Ordering and Referring Initiative - Will Phase 2 Begin January 6th?


To complete a two-phase initiative that began in 2009, CMS again announced its intent to implement the Phase 2 claims edits, which would result in claim denials if the ordering or referring physician or nonphysician practitioner does not have an enrollment record in PECOS or has not validly opted out of Medicare. In a revised Medicare Learning Network Matters publication [PDF], CMS confirmed the January 6, 2014 implementation date.

Providers and suppliers may be skeptical that Phase 2 will really begin as announced, as there has been a series of postponements since the initial implementation date some time ago. Much of the delay, however, was due to the workload of the Medicare Administrative Contractors in processing enrollment forms for physicians and nonphysician practitioners who had not previously had an enrollment record in PECOS. Processing of these applications has been a priority and implementation may well go forward as announced.

For more information about the two-phase claims edit initiative, refer to our March 21, 2013 Payment Matters article.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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