Medicare Enrollment of Ordering/Referring Providers
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. The Centers for Medicare & Medicaid Services (CMS) requires that Medicare contractors verify that the ordering/referring provider on Medicare claims (1) has a current enrollment record in 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) Medicare 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;
- Doctors of chiropractic medicine;
- Physician assistants;
- Certified clinical nurse specialists;
- Nurse practitioners;
- Clinical psychologists;
- Certified nurse midwives; and,
- Clinical social workers.
Dentists and pediatricians who have not enrolled in Medicare because they see so few Medicare patients or because their own services may not be covered by Medicare are considered "physicians" in terms of eligibility to order/refer. They have been and continue to be eligible to enroll in the Medicare program, and are required to do so in order to be the ordering/referring provider on Medicare claims.
Note: Licensed physicians who are residents or fellows in a Medicare-approved training program do not enroll in the Medicare program because their services are not payable by Medicare Part B, and they will not be enrolled for purposes of this ordering/referring provision. The teaching physician-not the resident or fellow-should be identified on claims as the ordering/referring provider when a resident or fellow orders or refers items or services for Medicare beneficiaries.
Diagnostic Test Claims and Other Claims Submitted to WPS
The ordering/referring provider on claims submitted to WPS that require an ordering/referring provider must 1) have a current Medicare enrollment (including his or her National Provider Identifier) in the national Provider Enrollment, Chain and Ownership System (PECOS) or in WPS' own master provider file and 2) be of a specialty that is eligible to order and refer. Providers already enrolled with WPS Medicare, before or since the November 2003 implementation of PECOS, need not take any action in order to be accepted as ordering/referring providers on claims submitted to WPS.
DMEPOS Claims Submitted to DMEMACs
The ordering/referring provider must 1)have a current Medicare enrollment (including his or her National Provider Identifier) in the national Provider Enrollment, Chain and Ownership System (PECOS) and 2) be of a specialty that is eligible to order and refer. Providers who enrolled in Medicare since November 2003 or who have updated their Medicare information since then are already enrolled in PECOS and need not take any action in order to be accepted as ordering/referring providers on DMEPOS claims.
For both categories of claims:
- During Phase 1 (October 5, 2009 through January 2, 2011), providers who report ordering/referring providers who do not meet both of the required criteria will receive an informational message on their remittance notice. (Paper billers will not receive an informational message.) The claims will be paid.
- During Phase 2 (January 3, 2011, and thereafter), claims reporting ordering/referring providers who do not meet both required criteria will be rejected.
Prior to the implementation of Phase 2, CMS will issue instructions to Medicare contractors for enrolling Department of Veterans Affairs, Public Health Service, and Department of Defense Tricare physicians for the sole purpose of being eligible to order/refer. CMS will also issue a Special Edition Medicare Learning Network (MLN) article regarding the implementation of these edits, which will expand on the information currently available in MLN Articles MM6417 and MM6421.
Ordering/Referring Providers for DMEPOS Claims--Action for Providers Not in PECOS
Providers who enrolled prior to November 2003 and have not submitted any updates or changes to their enrollment information since then do not have an enrollment record in PECOS for purposes of being recognized as the ordering/referring provider on DMEPOS claims. They will have to submit a complete CMS-855I enrollment application to establish their enrollment in PECOS. Providers who are not enrolled and 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 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 if it cannot be verified on the licensing board's Website. 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 "new enrollee," with "Not in PECOS" indicated below the check box. We will process the enrollment application and notify the provider when his or her enrollment has been established in PECOS.
Providers can determine whether they have a current enrollment record in PECOS by reviewing the "Ordering/Referring Report" on the CMS Website at http://www.cms.hhs.gov/MedicareProviderSupEnroll 
. Click on "Ordering/Referring Report" on the left-hand side.
This file contains the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS that contain an NPI). (If a user is unsure of a physician or non-physician practitioner's NPI, he or she can look it up in the NPI Registry (https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do ). Keep in mind, however, that the record in the NPI Registry is not the Medicare PECOS enrollment record.)
Information about enrolling in Medicare can be found on the CMS Medicare Provider-Supplier Enrollment Web page at http://www.cms.hhs.gov/MedicareProviderSupEnroll . You can also find information about Internet-based PECOS and a link to Internet-based PECOS on this Website.
Medicare enrollment applications, Certification Statements and related documentation for Internet-based applications, and questions regarding Medicare enrollment should be directed to the following addresses and telephone numbers, based on the state in which the ordering/referring provider practices:
| Address | Phone | |
| IL, MI, WI |
Wisconsin Physicians Service Medicare Part B - Provider Enrollment Department P.O Box 8248 Madison, WI 53708-8248 |
877-908-8476 |
| MN |
Wisconsin Physicians Service Medicare Part B - Provider Enrollment Department 8120 Penn Avenue South Bloomington, MN 55431-1394 |
866-564-0315 |
Page Last Updated: Monday, 01-Mar-2010 13:34:57 CST
