October 6, 2009
Sent on behalf of the CEDI:
In compliance with the Centers for Medicare and Medicaid Services (CMS) Change Request, CR6421, and as supplement to the information provided within the MLN Matters article - Expansion of the Current Scope of Editing for Ordering/Referring Providers, MM6421, previously communicated, the following are new edits that will appear on the CEDI GenResponse Report (GENRPT) should one of the situations described be encountered.
These edits/errors will set as a WARNING message until January 1, 2010, after which time, if the edit is received, the claim will be rejected.
If one of the errors is received, and there are no other errors on the claim(s) that would result in a rejection, the claim(s) will appear in the CLAIMS WITH WARNINGS section of the CEDI GENRPT and the assigned Claims Control Number/ Internal Control Number (CCN/ICN) will appear in the ICN field beneath the claim information in this section and will not be found within the CLAIMS WITHOUT ERRORS section.
If one of the below errors is received and there are other error(s) on the claim(s) that resulted in the claim(s) being rejected, these warning errors will appear listed with the other claim error(s) in the CLAIMS WITH ERRORS section of the CEDI GENRPT and a CCN/ICN will not be assigned.
After January 1, 2010 these edits will no longer be WARNINGS and will result in claim rejection and be returned in the CLAIMS WITH ERRORS section.
Although these errors are only being returned as a WARNING and will not be rejecting claims at this time, it is imperative that these warnings be followed up on by Providers and/or Trading Partners and action taken to ensure the Providers/Suppliers being used to Order/Refer services are on file with Medicare Provider Enrollment, Chain and Ownership System (PECOS) as authorized to do so.
Edit/Error Code C200 shall set at the 2310A (Referring Provider), if present, and the submitted NPI (NM1-09) and name (NM1-03/04) are not found on the CMS supplied file of Providers/Suppliers who are authorized to Order/Refer services for Medicare
-Error Description: REFERRING PROVIDER NOT AUTHORIZED
Edit/Error Code C201 shall set at the 2310F (Referring Provider), if present, and the submitted NPI (NM1-09) and name (NM1-03/04) are not found on the CMS supplied file of Providers/Suppliers who are authorized to Order/Refer services for Medicare
-Error Description: REFERRING PROVIDER NOT AUTHORIZED
Edit/Error Code C202 shall set at the 2420E (Ordering Provider), if present, and the submitted NPI (NM1-09) and name (NM1-03/04) are not found on the CMS supplied file of Providers/Suppliers who are authorized to Order/Refer services for Medicare
-Error Description: ORDERING PROVIDER NOT AUTHORIZED
For more information, view the MLN article by clicking on the link below or pasting the following into your Internet browser: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6421.pdf
For more information about the edits, please contact the CEDI Help Desk at ngs.cedihelpdesk@wellpoint.com or at 866-311-9184. |