Knowledge Base Article

Way back in January 2017, CMS published two transmittals (MM9613 and MM9907) that described the requirement for hospitals’ service addresses reported on claims to be an exact match to the facility’s practice locations reported on their CMS 855A enrollment form. The correct reporting of service addresses to Medicare is required to allow accurate payments based on service location. Per the Background information in MLN Matters Article SE19007,

“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, 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.”

Although the requirements for correct service address reporting became effective back in 2017, Medicare did not put systematic validation edits in place at that time. With the release of MLN Matters Article SE18023 in October 2018, edits were scheduled to go into place on April 1, 2019. CMS had already conducted one round of “behind-the-scenes” testing and concluded that “many providers are not sending the correct exact service facility location on the claim that produces an exact match with the Medicare enrolled location as based on the information entered into the PECOS for their off-campus provider departments.” Most of the discrepancies had to do with spelling variations (Road vs Rd, for example). After a second round of testing in November 2018, CMS decided to:

• delay implementation until July 2019,
• provide further guidance to hospitals,
• make the practice location address screen available to providers in DDE beginning April 2019, and
• conduct additional round(s) of testing “to ensure that we have a smooth implementation of the edits.”

This resulted in the March 2019 release of SE19007 referenced above with link provided. For more details on the reporting requirements of service locations, read SE19007 and see this prior Wednesday@One article. 

Hospitals must finally be paying attention to the requirement because a recent updated version of SE19007 “discovered no major issues during round 3 testing” conducted in June 2019. However, CMS is still being cautious so in response to stake-holder comments and to further evaluate the results of round 3 testing, they are again delaying the claim edits, this time until October 1, 2019.

Unless there are more delays, at that time, CMS will direct the Medicare Administrative Contractors (MACs) to permanently turn on the edits. Claims with service location addresses that do not exactly match the address in PECOS will Return-to-Provider (RTP). Per the article, “Providers can make corrections to their service facility address for a claim submitted in the DDE MAP 171F screen for DDE submitters. Providers who need to add a new or correct an existing practice location address will still need to submit a new 855A enrollment application in PECOS.”

In the final sentence of the article, CMS states they think 2 ½ years has been ample time for providers to prepare for these edits and get their systems in order. I have to agree with CMS on this one – 2 ½ years to get an address correct is plenty of time.