What We’re Reading – Getting prepared for ordering and referring denial edits

Are you aware that, effective May 1, 2013, CMS will deny claims if the ordering and/or referring providers are not enrolled in the Medicare system?  This will affect all Medicare Part B covered services, durable medical equipment, orthotics, and supplies (DMEPOS) and Medicare Part A home health agency (HHA) services.  This article summarizes the three components of the claim edit that will be used to make the determination.

  1. Is the ordering and/or referring provider enrolled in Medicare?
  2. Does the NPI listed on the claim match the ordering and/or referring provider’s information?
  3. Is the specialty provider approved to order and refer services?

Providers should make sure that all their information is the most current, correct (watch for spelling errors) and the same in the PECOS and the NPI Registry systems.  Also, you should verify that the ordering and/or referring providers are registered with Medicare (click here).  May 1st is around the corner, so please start the implementation now to avoid denials.

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