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:
- The provider must be enrolled in Medicare in an approved or an opt-out status
- The NPI must be for an individual provider, not an organizational NPI
- 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:
- Physician (Doctor of Medicine or Osteopathy, Doctor of Dental Medicine, Doctor of Dental Surgery, Doctor of Podiatric Medicine, Doctor of Optometry)
- Physician Assistant
- Clinical Nurse Specialist
- Nurse Practitioner
- Clinical Psychologist
- Certified Nurse Midwife
- Clinical Social Worker
- 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.
