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Last Modified: 8/1/2020 Location: FL, PR, USVI Business: Part A

Activation of systematic validation edits for OPPS providers with multiple service locations

Effective date: N/A
Implementation date: N/A


Increasingly, hospitals operate an off-campus, outpatient, provider-based department of a hospital. In some cases, these additional locations are in a different payment locality than the main provider. For Medicare physician fee schedule (MPFS) and OPPS payments to be accurate, the Centers for Medicare & Medicaid Services (CMS) uses the service facility address of the off-campus, outpatient, provider-based department of a hospital facility to determine the locality in these cases.
Additionally, in accordance with Section 1833(t)(21) of the Social Security Act (the Act), as added by Section 603 of the Bipartisan Budget Act of 2015 (Pub. L. 114-74), non-excepted services provided at an off-campus, outpatient, provider-based department of a hospital were required to be identified, as the payment rate for non-excepted items and services billed on an institutional claim are to be paid under the MPFS and not the OPPS rates.
This article conveys the activation of systematic validation edits to enforce the requirements in the Medicare claims processing manual, Chapter 1, Section 170, which describes payment basis for institutional claims.
How can you prepare?
Verify practice addresses in Provider Enrollment, Chain and Ownership System (PECOS)
If any locations are not in PECOS, submit the CMS-855A enrollment form to add locations
Ensure claims are submitted with practice location as listed in Direct Data Entry (DDE)/PECOS (e.g., Road vs. Rd, Suite vs. Ste etc.)
Include special characters if listed in the address (e.g., ! &, (), +, *, ;, : etc.)
Full edit implementation
Claims will return-to-provider (RTP) with reason codes:
34977: Claim service facility address doesn’t match provider practice file address
34978: Off-campus provider claim line that contains a Healthcare Common Procedure Coding System (HCPCS) code must have a PN or PO
Correct service facility address for claim submitted in DDE MAP 171F screen
Submit new 855A form to add a new or correct an existing practice location address
View complete special edition MLN Matters® article at: SE19007 external pdf file.
Source: SE 19007
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