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CMS Phase 2 Denial Edits Will Begin January 6, 2014

Several years ago, CMS mandated that payment for referral services would only be paid if the referring provider were properly enrolled in Medicare.  Due to industry pressure, the effective date for this policy was continually delayed to allow providers sufficient time to meet the enrollment criteria.  According to the following announcement, CMS intends to instruct their Contractors to turn on the ordering and referring edits on January 6, 2014.  

CMS will instruct contractors to turn on Phase 2 denial edits on January 6, 2014. These edits will check the  following claims for a valid individual National Provider Identifier (NPI) and deny the claim when this information is invalid:

  • Claims from clinical laboratories for ordered tests;
  • Claims from imaging centers for ordered imaging procedures;
  • Claims from suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for ordered DMEPOS; and
  • Claims from Part A Home Health Agencies (HHAs).
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