PECOS Tips as Edits Draw Near
January 6, 2014 is the date for activation of the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) edits that will result in denial of home health claims if the ordering physician is not enrolled in PECOS or officially opted-out of Medicare. In order to protect against non-payment by Medicare, home health agencies must verify enrollment of all ordering physicians.
The Centers for Medicare & Medicaid Services (CMS) clarified in their most recent communication (MLN Matters Article SE 1305) that claims denied because they failed the ordering/referring edit will not expose a Medicare beneficiary to liability. Therefore, an Advance Beneficiary Notice is not appropriate in this situation. CMS also informed the National Association for Home Care & Hospice (NAHC) that since the beneficiary can not be held liable for services ordered by a provider who is not registered in PECOS, no notice is to be given because the beneficiary can not be charged.
CMS’ position would prohibit the beneficiary from choosing to privately pay for services even if informed of Medicare non-payment in advance of the initiation of care. NAHC has expressed its disagreement with this policy and requested that CMS reconsider their position. NAHC advices that home health agencies should not initiate services for beneficiaries who are unable to identify a PECOS-enrolled physician to assume ordering responsibilities for episodes of care beginning on and after January 6.