PECOS - N264/N265 Denials

Are you currently receiving the following error messages on your Remittance Advices (RAs)? Effective January 6, 2014, claims missing necessary referring/ordering physician information will be denied.

  • N264 - Missing/incomplete/invalid ordering provider name
  • N265 - Missing/incomplete/invalid ordering provider primary identifier

Ordering and Referring Denial Edits Will Be Implemented 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).

For more information

  • CMS Ordering & Certifying - Learn more about CMS's requirements for ordering and referring providers, or to view the list of providers able to order and refer patients for services, visit their page

Source: LEARNRESOURCE -L Email Update, National Institutes of Health, U.S. Department of Health and Human Services dated November 6, 2013

Claim Submission

  • Ensure the physicians and non-physician practitioners on accepted orders and referrals have current Medicare enrollment records and are of a type/specialty that is eligible to order or refer in the Medicare program.
  • Correctly spell the ordering/referring provider's name.
  • Do not use "nicknames" on the claim.
  • Do not enter credentials
  • Item 17 on Paper Claims: Enter the ordering/referring provider's name in the following order:
    • First Name, Last Name (e.g., John Smith)
  • Electronic Claims: The qualifier in the electronic claim, 2310A NM102 loop is a 1.
  • Enter the individual NPI and ordering/referring provider name, not the organization.

Claim Processing

If the ordering/referring provider:

  • Is not on the claim, the claim will not be paid.
  • Is on the claim, Medicare will verify the ordering/referring provider is in PECOS and eligible to order and refer.
  • Is not in PECOS or is in PECOS but is not of the specialty to order or refer, the claim will not be paid.

Resources

 

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