The Centers for Medicare & Medicaid Services (CMS) recently announced it will postpone implementation of the “exact match” validation edits to the hospital outpatient prospective payment system (OPPS) until October 2019. Once implemented, such edits will require certain hospital outpatient providers’ location address set forth on submitted claims exactly match the corresponding address listed in providers’ Provider Enrollment, Chain and Ownership System (PECOS) profiles. Even slight discrepancies in service facility locations (e.g., variations such as “Road” versus “Rd.”) could result in a claim being returned to a provider.
As detailed in an April 30, 2019, McGuireWoods legal alert, the exact-match validation edits stem from the Bipartisan Budget Act of 2015 and resulting CMS “site-neutral” payment policies for outpatient services furnished at non-excepted off-campus provider-based departments. Following a three-round series of nationwide tests, CMS intended to fully implement the validation edits in July 2019.
However, in a recent MLN Matters revision announcing the delay, CMS explained that after completion of round-three testing, CMS decided to postpone full production implementation for three additional months to allow for “stake-holder comments and additional time to review the results of round 3 testing.” Once CMS fully implements the validation edits this October, it will direct Medicare administrative contractors to permanently turn on the edits and set them up to return to the provider any claims that do not exactly match the information set forth in a provider’s PECOS profile.
In announcing its decision to delay implementation, CMS urged and advised providers to make all corrections necessary to their facility addresses on Medicare claims, which can be submitted in the direct data entry system. Any provider who needs to add a new or correct an existing practice location address must still submit a new 855A enrollment application through PECOS. Once a provider confirms that all addresses are accurate and current, it should ensure compliance with all CMS rules and protocols for including addresses on all future claim forms, which may require educating billing staff and creating additional protocols in the provider’s billing process.
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As CMS has cautioned, providers should ensure they are ready for full implementation of the exact-match validation edits come October to avoid delays in claims processing — this includes easily missed but correctable information, such as the facility’s address and suite number. To discuss potential implications of the exact-match validation edits, please consult one of the authors.