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Oct 18

9 digit zip code needed to get paid by Medicare?

The post is taken from a AHLA listserv post by Louise Joy, a healthcare attorney in Austin, Texas. As she states in the last paragraph, this issue affects providers in 30 states:

If you are working with a client hospital or other medicare provider (physicians, CORFs, IDTFs, therapy providers, etc.) that is paid under the Physician Fee Schedule, please note that the Medicare Program just initiated a payment hold for providers that do not have a 9-digit zipcode for the provider’s address and possibly its "pay to" address" if the provider is located in a 5-digit zip code that crosses more than one payment locality for the Physician fee schedule and the provider does not have 9-digit zipcodes listed in its master file.  We have just started hearing from clients who are not getting paid due to this new initiative.

Example:  In Texas there is a physician payment locality for the Houston area and there is another locality "for the rest of Texas."  Some zipcodes at the edge of Houston are in more than one payment locality.  For providers that are located in those zipcodes that cover more than one payment locality, their medicare master file must have a 9-digit zip code or they must include the 9-digit zip code on claims.   If their medicare master file has a 9-digit zipcode, they will not get paid if the nine-digit zip code included on their claims does not match what it is in the master file.  *** Also make sure the NPI filing has the same 9-digit zip code for the practice location address. *** 

We’re being told that if the master file has only a 5-digit zipcode or if the 9-digit zip code is wrong, the provider must file an 855 change or a full 855 to get the master file corrected.  In the meantime, the claims will be RTP’d (returned to provider).  Given how long it takes the FIs and Carriers to process these changes, it could take months (even 6+ months) to get these changes processed.   It makes me wonder if CMS will figure out a way to prioritize the processing to add the 9 digit zipcode update rather than subjecting the providers to the arduous process of getting an 855 processed.

Here’s a link to the notice on the Trailblazer website (posted 10/11): 

http://www.trailblazerhealth.com/Tools/Notices.aspx?ID=12069

Here’s a link to the medicare notices regarding the zipcode and the list of zipcodes (you must look at both to get an accurate list).

http://www.cms.hhs.gov/MLNMattersArticles/downloads/mm5208.pdf

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5730.pdf

It appears that this zipcode issue affects 30 states.  The main locations tend to be at zipcodes near major metropolitan areas.  The longest list of zip codes are for the following states:  California, Georgia, Illinois and Texas (which has the longest list).

About Reed Tinsley, CPA

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