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Update on CMS Claim Edits for Providers with Multiple Service Locations

on Wednesday, 3 July 2019 in Health Law Advisory: Zachary J. Buxton, Editor

CMS has pushed back the full implementation date for claim edits for providers with multiple service locations until October 2019. CMS has piloted claim edits that validate whether the service facility location on the claim form matches exactly the information submitted by the provider on its enrollment forms (CMS-855A) and in the Provider Enrollment, Chain and Ownership System (“PECOS”). CMS has completed Round 1, Round 2 and Round 3 testing, but is delaying full implementation of the claim validation process for three additional months, until October 2019.

During the testing, CMS turned on the system edit for one billing cycle, but then turned off the edit so the claims could continue processing as normal. Beginning in October 2019, CMS will instruct the Medicare Administrative Contractors (“MACs”) to permanently turn on the system edits and to reject and return claims with addresses that are not exact matches to providers. Reason Codes for denied claims will be 34977 (“claim service facility address doesn’t match provider practice file address”) and 34978 (“off-campus provider claim line that contains a HCPCS must have a PN or PO”). A provider will then have the option of correcting the service facility address on the claim, or if the¬†provider needs to add a new practice location address or make a correction to an existing practice location address, the provider will need to submit an enrollment update application to change the provider’s enrollment information.

CMS stated in its MLN Matters Number SE19007 (“Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations,” available here that it believes that the two and a half year time frame during which the edits have been in the testing mode has been “ample time for providers to validate their claims submission system and the PECOS information for their off-campus provider departments are exact matches” (emphasis in the original). In the first round of testing, CMS noted that most discrepancies it identified involved spelling variations, such as “Road” in PECOS and “Rd” or “Rd.” on the claim form address, or “STE” in PECOS and “Suite” on the claim form address.

We would recommend that clients take this last opportunity to verify their claims service location addresses match with their enrollment data information to avoid future denials. CMS states it has made the practice location screen in PECOS available for providers to query in order to verify their location addresses. This is also a good opportunity to confirm the provider-based status of each location and whether the appropriate modifiers are being added for claims for services rendered at those locations.

Kimberly A. Lammers

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