Centers for Medicare & Medicaid Services (CMS) to Deny Claims When Ordering/Referring Provider Not Enrolled in Medicare
Effective May 1, 2013, the Centers for Medicare & Medicaid Services (CMS) will begin to deny Part B Durable Medical Equipment (DME) and Part A Home Health Agency (HHA) claims for services or supplies when the ordering/referring practitioner (1) does not have a current Medicare enrollment record with a valid National Provider Identifier (NPI) or (2) is of a type that is not eligible to order or refer for Medicare beneficiaries.
This change reflects the implementation of a long-delayed initiative to ensure Medicare only pays for items and services ordered by an authorized practitioner. Since October 2009, CMS has alerted billing providers when the identification of the ordering/referring practitioner was missing, incomplete or invalid, or when the ordering/referring practitioner was not eligible to refer. However, such claims were not denied, and the date for implementing denials was extended while CMS established initiatives to ensure physicians and non-physician practitioners were aware that they must have a current Medicare enrollment record with a valid NPI. CMS also has implemented a special enrollment form (CMS-855O) for physicians and non-physician practitioners who do not themselves submit claims, so items and services they order or refer for will not be denied.
Providers and suppliers who bill Part B DME and HHA claims need to ensure the physicians and non-physician practitioners they accept orders and referrals from have current Medicare enrollment records and are of a type/specialty that is eligible to order or refer in the Medicare program. Providers and suppliers may review this information on the Ordering Referring Report.