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) 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.
Note that 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.

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 3, 2010), 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 4, 2010, 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 is taking the following actions to reduce the number of informational messages and potential rejections that providers receive:
  1. CMS will systematically add NPIs to the PECOS enrollment records of all physicians and non-physician practitioners whose PECOS records do not already contain their NPIs.
  2. CMS will make publicly available on the Internet a national file of Medicare physicians and non-physician practitioners who are eligible to order/refer. The file will contain the NPI and the provider’s legal name from the Medicare PECOS enrollment record.
  3. CMS will issue instructions that will assist Medicare contractors in enrolling licensed residents, Department of Veterans Affairs physicians, and Public Health Service physicians solely for the purpose of being eligible to order/refer.
Ordering/Referring Providers for DMEPOS Claims--Action

Providers not enrolled in the Medicare program, or 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 the ordering/referring provider on DMEPOS claims. They will have to enroll in the Medicare program or “revalidate” their Medicare enrollment information for this purpose.

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 filling out the appropriate paper Medicare provider enrollment application(s) and mailing it, along with any required additional paper information, to WPS; we will then process the enrollment application and enter the provider’s information into PECOS. Information about enrolling in Medicare can be found on the CMS web site at http://www.cms.hhs.gov/MedicareProviderSupEnroll.

Providers can determine if they have a current enrollment record in PECOS by going on-line, using Internet-based PECOS, to view their enrollment record. Providers whose PECOS record does not include their NPI may add it at that time. As an alternative, the “Physician and Other Healthcare Professional Directory” can be used to determine if providers are already enrolled in PECOS. This directory is intended to assist Medicare beneficiaries in locating physicians and nonphysician practitioners. Its source is PECOS, however, and may be used for this purpose as well. Medicare enrollment applications, Certification Statements and related documentation for Internet-based applications, and questions regarding Medicare enrollment should be directed to the following, based on the state in which the referring/ordering provider practices:

Wisconsin, Illinois, and Michigan:

Wisconsin Physicians Service, Medicare Part B, Provider Enrollment Department, Post Office Box 8248, Madison, WI 53708-8248 (877-908-8476)

Minnesota:

Wisconsin Physicians Service, Medicare Part B, Provider Enrollment Department, 8120 Penn Avenue South, Bloomington, MN 55431-1394 (866-564-0315)



Page Last Updated: Friday, 06-Nov-2009 14:16:14 CST