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.
