CMS Announces Claim Validation Edits for Hospitals with Multiple Service Locations - McDermott Will & Emery

CMS Announces Claim Validation Edits for Hospitals with Multiple Service Locations



In Depth

On March 26, 2019, the Centers for Medicare and Medicaid Services (CMS) published a Medicare Learning Network (MLN) Matters Special Edition Article describing the timing and implementation of claim edits for hospitals submitting claims under the Outpatient Prospective Payment System (OPPS) for services furnished at locations other than the main hospital campus location. CMS initially announced the implementation of claim edits to match reported service locations in the Provider Enrollment, Chain and Ownership System (PECOS) in 2017, which was followed by rounds of national testing. CMS has instructed the Medicare Administrative Contractors (MACs) to activate the claim edits after the final round of testing in July 2019, at which point hospital claims under OPPS that do not have an exact match between the service location reported on the claim and the practice location listed in PECOS will be denied. CMS reports that even spelling variations in addresses, e.g., the PECOS address contains “Road” or “STE,” but the claim submission contains “Rd” or “Suite” will constitute deficiencies.

Next Steps

CMS advises that hospitals should immediately review their Medicare enrollment record in PECOS to ensure that all practice locations are accurately reported and that the information in PECOS is an exact match with the service location information reported on Medicare claims. Hospitals that identify discrepancies in the practice location information in PECOS should make edits in PECOS or submit a CMS-855A Medicare Enrollment Application to their applicable MAC as soon as possible to correct or add practice locations. CMS further advises that hospitals should ensure that their billing systems are able to correctly report service location information and that the information being reported is an exact match to the records in PECOS. The full article can be accessed here.