Summer is Here, But Will Your Medicare Outpatient Claims Get Paid?

June 4, 2019 Alerts and Newsletters

CMS' Exact Match Requirement for Addresses

Your hospital may have some corrective work to do over the next few weeks if you want to avoid delays in receiving payment for your Medicare claims for services rendered at off-campus outpatient provider-based departments. According to CMS, Medicare outpatient claims will be rejected beginning in July 2019 if the service location address on the claim does not exactly match the address on record in the Provider-Enrollment, Chain and Ownership System ("PECOS"). Below, we delve into this Medicare outpatient claim edit, which could result in absurd denials and delays in getting paid.

CMS recently issued updated guidance regarding the activation of systematic validation edits for OPPS providers with multiple off-campus outpatient provider-based service locations; a copy of the MLN Matters article number SE19007 that addresses the issue can be found here. CMS delayed the "go-live" date for implementing the edit to Medicare outpatient claims for services at off-campus outpatient provider-based locations from April 1 to July 2019.

CMS' guidance indicates that, if addresses on Medicare outpatient claims do not exactly match the address listed on the 855A enrollment form/address in PECOS or if a hospital with more than one service location does not report the correct location where the service was provided, the claim will be rejected. This is not a surprise, but CMS' application of this principle could cause delays for many providers. For example, discrepancies could be based on simple spelling differences or abbreviations. According to CMS, an outpatient claim will be rejected if a provider enters "Rd." or "Rd" as part of the address on the claim submission, but the address in PECOS reads, "Road." Denials will similarly result for other abbreviated words such as "street" (St. or St or Str) or "suite" (Ste.).

The good news is that CMS recently enabled a new query function so that a hospital can confirm its address in PECOS and ensure that address matches the address of the location where the service was provided, as indicated on Medicare outpatient claims. The updated CMS guidance includes instructions for how to perform such a query. Hospitals should immediately begin reviewing their Medicare enrollment records in PECOS so as to avoid potential roadblocks.

Verrill Dana will continue to monitor and bring you updates on this matter. For assistance with questions regarding CMS' Medicare outpatient claim edit, please reach out to Gary Rosenberg, Cecilie MacIntyre, or your regular Verrill Dana attorney.

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