Medicare Enrollment Guidelines for Order/Referring Providers

Medicare Ordering/Referring Requirement

The Affordable Care Act requires that all eligible providers be enrolled with Medicare to order/refer items to Medicare beneficiaries.  Providers who do not submit claims to Medicare must still be enrolled with the program to order/refer items or services.  Providers who do not bill Medicare can utilize form CMS855O or PECOS to enroll in Medicare for the sole purpose of ordering/referring services or items.

There are three basic requirements for order/referring Medicare beneficiaries:

1. The provider must be enrolled in Medicare in an approved or an opt-out status
2. The NPI must be for an individual provider, not an organizational NPI
3. The provider must be of a specialty type that is eligible to order and refer

Medicare enrollment providers who are eligible to order and refer:

1. Physician (Doctor of Medicine or Osteopathy, Doctor of Dental Medicine, Doctor of Dental Surgery, Doctor of Podiatric Medicine, Doctor of Optometry)
2. Physician Assistant
3. Clinical Nurse Specialist
4. Nurse Practitioner
5. Clinical Psychologist
6. Certified Nurse Midwife
7. Clinical Social Worker
8. Interns*, Residents*, and Fellows

*must include the name and NPI of the teaching physician

There are additional restrictions related to order portable X-Ray services, lab, Home Health Agency services, and other X-Ray services.  Click here for more information about order/referring.

Phase 1 of the ordering/referring requirement was not notify billing providers when an ordering/referring provider submitted on a claim form was not eligible.  When phase 2 of the requirement is implemented, claims will be denied if the ordering/referring provider is not eligible or enrolled with Medicare.  CMS is required to give ample notice prior to implementing phase 2 of the ordering/referring requirement.