Ordering/Referring Provider Edits To Be Turned On Effective January 6, 2014


On November 6, 2013, CMS announced that it plans to turn on claims processing edits (effective January 6, 2014) to deny Part B clinical laboratory and imaging, and DMEPOS, and Part A home health agency claims that fail ordering/referring provider edits.  CMS uses the edits to determine if the ordering/referring provider has a current Medicare enrollment record, a valid NPI, and is of a provider type that is eligible to order or refer for Medicare beneficiaries. 

The edits are part of the implementation of Section 6405 of the Affordable Care Act and 42 C.F.R. § 424.507, which require physicians and or other eligible professionals to be enrolled in the Medicare Program to order or refer items or services for Medicare beneficiaries.  CMS has staged the implementation of these edits beginning in October 2009.  During the first phase, the edits resulted in an informational alert back to the provider that the identification of the ordering/referring provider was missing, incomplete or invalid, or that the ordering/referring provider is not eligible to order or refer, and, thus, the claim lacked information necessary for adjudication.  Phase Two, which will be turned on effective January 6, 2014, will result in a denial of claims that do not pass the edits, although claims that identify the ordering/referring provider but fail to include the NPI will be rejected (rather than denied).  CMS had previously delayed implementation of Phase Two and announced that it would provide 60 days’ advance notice prior to turning on the edits.  The announcement on November 6, 2013, constitutes the 60-day notice period. 

The phased implementation of the edits has provided time for practitioners to establish a Medicare enrollment record.  It has also afforded CMS with an opportunity to provide guidance on, among other things, how orders and referrals by interns and residents must be reflected on the claim and to provide a Medicare enrollment process to capture physicians and non-physicians practitioners who work for the Department of Veterans’ Affairs, the Public Health Service, or the Department of Defense/Tricare and order or refer services for Medicare beneficiaries. 

For access to the MLN Matters Article, please click here.

Reporter, Tracy Weir, Washington, D.C., +1 202 626 2923, tweir@kslaw.com.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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