CMS Requires Claim Validation Edits For Hospitals With Multiple Service Locations


On March 26, 2019, the Centers for Medicare and Medicaid Services (CMS) published a Medicare Learning Network (MLN) Matters Special Edition Article describing the timing and implementation of claim edits for hospitals submitting claims under the Outpatient Prospective Payment System (OPPS) for services furnished at locations other than the main hospital campus location.

What Does This Mean?

CMS has instructed the Medicare Administrative Contractors (MACs) to activate the claim edits after the final round of testing in July 2019, at which point hospital claims under OPPS that do not have an exact match between the service location reported on the claim and the practice location listed in PECOS will be denied. CMS reports that even spelling variations in addresses, e.g., the PECOS address contains “Road” or “STE,” but the claim submission contains “Rd” or “Suite” will constitute deficiencies.


We understand the complexities and variations in data across organizations and the maintenance problems associated with the variations. Contact us to discuss how we can help organizations quickly meet the exact match requirements. We have tools in place to map service locations to practice locations in PECOS.

The full article from CMS can be accessed here.

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