**Claim Denials for Non-PECOS Enrolled Ordering/Referring Providers**

Good Morning MFS Bloggers, I hope you each had a very happy thanksgiving. CMS recently posted a new article regarding the PECOS enrollment requirements for all referring physician's. It is imperative for the sustainability of your cash-flow that you confirm your referral sources are PECOS enrolled.

Providers who order or refer items or services for Medical beneficiaries and who are not enrolled in the Provider Enrollment, Chain and Ownership System (PECOS), must submit an enrollment application to Medicare. This can be done using internet-based PECOS or by completing the paper enrollment application. If you reassign your Medicare benefits to a group or clinic, you will also need to complete the CMS-855R.

Phase 1 of the claim editing initiative began on October 5th, 2009, and is scheduled to end on January 2, 2011. During phase 1, if the ordering/referring provider does not pass the edits, the claim will be processed and paid (assuming there are no other problems with the claim); however, the billing provider (the provider who furnished the item or service that was ordered or referred) will receive an informational message from Medicare in the remittance advice.

Scheduled to begin January 3, 2011, these messages will no longer be informational. They will be denial messages and the billing provider will not be paid for the items or services that were furnished based on the order or referral of the physician not enrolled in PECOS.

Home Health Change of Information 855A Applications

Good Morning MFS Bloggers, With the new arsenal of overpayment weapons PGBA is utilizing to sanction providers for failing to notify them of changes within their organization, I thought this was a good time to post a blog regarding the Change of Information (COI) issue.

Home Health Providers are required to use the CMS 855A Provider/Supplier Enrollment Application for notifying Medicare of changes of information. Providers must notify the Medicare contractor of any changes to the information contained in the application within 90 days of the effective date of the change except for Change of Addresses which must be made within 30 days.

All provider changes must be signed by the authorized representative or a delegated official for the facility. The authorized representative is an appointed official to whom the provider has granted legal authority to enroll it in the Medicare program, to make changes and/or updates to the provider’s status in the Medicare program and to commit the provider to fully abide by the laws, regulations, and program instructions of Medicare. The authorized official must be the provider’s general partner, chairman of the board, chief financial officer, chief executive officer, president, direct owner of 5% or more of the provider.

Wishing you all a very happy thanksgiving. CP

CMS Publishes Home Health Agency Patient Transfer Updates

Good Morning MFS Bloggers, Due to the vast number of regulatory and reimbursement changes in the industry, more and more agencies are trandferring and thus, receiving, patients to/from thsir agency.

According to CMS, a transfer is described as a single beneficiary choosing to change HHAs during the same 60-day period.

During this transfer prociess, it is imperative that both HHAs work together.

I. Steps for the Receiving HHA:
• Check the Health Insurance Query (HIQH) for HHAs to determine if the beneficiary is currently under an established Plan of Care with another HHA. A patient status of “30” indicates that the patient is currently under an established plan of care. Therefore, regardless if whether or not the receiving agency is admitting a patient outside of the episode currently reflected in HIQH, the transfer requirements apply.
• Document in the record that you accessed HIQH by printing and stamping page 3 in HIQH.
• If the patient is under the care of another HHA:
- Contact the initial HHA to work out the transfer date.
- Document you contacted the other agency and include; who you talked to at the agency, date contacted and time contacted.
- Inform the beneficiary that the initial HHA will no longer receive Medicare payment on behalf of the patient and therefore, will no longer provide Medicare covered services to the patient after the date of the patients elected transfer.
- Document in the patient’s file that the beneficiary was notified of the transfer criteria and the possible payment implications.

II. Steps for the Transferring HHA:
- Document the receiving agency contacted you to inform you of the beneficiary transfer and that you accepted the transfer.
- Include the name of the person you spoke with at the agency, date, time and date agreed upon for the transfer to take place.
- Submit your final claim with Patient Status Code ‘06’ to indicate transfer to another HHA.

**For a full explanation of CMS’s transfer guidelines, please refer to the Medicare Claims Processing Manual (PUB 100-02.)

LUPA Claims Paying Incorrectly

Recently, CMS identified that the Home Health Low Utilization Payment Adjustment (LUPA) are being paid incorrectly by the RHHI. CMS is rectifying the problem and will adjust any underpayments in future DDE/EOB’s. Please forward this on to all interested billing personnel.