Medicare “Exact Match” Requirements Enforcement Begins July 1

Posted on June 04, 2019

Effective July 1, the Centers for Medicare & Medicaid Services (CMS) will begin enforcing the “exact match” Medicare claim edit requirement for outpatient services provided at off-campus hospital outpatient departments (HOPDs). Medicare claims will return-to-provider (RTP) if:

  • The service location and information in the Provider Enrollment, Chain and Ownership System (PECOS) do not match exactly. The exact match edit requires that the address used by a hospital on submitted claims for services provided at off-campus HOPDs must exactly match the address provided in PECOS for Medicare enrollment. For example, if a hospital entered “Road” in PECOS and submits a claim using “Rd,” “RD” or “Rd.,” the claim will RTP.
  • The correct PO or PN modifier is not reported on the claim based on whether the off-campus HOPD is grandfathered under Section 603 of the Bipartisan Budget Act of 2015, as defined below.

In the 2015 outpatient prospective payment system (OPPS) final rule, the CMS created modifier PO, with reporting required starting Jan. 1, 2016, for hospitals to report on each claim line with a HCPCS code for services provided in off-campus HOPDs that were grandfathered under Section 603 of the Bipartisan Budget Act of 2015. Since Jan. 1, 2017, the CMS has required nongrandfathered off-campus HOPDs to report the PN modifier on each claim line for items and services, which triggers payment at the lower Medicare physician fee schedule rate rather than the OPPS rate. The CMS released MLN Matters Article SE19007 to provide additional detailed information, including examples.

Hospitals are encouraged to ensure that their information matches exactly. Providers that need to add a new address or correct an existing address will be required to submit a new 855A enrollment application in PECOS. Members with questions should contact Vickie Kunz at the MHA.

Tags: HOPD, OPPS, off-campus hospital outpatient departments, RTP, PECOS, exact match, address

Posted in: Member News

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