Ordering and Referring Denial Edits Will Be Implemented on January 6, 2014

PECOS – N264/N265 Denials

Are currently receiving the following error messages on your Remittance Advices (RAs)? Effective January 6, 2014, claims missing necessary referring/ordering physician information will be denied.

• N264 – Missing/incomplete/invalid ordering provider name

• N265 – Missing/incomplete/invalid ordering provider primary identifier

CMS will instruct contractors to turn on Phase 2 denial edits on January 6, 2014. These edits will check the following claims for a valid individual National Provider Identifier (NPI) and deny the claim when this information is invalid:

• Claims from clinical laboratories for ordered tests;

• Claims from imaging lefts for ordered imaging procedures;

• Claims from suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for ordered DMEPOS; and

• Claims from Part A Home Health Agencies (HHAs).

For more information:

• MLN Matters Article SE1305, “Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696, and 6856)”

Source: LEARNRESOURCE-L Email Update, National Institutes of Health, U.S. Department of Health and Human Services dated November 6, 2013
Ordering Referring Report: Suppliers may access the file maintained by CMS that contains the NPIs and the names of physicians and non-physician practitioners who have current enrollment records in PECOS and are of a type/specialty that is eligible to order and refer.

Claim Submission

• Ensure the physicians and non-physician practitioners on accepted orders and referrals have current Medicare enrollment records and are of a type/specialty that is eligible to order or refer in the Medicare program: www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html

• Correctly spell the ordering/referring provider’s name.

• Do not use “nicknames” on the claim.

• Do not enter credentials

• Item 17 on Paper Claims: Enter the ordering/referring provider’s name in the following order:

• • First Name, Last Name (e.g., John Smith)

• Electronic Claims: The qualifier in the electronic claim, 2310A NM102 loop is a 1.

• Enter the individual NPI and ordering/referring provider name, not the organization.

Claim Processing

If the ordering/referring provider:

• Is not on the claim, the claim will not be paid.

• Is on the claim, Medicare will verify the ordering/referring provider is in PECOS and eligible to order and refer.

• Is not in PECOS or is in PECOS but is not of the specialty to order or refer, the claim will not be paid.

Resources

• PECOS – Self Paced Tutorial

• Code List for Certain Designated Health Services (DHS)

• PECOS – Dear Physicians Letter

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