Medicare Issues Important Change Regarding Ordering and Referring Provider Information on Claim Forms

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Beginning May 1, 2013, claims for all covered Medicare Part B, durable medical equipment, orthotics, and supplies (DMEPOS), and Part A home health agency (HHA) services will be denied when the ordering or referring provider is not enrolled in Medicare, or the claim does not properly list the National Provider Identification (NPI) number for the ordering or referring provider.  The ordering and referring edits will review three important elements:

  1. Whether the physician or other provider is enrolled in Medicare, either in an approved or an opt-out status.
  2. Verification that the NPI of the ordering or referring physician or other provider matches that of the individual provider and that the spelling of the ordering or referring physician or other provider is correct and matches the NPI database.
  3. Determination of whether the ordering or referring physician or other provider listed on the claim is of a specialty type that is eligible to order and refer the particular service.

The information of the ordering or referring physician or other provider will be identified on lines 17 and 17b of Form CMS-1500 for Medicare Part B and DMEPOS.  For Medicare Part A HHAs, the information should be identified on line 76 of Form CMS-1450.

In anticipation of this change, Medicare contractors have been systematically alerting providers when claims were missing or did have complete and/or accurate provider enrollment information on referring or ordering providers.  Providers who regularly order or refer such services or supplies for Medicare beneficiaries should prepare for this change so their claims are not denied payment once the edits go into effect.  Also, laboratories, imaging centers, DMEPOS suppliers, and HHAs should begin immediately working with ordering and referring providers to ensure they are prepared for this change so claims of the billing suppliers are not denied payment.