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.

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: 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.

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

 

Last Updated Tue, 14 Aug 2018 13:40:59 +0000