Summary
The Provider Enrollment, Chain, and Ownership System (PECOS) allow the
contractor to verify all national provider identifiers (NPIs), regardless of
the jurisdiction in which they are enrolled.
Beginning April 1, 2015, physicians and suppliers billing anti-markup and
reference laboratory claims must report the national provider identifier (NPI)
of the physician or supplier who actually performed the service. This new
requirement applies to all claims, including claims for services where the
performing provider is out of the processing contractor's jurisdiction.
This article is based on Change Request (CR) 8806, which provides guidance for
physicians and suppliers billing anti-markup and reference laboratory claims.
Effective for anti-markup and reference laboratory claims submitted with a
receipt date on and after April 1, 2015, billing physicians and suppliers are
required to report the name, address, ZIP code, and the National Provider
Identifier (NPI) of the performing physician or supplier when the performing
physician or supplier is enrolled in a different contractor's jurisdiction.
Make sure your billing staffs are aware of this update.
The Health Insurance Portability and Accountability Act of 1996 (HIPPA)
requires that all covered health care entities follow the same standard for
submitting and processing electronic claims transactions. According to the
instructions for use of the American National Standards Institute (ANSI) X12
837 professional electronic claim transaction, suppliers must submit the NPI
that matches the name and address of the servicing provider/supplier identified
on the claim.
On anti-markup and reference laboratory claims, physicians and other suppliers
are required to identify the supplier's name, address, and ZIP code in Item 32
of the CMS-1500 claim, or the corresponding loop and segment of the ANSI X12
837 professional electronic claim format. The NPI of the physician or supplier
who actually performed the service is required in Item 32a of the CMS-1500
claim form or the corresponding loop and segment of the ANSI X12 837
professional electronic claim transaction.
However, prior to the implementation of the Provider Enrollment, Chain, and
Ownership System (PECOS), MACs used systems that were specific to each MAC and
did not allow MACs from one State to view provider enrollment information from
another State. This systems limitation prevented MACs from being able to share
information about existing providers/suppliers, and increased the potential for
fraud. As a result, physicians and suppliers that were enrolled in another
MAC's jurisdiction could not validate the NPI in Item 32a of the CMS-1500 claim
form or on the ANSI X12 837 professional electronic claim format, because the
function was not available in PECOS.
Since the NPI of the physician/supplier that actually performed the test may
not be available to the billing physician or supplier, the "Medicare
Claims Processing Manual" currently instructs physicians and suppliers to
submit their own NPI with the name and address of the actual performing
physician or supplier in Item 32a (and its electronic equivalent) when billing
for reference laboratory services, or services subject anti-markup, when the
performing physician or supplier is enrolled in another contractor's
jurisdiction.
Effective April 1, 2015, changes to PECOS will allow MACs the ability to verify
all physician and supplier NPIs, regardless of the jurisdiction in which they
are enrolled. Therefore, beginning with claims
received on or after April 1, 2015, physician and suppliers billing anti-markup
and reference laboratory claims must report the NPI of the physician or
supplier who actually performed the service in Item 32a of the CMS-1500 claim
form or the corresponding loop and segment of the American National Standards
Institute (ANSI) X12 837 professional electronic claim format. This new requirement applies to all claims,
including claims for services where the performing physician/supplier is out of
the processing MAC's jurisdiction.
Anti-mark up claims will be identified by the presence of the "Yes"
indicator in ITme 20 of th eCMS-1500 or its electronic equivalent. Reference
laboratory claims will be identified by the presence of 90 on any service line.
MACs will return as unprocessable a claim:
• Where the NPI in Item 32a (or its electronic
equivalent) does not belong to the entity whose name and address are identified
in Item 32 (or its electronic equivalent)
• For a reference laboratory or anti-markup service that is
performed outside the MAC's billing jurisdiction when submitted without the
name, address, and ZIP code of the performing physician/supplier in Item 32,
and the NPI of the performing physician/supplier in Item 32a of the CMS-1500
claim form, or on the ANSI X12 837 professional electronic claim format, in the
appropriate loops/segments
• For a reference laboratory or anti-markup service performed
outside the contractor's billing jurisdiction when the NPI in Item 32A (or its
electronic equivalent) does not match the name and address of a valid servicing
physician/supplier identified on the existing table in PECOS.
MACs use the following codes for claims returned as unprocessable:
• Claim Adjustment Reason Code (CARC) 16-Claim/service lacks
information which is needed for adjudication.
• For reference lab claims, Remittance Advice Remarks Code
(RARC) N270 - Missing/incomplete/invalid other provider primary identifier.
• For anti-markup claims, RARS N283-
Missing/incomplete/invalid purchased service provider identifier.
• Group Code : Contractual Obligation (CO).
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