CMS “EXACT MATCHING” VALIDATION BETWEEN OUTPATIENT CLAIMS DATA AND 855A ENROLLMENT RECORDS
Billing for provider-based departments, off-site emergency departments, and drugs purchased via the 340B Program has become increasingly complex. As CMS continues to expand regulations for hospital institutional billing (e.g., the UB-04 or electronic 837I), it’s important to remind stakeholders of these claim and line level requirements. Furthermore, CMS has directed MACs to employ “direct matching” validation between hospital claims data and Medicare 855A enrollment records. CMS states that “Medicare systems will validate service facility location to ensure services are being provided in a Medicare enrolled location” and this validation will be an “exact matching based on the information submitted on the Form CMS-855A.” CMS warns that it is the providers’ responsibility to ensure claims are appropriately submitted, and that claims data matches 855A enrollment records.
As such, providers will find it vital to audit enrollment records and claims data to ensure accuracy and avoid Medicare denials. This process requires a detailed review of all existing outpatient locations, including but not limited to any provider-based departments, 340B child sites, off-site emergency departments, and Rural Health Clinics, where “non-RHC services” (e.g., the TC of diagnostic imaging) are rendered.
Advis developed the overview in our tool, a high-level summary of mandatory line level modifiers and claim level location identification fields to assist you in ensuring appropriate identification of these service facilities. Advis is a nationally-recognized expert in both institutional billing and coding requirements and provider enrollment. For more information on these requirements, or for assistance in implementation and/or review of your processes, please contact our offices at (708) 478-7030.