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Update to Scope of DMEPOS Claims Editing for Referring/Ordering Provider

Posted on November 11, 2011 in Long-Term Care, Home Health & Hospice

Written by: Kendra Conover

Change Request (CR) 6421 was recently revised to remove chiropractors from the list of providers who may order or refer for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS).  All other information in the CR remained the same.  As you will recall, in CR 6421, the Centers for Medicare & Medicaid Services (CMS) started the expansion of claim editing to meet the Social Security Act requirements for ordering and referring providers.    The claim editing is being expanded to verify that the ordering/referring provider on a claim is eligible to order/refer and is enrolled in Medicare and the Provider Enrollment, Chain and Ownership System (PECOS).

The editing expansion is being done in two phases.  We are still in Phase 1 of the implementation process, which began on October 5, 2009.   Under Phase 1, if the billed service requires an ordering/referring provider and the ordering/referring provider is not on the claim, the claim will not be paid. If the ordering/referring provider is on the claim, it will be verified that the ordering/referring provider is on the national PECOS file. If the ordering/referring provider is not on the national PECOS file, the claim will continue to process. 

Once Phase 2 is started, however, Centers for Medicare & Medicaid Services (CMS) will begin to reject claims if the ordering/referring provider does not have a PECOS record.  CMS has not yet announced when Phase 2 will begin, but has acknowledged that it will give providers sufficient notice before claims rejections begin.

If you have questions or concerns regarding the foregoing or would like additional information, please contact your regular Hall Render attorney, or Todd Selby at tselby@hallrender.com or 317.977.1440, or Kendra Conover at kconover@hallrender.com or 317.977.1456.