Medicare Enrollment of Ordering/Referring Providers

The Centers for Medicare & Medicaid Services (CMS) has not yet determined when it will begin to apply the expanded claim edits for ordering/referring providers. These edits are applicable to ordering/referring providers that do not have a record in the Provider Enrollment, Chain and Ownership System (PECOS). CMS will provide ample notice in advance of applying these edits to claims.

Until CMS issues further instructions in this regard, WPS will continue to process claims for ordered and referred services based on prior instructions. For Part B Medicare claims submitted to this office, we will continue to check both PECOS and our own master provider file to determine if the ordering/referring provider is enrolled in Medicare. (DMEPOS claims require that the ordering/referring provider be enrolled in PECOS.) Billing providers who report ordering/referring providers who do not meet the required criteria will continue to receive an informational message on their remittance notice, and their claims will continue to be paid.

In the interim, ordering/referring providers, and providers who submit claims for ordered and referred services, should be aware of the requirements and ensure that they are in compliance with them.

Medicare claims that are the result of an order or a referral must contain the National Provider Identifier (NPI) and the name of the ordering/referring provider. CMS requires that Medicare contractors verify that the ordering/referring provider on Medicare claims (1) has an approved enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS) or has validly opted out of Medicare, and (2) is of a specialty that is eligible to order and refer. This applies to all claims that require an ordering/referring provider, including claims for diagnostic tests and other services that are submitted to Wisconsin Physicians Service (WPS) and claims for durable medical equipment, prosthetics and orthotics, and supplies (DMEPOS) submitted to durable medical equipment Medicare administrative contractors (DMEMACs).

The following physicians and non-physician practitioners may be ordering/referring providers on Medicare claims:

  • Doctors of medicine or osteopathy;
  • Doctors of dental surgery and dental medicine;
  • Doctors of podiatric medicine;
  • Doctors of optometry;
  • Physician assistants;
  • Certified clinical nurse specialists;
  • Nurse practitioners;
  • Clinical psychologists;
  • Certified nurse midwives; and,
  • Clinical social workers.

Providers who enrolled in Medicare since November 2003 or who have updated their Medicare information since then need not take any action in order to be accepted as ordering/referring providers on claims submitted to WPS or DMEPOS claims submitted to DMEMACs if their enrollment continues to be in approved status or if they have validly opted out of Medicare. (Providers whose initial enrollment applications were received March 25, 2011, or earlier are, however, subject to revalidation by March 23, 2015, in accordance with provisions of the Patient Protection and Affordable Care Act, Section 6401. They will be notified when they are required to revalidate.)

Action for Ordering/Referring Providers Who Are Not in PECOS

Providers who enrolled prior to November 2003 and have not submitted any updates or changes to their enrollment information since then, or whose records have been deactivated, do not have an enrollment record in PECOS for purposes of being recognized as the ordering/referring provider. These providers are being notified of the requirement that they revalidate their enrollment in accordance with provisions of the Patient Protection and Affordable Care Act, Section 6401. This revalidation process will establish a PECOS enrollment record for them, which will allow them to be the ordering/referring provider on Medicare claims.

These providers will need to submit a complete CMS 855I enrollment application to revalidate their enrollment. Providers who are reassigning their Medicare benefits to a group practice or organization must also complete a CMS 855R. This may be done by (1) using Internet-based PECOS, which transmits enrollment applications to WPS via the Internet. The signed and dated Certification Statement, along with any required documents, should be sent to our office immediately after submitting the application; or, (2) by completing a paper CMS 855I Medicare provider enrollment application(s) and mailing it, along with a CMS 855R if applicable and any required additional documents, to WPS.

Note that, for nonphysician practitioners, required documents include a copy of their diploma (and a copy of their academic transcript if the diploma itself does not document that they meet the academic requirement for their specialty); a copy of the certification issued by the appropriate certifying body for their specialty, if applicable; and any additional documentation appropriate to their specialty, such as post-degree supervised clinical experience for clinical social workers. A copy of the provider's license is also required. Any questions in this regard should be directed to our Provider Enrollment Department before submitting the application.

The "Reason for Application" in Section 1.A. of the application should be indicated as you are "revalidating your Medicare enrollment." We will process the enrollment application and notify the provider when his or her enrollment has been established in PECOS.

Enrollment for the Sole Purpose of Being an Ordering/Referring Provider - CMS 8550

Physicians and non physician practitioners of the specialty types eligible to order and refer whose services are not submitted on claims to the Medicare program may apply for Medicare enrollment for the sole purpose of ordering items or services for Medicare beneficiaries or referring Medicare beneficiaries to other providers or suppliers. These include employees of the Department of Veterans Affairs (DVA), Department of Defense (DOD) TRICARE program, and the Public Health Service (PHS); employees of federally qualified health centers (FQHCs), rural health clinics (RHCs), and critical access hospitals. Other providers, including dentists, may also enroll on this basis irrespective of their employer.

These providers may apply for this type of enrollment by submitting the CMS 855O enrollment form, "Medicare Enrollment Application for Eligible Ordering and Referring Physicians and Non-Physician Practitioners." CMS 855R forms for reassignment of benefits are not submitted for this purpose, because no benefits will be payable with this type of Medicare enrollment.

Nonphysician practitioners submitting the CMS 855O enrollment application must include a copy of their diploma (and a copy of their academic transcript if the diploma itself does not document that they meet the academic requirement for their specialty); a copy of the certification issued by the appropriate certifying body for their specialty, if applicable; and any additional documentation appropriate to their specialty, such as post degree supervised clinical experience for clinical social workers. A copy of the provider's license is also required. Any questions in this regard should be directed to our Provider Enrollment Department before submitting the application.

Note: The CMS-855O enrollment form indicates that doctors of chiropractic, resident physicians, and psychologists billing independently (i.e., non clinical psychologists) may enroll as ordering/referring providers. Current CMS instructions, however, prohibit the enrollment of these providers for this purpose.

MLN Matters article, SE1011, addresses the ordering/referring requirements and can be accessed on the CMS website. Information about enrolling in Medicare can be found on the CMS Medicare Provider Supplier Enrollment(external link) web page. You can also find information about Internet-based PECOS and a link to Internet based PECOS on this website. Enrollment application forms can be downloaded from the CMS Forms website(external link).

Medicare enrollment applications, Certification Statements, and related documentation for Internet-based applications, and questions regarding Medicare enrollment should be directed to the following address and telephone number:

Wisconsin Physicians Service
Medicare Part B - Provider Enrollment Department
Post Office Box 8248
Madison, WI 53708-8248
(866) 503-7664

Page Last Updated: Friday, 10-Feb-2012 07:32:22 CST