Ordering and Referring Denial Edits Will Be Implemented on January 6, 2014

CMS will instruct contractors to turn on Phase 2 denial edits on January 6, 2014. These edits will check the following claims for a valid individual National Provider Identifier (NPI) and deny the claim when this information is invalid:

• Claims from clinical laboratories for ordered tests;
• Claims from imaging centers for ordered imaging procedures;

Phase 1: Informational messaging began October 5, 2009, to 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 adjustment claim that did not pass the edits indicated the claim/service lacked information that was needed for adjudication. The informational messages used are identified below:

N264: Missing/incomplete/invalid ordering provider name

N265: Missing/incomplete/invalid ordering provider primary identifier

 

Phase 2: edits will be turned on by CMS effective January 6, 2014. In Phase 2, if the ordering/referring provider does not pass the edits, the claim will be denied. This means that the billing provider will not be paid for the items or services that were furnished based on the order or referral.

Below are the denial edits for Part B providers and suppliers who submit claims to Part A/B MACs:

CARC code 16 or 183 and/or the RARC code N264, N574, N575 and MA13 shall be used for denied or adjusted claims.

 

Claims submitted identifying an ordering/referring provider and the required matching NPI is missing (edit 289D) will continue to be rejected. CARC code 16 and/or the RARC code N265, N276 and MA13 shall be used for rejected claims due to the missing required matching NPI.

 

16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.

183: The referring provider is not eligible to refer the service billed.

N574: Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer. Please verify that the claim ordering/referring provider information is accurate or contact the ordering/referring provider.

N575: Mismatch between the submitted ordering/referring provider name and the ordering/referring provider name stored in our records.

MA13: Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code.

N276: Missing/incomplete/invalid other payer referring provider identifier.

Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf