Medicare Ordering/Referring Provider Requirements

1 Medicare Ordering/Referring Provider Requirements The Affordable Care Act, Section 6405, requires physicians and other eligible Non Physician Practitioners (NPPs) to enroll in the Medicare Program to order/refer items or services for Medicare beneficiaries, including those physicians and other eligible NPPs who do not and will not send claims to a Medicare Contractor for the services they furnish.

2 Effective May 1, 2013, Medicare will deny claims for all covered Medicare Part B, durable medical equipment, orthotics, and supplies (DMEPOS), and Part A home health agency (HHA) services when the Ordering/Referring Provider is not enrolled in Medicare and the claim does not list the national Provider identification (NPI) number for the ordering or referring Provider . Providers eligible to order/refer services: Physicians (doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery, doctor of podiatric medicine, doctor of optometry and optometrists) Physician Assistants Clinical Nurse Specialists Nurse Practitioners Clinical Psychologists Interns, Residents and Fellows Certified Nurse Midwives Clinical Social Workers This includes interns, residents, fellows, and those who are employed by the Department of Veterans Affairs (DVA), the Department of Defense (DoD), or the Public Health Service (PHS) who order or refer items or services for Medicare beneficiaries.

3 State licensed residents may enroll to order or refer and may be listed on claims. Claims from unlicensed interns and residents may still specify the name and NPI of the teaching physician. If States provide provisional licenses or otherwise permit residents to practice or order and refer services, interns and residents are allowed to enroll to order and refer consistent with State law. Limitations: Chiropractors are not eligible to order or refer supplies or services for Medicare beneficiaries. All services ordered or referred by a chiropractor will be denied. Optometrists may only order and refer DMEPOS products/services, and laboratory J11 B & HHH Provider Outreach and Education 1 For DME suppliers who submit claims: N544 Alert: Although this was paid, you have billed with a referring / ordering Provider that does not match our system record.

4 Unless, corrected, this will not be paid in the future and X Ray services payable under Medicare Part B. Providers eligible to order/refer for Medicare Part A Home Health Agency (HHA) services: Doctors of Medicine or Osteopathy Doctors of Podiatric Medicine Claims for HHA services ordered by any other practitioner specialty will be denied. Informational Messages Providers billing services that require the reporting of an Ordering/Referring physician or NPP, including laboratories, imaging centers, DMEPOS suppliers, and HHAs get an informational message if the Ordering/Referring or attending physician/NPP reported on the claim does not meet the three basic Requirements for Ordering/Referring .

5 Currently, informational messages alert the billing Provider that the identification of the Ordering/Referring Provider is missing, incomplete, or invalid, or that the Ordering/Referring Provider is not eligible to order or refer. The informational message on an adjusted claim that did not pass the edits indicates the claim/service lacked information that was needed for adjudication. The informational messages used are identified below: For Part B providers who submit claims: N264 Missing/incomplete/invalid ordering Provider name N265 Missing/incomplete/invalid ordering Provider primary identifier For Part A HHA providers who submit claims: N272 Missing/incomplete/invalid other payer attending Provider identifier If you have received these messages on your remittance advice, the physician/non physician practitioner that ordered/referred the services may not: Be enrolled in Medicare , either in an approved or an opt out status Have an Individual National Provider Identifier (NPI) Be of a specialty type that is eligible to order and refer On and after May 1, 2013 your claims will be denied if the physician/NPP that ordered/referred the services you billed does not meet the above Requirements .

6 2J11 B & HHH Provider Outreach and Education Denial Messages Effective May 1, 2013, if the Ordering/Referring Provider does not pass the edits, the claim will be denied.

7 This means that the billing Provider will not be paid for the items or services that were furnished based on the order or referral. For Part B providers and DME suppliers who submit claims: 254D referring / ordering Provider Not Allowed To Refer 255D referring / ordering Provider Mismatch 289D referring / ordering Provider NPI Required CARC code 16 and/or the RARC code N264 and N265 shall be used for denied or adjusted claims. For Part A HHA providers who submit claims: 37236 The statement From date on the claim is on or after the date the This reason phase 2 edits are turned on code will The type of bill is '32' or '33' assign when: Covered charges or Provider reimbursement is greater than zero but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claim is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from EPCOS or the specialty code is not a valid eligible code 37237 The statement From date on the claim is on or after the date the This reason phase 2 edits are turned on code will The type of bill is '32' or '33' assign when.

8 The type of bill frequency code is '7' or 'F P' Covered charges or Provider reimbursement is greater than zero but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claims is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from PECOS or the specialty code is not a valid eligible code Contractors will use group code PR and MSN for denied claims. Billing Providers should be aware that claims that are denied because they failed the Ordering/Referring Provider would not expose the Medicare beneficiary to liability. Therefore, an Advance Beneficiary Notice is not appropriate. 3J11 B & HHH Provider Outreach and Education Instructions for

9 Ordering/Referring Providers There are three basic Requirements you must meet in order to be considered eligible to order/refer services. They are: 1. The physician or NPP must enroll in Medicare , either in an approved or an opt out status. 2. The Ordering/Referring National Provider Identifier (NPI) must be for an individual physician or NPP (not an organizational NPI). 3. The physician or NPP must be of a specialty type that is eligible to order and refer. If you are not sure you are enrolled in Medicare , check the ordering referring Report located on the CMS website ( Enrollment and Certification/ ). If you ARE listed on the report, you have a current enrollment record in Medicare that contains your NPI If you ARE NOT listed on the report, you will need to verify your NPI and Medicare enrollment record National Provider Identifier (NPI) information : There are two types of NPIs: Type 1 and Type 2. An individual s NPI is Type 1, and an organization s NPI is Type 2.

10 Only Type 1 NPIs can be used for Ordering/Referring purposes. To apply for an NPI or verify your NPI, access the National Plan and Provider Enumeration System (NPPES) at Medicare Enrollment information : To verify your enrollment or to enroll in Medicare you can access Internet based PECOS, located on the CMS website ( ). To check the status of your enrollment application, use the Enrollment Application Finder located in the Self Service Tools section on the Palmetto GBA homepage. Opt out Physicians: If you are a physician who has opted out of Medicare , you may order items or services for Medicare beneficiaries by submitting an opt out affidavit to Palmetto GBA. Your opt out information must be current (an affidavit must be completed every 2 years, and the NPI is required on the affidavit). Best Practices for Billing Providers Ordering/Referring Report: To ensure that the physicians and non physician practitioners from whom you accept orders and referrals have current Medicare enrollment records and are of a type/specialty that is 4J11 B & HHH Provider Outreach and Education eligible to order or refer you should check the