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CMS Delays Edits That Reject Claims Without Address Match, Correct Location Until July

CMS has delayed until July the edits that will reject Medicare claims for services performed at off-campus provider-based departments if their addresses on claims aren’t a perfect match with their addresses on 855A enrollment forms or hospitals with multiple service locations don’t report the correct place where services were provided on claims. The edits were supposed to take effect in April, but hospitals got a brief reprieve because compliance apparently isn’t great. CMS also is making available a new practice location screen to help hospitals determine whether addresses match and, if not, correct them, according to a March 26 MLN Matters (SE19007).

“Hospitals need to ensure that each physical location where patient services are performed is properly enrolled with CMS by updating their 855A enrollment,” says Valerie Rinkle, president of Valorize Consulting.

CMS said it will instruct Medicare administrative contractors (MACs) to turn on edits in July that return claims to providers (RTP) if the addresses on claims aren’t an exact match to the addresses in the Provider Enrollment, Chain and Ownership System (PECOS). Hospitals got a heads-up in an October 2018 MLN Matters with the April implementation date, but testing, which has been going on for two years, uncovered noncompliance (“CMS to Reject Claims in April if Off-Campus Addresses Don’t Match Enrollment Forms,” RMC 28, no. 8).

“I don’t think they were seeing the trajectory of improvement on claims they hoped to with prior notification, so they pushed it out another three months, but at some point CMS will turn the edits on,” Rinkle says. “It could create cash-flow havoc for certain hospitals if they are not aware and paying attention to this.”

There are three intersecting requirements, she says. For one thing, CMS takes the phrase “exact match” seriously when it comes to the requirement that hospitals submit claims for services performed at off-campus provider-based departments using the same address they put on the 855A. As CMS said in SE18023, national testing brought discrepancies to light, mostly with spelling variations. “For example, in PECOS the word entered was ‘Road’ as part of their address, but the provider entered ‘Rd’ or ‘Rd.’ as part of their address on the claim submission.”

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