Ordering, Referring and Attending Physician Claim Denials


Claims denied because the identification of the ordering/referring/attending provider does not match the physician's information on the Provider Enrollment, Chain, and Ownership System (PECOS), or because the physician is not eligible to order and refer Home Health (HH) services, may be either be adjusted or qualify for an appeal using the redetermination process. Claims denied for this reason will appear in status/location D B9997. Claim reason codes 37236, 37237, 37247, 37248, 32072 or 32092 may be assigned to the denial for claims with dates of service prior to March 1, 2020. As of March 1, 2020, CMS allows NPPs to order home health services.

Denials that Are Not Reversible

  • The ordering/referring/attending physician has not established a Medicare enrollment record in PECOS
  • His/her specialty is not eligible to order and refer home health services. HH services may only be ordered or referred by a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), or Doctor of Podiatric Medicine (DPM)
  • The PECOS physician file has a termination date present and it is equal to or less than the claim from date

If the ordering/referring/attending physician meets one of the above criteria, the claim is not payable. Therefore, do not submit an adjustment or appeal.

Reason Codes 37236, 37237, 37247 and 37248
If you receive reason code 37236, 37237, 37247 or 37248, it means one of the following issues has occurred:

  • The physician on the claim is not present in eligible physician file from PECOS
  • The physician NPI on the claim is present in files from PECOS but the first four letters of the last name on the claim do not match first four letters on the PECOS file
  • The physician’s specialty code is not a valid eligible code

An adjustment should be submitted when an input error (i.e., incorrect National Provider Identifier (NPI), incorrect name spelling) is being corrected or the physician’s PECOS record has been updated. Providers shall initiate an adjusted claim through their electronic billing software (Direct Data Entry (DDE) cannot be used). PC-ACE Pro32 software does allow for submission of adjusted claims. If your software does not allow you to adjust non-medical claim denials, you may download the PC-ACE Pro32 software or contact you software vendor.

If your claim did not initially pass the ordering/referring/attending provider edits, you also may file an appeal through the standard claims appeals process. If an appeal is submitted to remove, add or change the NPI and physician name, you must provide a corrected UB-04 (XX7) along with supporting documentation, such as the home health certification/plan of care, the face-to-face information, etc.   The appeal should follow guidelines contained in the "Medicare Claims Processing Manual," Chapter 29, Section 290.

Home Health Agencies (HHA) are required to report the NPI of the physician who certifies or recertifies the patient's eligibility (certifying physician). This is in addition to reporting the NPI and name of the physician who signs the patient's plan of care (attending physicians) when the attending physician is not the same physician who certified/recertified the patient’s eligibility to receive services under the Medicare HH benefit.

  • If the Certifying and Attending physicians are different, both physicians are subject to the ordering and referring denial edits
  • If the Certifying and Attending physicians are the same, the edits will only be applied to the "Attending" field

In addition, the physician(s) must have an active PECOS enrollment record prior to the episode start date

Reason Codes 32072 and 32092
Reason codes 32072 and 32092 state the physician’s PECOS file has a termination date present and it is equal to or less than the claim from date. If you disagree and the physician is active in PECOS, you should submit an appeal through the redetermination process.

Note: Do not submit an adjustment to the final claim unless there is a correction to the ordering/referring/attending physician’s PECOS record or you are correcting an input error. The physician must work with their Part B Medicare Administrative Contractor to update his/her PECOS record, if the file was incorrect.

Adjustment Requirements

  • Enter bill type XX7
  • The correct ordering/referring/attending physician’s NPI and name
  • Condition code "D9" (FL 18–28)
  • Remarks (FL80) indicating the reason for the adjustment (i.e., correction to ordering/referring/attending physician NPI and/or name or the physician’s PECOS record has been updated)
  • Ensure the claim number of the denied final claim (not the RAP) is entered in the cross-reference (X-Ref) Document Control Number field

Notes: To help reduce ordering/referring/attending denials, billing providers may enter the physician’s taxonomy code for 5010 final claim electronic submissions. The Fiscal Intermediary Standard System (FISS) will populate the specialty code based on the information from the physician's enrollment record. Providers may then view the specialty code in DDE on claim page three.

References

  • MLN Matters®Number: SE1413
  • MLN Matters® Number: SE1305 




Last Updated: 11/17/2020