Three Reminders to Medicare Providers for Billing Correctly for Ordered/Referred Services

Any Medicare-enrolled Part B organizational provider, DMEPOS supplier, or Part A Home Health Agency (HHA) provider may file claims with ordering or referring information.

1.  There are three basic requirements for ordering and referring:

• The physician or non-physician practitioner must be enrolled in Medicare or in an opt-out status.
• The National Provider Identifier (NPI) used for ordering/referring must be for an individual physician or non-physician practitioner (cannot be an organizational NPI).
• The physician or non-physician practitioner must be of a specialist type that is eligible to order and refer.

If you don’t meet the three basic requirements listed above, refer to item #3 below on how to obtain an NPI and enroll in Medicare for ordering and referring purposes.

2.  Only Medicare-enrolled individual physicians and non-physician providers of a certain specialist type are eligible to order/refer for Part B and DMEPOS Medicare beneficiary services.  (Organizational providers cannot order and refer.)  Eligible individual physicians and non-physician providers include:

• Doctor of Medicine or Osteopathy
• Doctor of Dental Medicine
• Doctor of Dental Surgery
• Doctor of Podiatric Medicine
• Doctor of Optometry
• Doctor of Chiropractic Medicine
• Physician Assistant
• Certified Clinical Nurse Specialist
• Nurse Practitioner
• Clinical Psychologist
• Certified Nurse Midwife
• Clinical Social Worker

3.  In order to order/refer, the provider must have an enrollment record in PECOS.

• Providers who order or refer should verify their enrollment in PECOS.  Note that receiving payments from Medicare does not necessarily mean you have an enrollment record in PECOS.  The easiest way to check on enrollment status is by visiting internet-based PECOS at https://pecos.CMS.hhs.gov and navigating to the “My Enrollments” page; if no record is displayed, you do not have an enrollment record in PECOS.  (More detailed instructions on accessing and navigating internet-based PECOS are available here.)  Another option is to check the Ordering and Referring Report.

• If you believe an enrollment application has been submitted but no enrollment record exists in PECOS, check the list ofpending applications, available at http://www.CMS.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp(scroll to the “Initial Physician Applications Pending Contractor Review” in the Downloads section of the page).

• Providers with neither an enrollment record in PECOS nor an entry on the list of pending applications should make arrangements to submit their enrollment application.  Internet-based PECOS is the fastest and most efficient way to do so.  For instructions, review the Basics of Internet-based PECOS for Physicians and Non-Physician Practitioners.

For additional information, review the Medicare Learning Network’s “Medicare Enrollment Guidelines for Ordering/Referring Providers” fact sheet at http://www.CMS.gov/MLNProducts/downloads/MedEnroll_OrderReferProv_FactSheet_ICN906223.pdf.