Claim Editing for Ordering/Referring Providers

CMS previously announced that, beginning January 3, 2011, if certain Part B billed items and services require an ordering/referring provider and the ordering/referring provider is not in the claim, is not of a profession that is permitted to order/refer, or does not have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS), the claim will not be paid. The automated edits will not be turned on effective January 3, 2011. A placeholder date of July 5, 2011 is being issued to give CMS more flexibility to determine the appropriate date for nonpayment of claims that fail the ordering/referring provider edits. CMS is working diligently to resolve enrollment backlogs and other system issues and will provide ample advanced notice to the provider and beneficiary communities before they begin any automatic nonpayment actions. Source: JSM/TDL 11051


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