Palmetto GBA Reminds Providers to Make Sure Physicians Are Enrolled in PECOS

Palmetto GBA is reminding Medicare providers of the importance of billing the Individual NPITo receive payment for home health services, any Medicare-enrolled home health agency must file claims containing the name and National Provider Identifier (NPI) of the physician who ordered the service. When billing for an ordered home health service:

  • The individual physician must be enrolled in Medicare or in an opt-out status. You can verify that the ordering physician is enrolled in Medicare by reviewing the Ordering/Referring Report on the CMS Web site.
  • The NPI used for ordering must be for an individual physician (cannot be a group or organizational NPI)
  • The individual physician must be of a specialist type that is eligible to order. These individuals include:
    • Doctors of Medicine or Osteopathy
    • Doctors of Podiatric Medicine

Failure to meet the requirements mentioned above will result in denied claims once the automatic edits are activated. No date has been announced for when automatic edits will be activated. For additional information, review the Medicare Learning Network’s ‘Medicare Enrollment Guidelines for Ordering/Referring Providers (PDF, 1 MB) fact sheet.

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