Revised: Expansion of the Current Scope of Editing for Ordering/Referring Providers for claims processed by Medicare Carriers and Part B Medicare Administrative Contractors (MACs)

Effective October 5, 2009, CMS is expanding claim editing to verify that the ordering/referring provider on a claim is enrolled in Medicare and is eligible to order or refer Medicare services. A physician or supplier who bills Medicare for a service or item that was the result of an order or referral must show the name and unique identifier of the ordering/referring provider on the claim. As of May 23, 2008, this unique identifier must be the National Provider Identifier (NPI).

During Phase 1 implementation (beginning October 5, 2009), if the claim does not pass the edits described above, Medicare will continue to process the claim and will include a remark message (M68 – missing/incomplete/invalid attending, ordering, rendering, supervising, or referring physician identification) on the remittance advice.

In Phase 2, if the billed service requires an ordering/referring provider and none is present, the claim will not be paid.

If the ordering/referring provider is on the claim, Medicare will verify the ordering/referring provider’s NPI and name reported on the claim against Medicare’s provider enrollment records to ensure the ordering/referring provider is enrolled in Medicare and is a specialty eligible to order or refer.

Therefore, upon Phase 2 implementation and thereafter, the claim that does not pass the edits described above the claim will not be paid.