titles may be included on electronic claims as long as they do not appear in first or last name fields on the claims, and must never appear on paper claims.
If you have any questions please do not hesitate to contact the clinical department at 21st Century Health Care Consultants (941) 723-1100 and we will be glad to answer any questions that you have. You can also send any questions you may have to rhonda@21hhc.com.