PECOS - JF Part B
PECOS - N264/N265 Denials
Are 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
- MLN Matters SE1305, "Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696, and 6856)"
Source: LEARNRESOURCE-L Email Update, National Institutes of Health, U.S. Department of Health and Human Services dated November 6, 2013
Ordering Referring Report : Suppliers may access the file maintained by CMS that contains the NPIs and the names of physicians and non-physician practitioners who have current enrollment records in PECOS and are of a type/specialty that is eligible to order and refer.
- 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: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html
- 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.
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.
- Dear Ordering/Referring Physician [PDF]
- PECOS – Self Paced Tutorial
- Code List for Certain Designated Health Services (DHS)
- PECOS - Dear Physicians Letter
- Medicare Enrollment Guidelines for Ordering/Referring Providers - December 2013
Last Updated Tue, 14 Aug 2018 13:40:59 +0000