Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations

This article conveys the activation of systematic validation edits for the enforcement of requirements in the Medicare Claims Processing Manual, Chapter 1, and Section 170 which describes Payment Bases for Institutional Claims.

After the November national test in November 2018 has been completed, CMS will review the results. One suggestion given during our Round 1 Testing was to have the practice location addresses available in DDE so providers could query their own PECOS practice location addresses. This should greatly reduce uncertainty as to the exact information found in the PECOS file and make claim practice location address comparison more efficient. As a result CMS has issued instructions to the FISS maintainer to make the practice location address screen available to providers in DDE at the April 2019 system quarterly release. Starting in April 2019, the practice location screen will be available in DDE. Full production implementation has been postponed until such time. CMS will continue with additional round(s) of testing to ensure that we have a smooth implementation of the edits.

Once the April 2019 Quarterly release has been implemented, CMS will direct A/B MACs to permanently turn on the edits and set them up to Return-to-Provider (RTP) claims that do not exactly match. Providers can make corrections to their service facility address for a claim submitted in the DDE MAP 171F screen for DDE submitters. Providers who need to add a new or correct an existing Practice location address will still need to submit a new 855A enrollment application in PECOS.

CMS expects that the 2 year time frame that the edits have not been active have provided ample time for providers to validate their claims submission system and the PECOS information for their off-campus provider departments are exact matches.

 

CR9613; 9907

Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18023.pdf