Ordering/Referring Physician PECOS
Mandate Delayed
Ordering/Referring
Physician File Now Available
Attention: Medicare Paper Claims
Submitters
Medicare Claims Not Crossing Over
to the Supplemental Insurer
CMS Issues Instructions for Processing
Claims Containing Anti-Markup Services
EBCBS Releases Physician Office
Administrative “Roadmap”
Another MSP Problem Surfaces with Regard
to Part B Claims
Aetna To Cut Assistant at Surgery
Payment Rate
Horizon BCBS Hit with Modifier 25 & 59
Compliance Dispute
Ordering/Referring
Physician PECOS Mandate Delayed
As reported previously, effective April 5, 2010, Medicare
Administrative Contractors (MACs) were slated to begin denying
claims for ordering/referring physician claims where the name
and NPI number of the physician listed in box 17 and 17a were
not in the Provider Enrollment Chain and Ownership Supply
(PECOS) system or the claims system of the MAC.
CMS is extending this deadline to enroll in the PECOS system
until January 3, 2011.
CMS indicates that it will send a reminder to all physicians to
enroll in the new PECOS system if they enrolled in Medicare more
than six years ago. To read more, go to:
http://www.cms.hhs.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp#TopOfPage
As more information becomes available, we will keep you
apprised.
For additional guidance on this issue, read the article below or
contact us through the Third Party Insurance Help Program.
Ordering/Referring
Physician File Now Available
CMS has made available a file that contains the National
Provider Identifier (NPI) and the name (last name, first name)
of all physicians and non physician practitioners who are of a
type/specialty that is eligible to order and refer in the
Medicare program and who have current enrollment records in
Medicare (i.e., they have enrollment records in PECOS that
contain an NPI).
This file is downloadable from the Medicare provider/supplier
enrollment Web site at:
www.cms.hhs.gov/MedicareProviderSupEnroll
Click on “Ordering/Referring File” on the left-hand side.
(Please note that this Adobe file contains approximately 800,000
records. Due to the large size of this Adobe file, Medicare
suggests you right click and select “Save as” before attempting
to open this file).
A new file will be made available periodically that will replace
the posted file; at any given time, only one file (the most
recent) will be available. The file can be viewed online. In
addition, it can be downloaded by users with technical expertise
and further sorted or manipulated. It can also be used to search
for a particular physician or non physician practitioner by NPI
or by name.
Please note the following: (1) Records are in alphabetical order
based on the surname of the physician or non physician
practitioner. (2) Name suffixes (e.g., Jr.), if they exist, are
not displayed. (3) There are no “duplicates” in the file. Many
physicians or non physician practitioners share the same first
and last name; their corresponding NPIs are the assurance of
uniqueness. (4) Deceased physicians and non physician
practitioners are not included in the file. (5) If a user is
unsure of a physician or non physician practitioner’s NPI, he or
she can look it up in the NPI Registry at:
https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do
Keep in mind that the record in the NPI Registry is not the
Medicare PECOS enrollment record.
Attention: Medicare Paper
Claims Submitters
Currently, paper claims that are received where the health
insurance claim number (HICN) and the beneficiary name do not
match, are returned to the provider with a development letter
advising the provider to correct the problem and submit as a new
claim.
The Centers for Medicare and Medicaid Services (CMS) is now
directing contractors to follow the current electronic rejection
process with all claims, electronic and paper.
These paper claims will now be rejected and returned to the
provider with a rejection letter specifying the reason the
claims were returned. The effective date of this change was
tentatively scheduled for February 26, 2010.
Medicare Claims Not Crossing
Over to the Supplemental Insurer
The Centers for Medicare & Medicaid (CMS) is informing all
physicians, and suppliers to an issue that occurred starting on
or about January 1, 2010, and would have negatively impacted
their patients’ crossover claims.
Due to a system issue with the Common Working File (CWF), some
claims are not crossing over to the supplemental insurance
carrier for benefits.
CMS, along with the CWF System Maintainer are working towards a
system solution.
Therefore, CMS' recommendation to all providers, physicians, and
suppliers is as follows:
-
Examine your
Electronic Remittance Advice (ERA) or standard paper
remittance advice from this time period to determine if your
patients' claims are identified as having been crossed over
to your patients' supplemental insurers. Remittance Remark
Code MA 18 will indicate your claim has crossed over to the
supplemental insurer.
-
If you
determine these claims were not crossed over, you are within
your rights to submit claims to your patients' insurers for
supplemental payment using methodologies acceptable to those
entities.
CMS Issues Instructions for
Processing Claims Containing Anti-Markup Services
Medicare Contractors have been provided with instructions for
processing claims for diagnostic services that are subject to
the ‘anti-markup payment limitation' and that are billed with
missing or incomplete information in Item 20 of the form
CMS-1500 or its electronic equivalent.
To
read more, go to the link below.
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6670.pdf
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
EBCBS Releases Physician
Office Administrative “Roadmap”
A
number of inquiries have been received from the membership with
regard to Empire Blue Cross Blue Shield’s Professional Relations
representatives. The calls run the gamut but most complaints or
issues concern the identification and/or availability of these
representatives to answer questions from the Network physicians.
As
a result, a contact was made with senior staff at EBCBS who have
provided the following access information so a practice can
identify who their representative or Network Management
Consultant is and how to contact them.
EBCBS has posted the “Physician Office Administrative Roadmap”
document on their web site under “Self Service & Support”. Aside
from other critical and important information, they instruct the
panel physicians to complete the following steps to find out
contact information on their Network Management Consultant.
Please call 1 800 992 BLUE (2583) and select the following
Prompts in order after listening to the recorded message.
-
Option 1 –
Medical Providers
-
Option 4 –
Updates and Other Information
-
Option 1 –
Participation and Credentialing Information - Enter your Zip
Code
The name and telephone number of your contact at EBCBS should
come up and you should save this information.
The document itself can be accessed at:
http://www.empireblue.com/provider/noapplication/f4/s8/t4/pw_b141799.pdf?refer=ehpprovider
If
your office experiences any problems with this methodology,
please contact us through the Third Party Insurance Help
Program. That way we can alert EBCBS to any issues that may
prevent you from identifying and contacting your Network
Management Consultant.
Another MSP Problem Surfaces with
Regard to Part B Claims
The Centers for Medicare & Medicaid Services (CMS) has
identified yet another problem where claims were not
automatically crossing over to supplemental payers even though
the provider remittance advice indicated otherwise. This
problem began January 5, 2010.
Your action is required where a remittance advice with an issue
date between January 5, 2010, and February 12, 2010, has two or
more service lines for a beneficiary where both of the following
apply:
-
One service
line is 100 percent reimbursable (i.e., the approved amount
and amount to be paid are equal,) AND
-
One service
line where part of or the entire Medicare approved amount is
applied to the Part B deductible and/or carries co-insurance
amounts.
They were not able to forward these beneficiary claims to
supplemental payers even though the remittance advice may
indicate otherwise. Providers will need to identify these
claims by reviewing their remittance advice with an issue date
between January 5, 2010, and February 12, 2010, that contain the
criteria noted above.
Once identified, providers will need to take action to balance
bill the beneficiary’s supplemental payer. As of February 12,
2010, this system problem was fixed and all claims are crossing
over to supplemental payers as indicated on the provider
remittance advice.
CMS has already notified supplemental payers of these issues and
regrets any inconvenience you may experience related to this
Medicare claim supplemental payer crossover problem.
Aetna To Cut Assistant at Surgery
Payment Rate
Effective May 1, 2010, Aetna will change their payment rate for
physicians assisting at surgery.
As
of this date, the rate will change from 20 percent of the
negotiated rate or recognized charge based on Aetna
reimbursement policies to 16 percent of the negotiated rate or
recognized charge.
They will reimburse multiple eligible assistant surgery codes as
follows:
-
16 percent for
the primary procedure
-
8 percent for
the second eligible procedure
-
4 percent for
each additional eligible procedure
Horizon BCBS Hit with Modifier 25 &
59 Compliance Dispute
Horizon Blue Cross Blue Shield of New Jersey (HBCBSNJ) has
released a February 2010 memo detailing changes to their
modifier payment policy. Two commonly used modifiers, 25 and 59,
had changes that have negatively impacted their reimbursement
levels.
As
a result, the Medical Society of New Jersey (MSNJ) has filed a
compliance dispute against Horizon alleging multiple violations
of the national class-action settlement agreement concerning
these modifiers.
The Horizon BCBSNJ memo announced that this change will become
effective on May 17, 2010, and will recognize services submitted
with a variety of modifiers as “nonstandard” and “not performed”
or pay for the services at significantly discounted amounts.
The class action settlement dictated that Horizon was supposed
to post on its web site the limited number of finite code
combinations not appropriately reported together for separate
payment of modifiers 25 and 59.
Horizon has not posted this list but, instead, has announced
this across-the-board policy of recognizing modifiers 25 and 59
appended procedures as “nonstandard.” They are also conducting
chart and claim audit review of some physicians’ services
submitted with a modifier 25 asserting over-utilization, without
first having provided notice of the limited number of finite
code combinations not appropriately reported together for
separate payment of modifier 25. The compliance dispute filed by
MSNJ requests that the carrier cease these audits until it has
first complied with the settlement agreement’s notice
requirement by posting the limited list. MSNJ will be posting
the full text of the compliance dispute on their web site
shortly.
In
the meantime, if you believe that you have an additional
violation, please contact MSNJ via
e-mail at info@msnj.org.
Put “Horizon Compliance Dispute” in the subject line or call
Melinda Martinson, MSNJ, Senior Manager, Physician Practice
Advocacy, at (609) 896 1766, ext. 276.
For your information and review, the full HBCBSNJ policies on
the modifiers in controversy are located at the link below.
Modifier 25
https://services5.horizon-bcbsnj.com/eprise/main/horizon/tsnj/tsweb/uploadimages/upload/Modifier_25.pdf
Modifier 59
https://services5.horizon-bcbsnj.com/eprise/main/horizon/tsnj/tsweb/uploadimages/upload/Modifier_59.pdf
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
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