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Providers Advised to Verify Medicare Enrollment to Avoid Claim Denials

October 13, 2009:

Beginning October 1, the Centers for Medicare & Medicaid Services (CMS) is expanding its claim editing to ensure that items and services are ordered or referred only by physicians and other providers who are eligible to order/refer such services. Claims for services that require an ordering or referring provider must contain the national provider identifier (NPI) of the ordering/referring provider or the claim will not be paid.

For this reason, providers who order services for Medicare beneficiaries are advised to verify their Medicare enrollment in order to avoid claim problems in the future. A physician or other eligible provider who bills Medicare for a service as the result of an order or referral must include the name and the NPI of the ordering/referring provider on the claim.

In addition, only Medicare-enrolled physicians and specific nonphysician practitioners are eligible to order services for Medicare beneficiaries. These system edits will verify that the ordering/referring provider on a claim is enrolled in Medicare and of the type or specialty eligible to order/refer services for Medicare beneficiaries. A match between the ordering provider’s information and the provider information in the national file will also be verified. 

Only those physicians and nonphysician practitioners enrolled in the CMS enrollment system known as PECOS (Provider Enrollment, Chain, and Ownership System) and eligible to order or refer under the Medicare program are included. A provider is considered enrolled in Medicare for the purpose of ordering /referring a service to a beneficiary if he or she is found in the PECOS file. The following providers are eligible to order and refer services under the Medicare program:

  • Doctor of medicine or osteopathy
  • Dental medicine providers
  • Dental surgeon
  • Podiatrist
  • Optometrist
  • Chiropractic medicine
  • Physician assistant
  • Certified clinical nurse specialist
  • Nurse practitioner
  • Clinical psychologist
  • Certified nurse midwife
  • Clinical social worker

The edit expansion will be implemented in two phases, with phase 2 implementation planned for January 2010. In both phases, in order to determine if the ordering/referring provider on the claim matches the provider in the national PECOS file, the NPI of the ordering/referring provider reported on the claim will be verified against the national file. If the names match, the provider on the claim is considered verified; however, if the names do not match, the claim will not be paid.

CMS originally announced the planned expansion of the current scope of editing for ordering/referring providers in the One-Time Notification Transmittal 480, which may be found on the CMS website at: http://www.cms.hhs.gov/transmittals/downloads/R480OTN.pdf. A related MLN Matters article (MM6421) was revised on September 14 2009, to add language emphasizing that a claim listing billed services requiring an ordering/referring provider must contain that provider’s NPI or the claim will not be paid.

All providers who order or refer services for Medicare beneficiaries should verify their enrollment. The CMS online enrollment system, known as Internet-based PECOS, is located at https://pecos.cms.hhs.gov/pecos/login.do. User information may also be found on the CMS website at: http://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp

Sarah A. Serling, CPC, CPC-H, CPC-I, CCS-P, CCS
Clinical/Technical Editor


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