Home Health & Hospice Week

Tip: Don’t bother filing a reopening if your doc isn’t yet in PECOS.

If you’re filing a redetermination when your claims get denied for physician PECOS edits, you’re wasting time and money. So say two HHH Medicare Administrative Contractors in new messages to providers.

In fact, for CGS “the only recourse to re-ceive Medicare payment for this type of denial is to request a reopening,” the MAC stresses in its email message to agencies. “Do not resubmit a new claim or submit a redetermination request.”

Palmetto GBA merely says that home health agencies “may qualify for an appeal using the Clerical Error Reopening process, rather than the redetermination process.”

Claims denied due to the ordering/referring edits will display reason code 37236 or 37237, the MACs explain.

Hold up: There’s no point in submitting your reopening request if the physician hasn’t updated her PECOS record, the MACs warn — it will only continue to deny. “The physician must work with their Part B Medicare Administrative Contrac-tor to update their PECOS record,” they say.

You’re out of luck if the physician’s enrollment date was after the dates of service on your claim though. Medicare will not pay such claims, Palmetto says.

Tip: “Remember that the NPI being reported in the Attending Physician field of the claim is only for the NPI of the physician that signed the Plan of Care,” Palmetto adds.