Tips on Ordering and/or Referring Providers

UPDATE ON 4/25/13:  CMS announced the delay of PECOS edits that would result in denial of home health claims & Medicare part B claims when the ordering/referring physician is not enrolled in PECOS.  CMS will advise the new implementation date in the near future. In the interim, informational messages will continue to be sent for those claims that would have been denied had the edits been in place.

On May 1st, 2013, CMS will turn on claim edits that will affect all Medicare Part B covered services, Durable Medical Equipment (DME), and Part A HHA (Home Health Agency) claims. The following providers are the only eligible individuals to order and refer the above services:

  • Certified Nurse Midwives
  • Clinical Nurse Specialists
  • Clinical Psychologists
  • Clinical Social Workers
  • Interns, Residents, and Fellows (including those employed by the Department of Veterans Affairs (DVA), the Department of Defense (DoD), or Public Health Service (PHS)).
  • Nurse Practitioners
  • Optometrists: can only order and/or refer for labs and X-Ray services under Medicare Part B and DMEPOS services
  • Physician Assistants

In order to avoid unnecessary denials because of the claims edits:

  • Ordering and/or Referring providers must be enrolled in the Medicare program as either an approved provider or with opt-out status (click here to verify a provider).  The list of providers is updated twice a week by CMS.
    • If an enrollment application for an ordering and/or referring provider is in a pending status, the claim will be denied.
    • If the provider only wants to order and/or refer items or services and not bill Medicare, he or she must send CMS an Opt-Out Affidavit including current info and NPI number.  This affidavit must be resubmitted every two years.
  • If a new provider wants to enroll in Medicare and become an Ordering and/or Referring Provider, he or she must complete a paper CMS-8550 or register online through PECOS.
  • This rule applies to physicians and non-physician practitioners.
  • If the claim is denied after 5/1/13, the provider will need to go through the appeals process to have the claim reprocessed.

Here are some to tips to keep in mind when filing a claim regarding the ordering and/or referring provider (which is box 17 on a paper CMS-1500 claim form):

  • Do not include any middle initials for the provider
  • Leave out any credentials (e.g., M.D., D.O., A.R.N.P., etc.)
  • Only include the First and Last name of the provider
  • Verify the NPI is for the individual provider and not the organization
  • Make sure the spelling of the provider’s name is correct and matches both the Medicare database & NPPES Registry

Any provider not listed above, who bills or refers for Part B, DME or HHA services, will not be paid after May 1st.

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