LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2013-03 Full Implementation of Edits on the Ordering/Referring Providers, Eff. 1 May 2013

Temporary Delay in Implementing Ordering and Referring Denial Edits-Announced-25-April

  • Jurisdiction 11 Part B
    Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME and Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696 and 6856)

MLN MattersĀ® Number: SE1305 Related Change Request (CR) #: 6421, 6417, 6696, 6856 Related CR Release Date: N/A Effective Date: May 1, 2013 Related CR Transmittal #: R642OTN, R643OTN, R328PI and R7810TN Implementation Date: May 1, 2013

Note: This Special Edition MLN MattersĀ® article is a consolidation and update of prior articles SE 1011, SE 1201, SE 1208 and SE 1221. Effective May 1, 2013, the Centers for Medicare & Medicaid Services (CMS) will turn on the Phase 2 denial edits. This means that Medicare will deny claims for services or supplies that require an ordering/referring provider to be identified and that provider is not identified, is not in Medicare’s enrollment records, or is not of a specialty type that may order/refer the service/item being billed.

Provider Types Affected
This MLN MattersĀ® Special Edition article is intended for:
Physicians and non-physician practitioners (including interns, residents, fellows and those who are employed by the Department of Veterans Affairs (DVA), the Department of Defense (DoD) or the Public Health Service (PHS)) who order or refer items or services for Medicare beneficiaries
Part B providers and suppliers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) who submit claims to Carriers, Part A/B Medicare Administrative Contractors (MACs) and DME MACs for items or services that they furnished as the result of an order or a referral
Part A Home Health Agency (HHA) services who submit claims to Regional Home Health Intermediaries (RHHIs), Fiscal Intermediaries (FIs who still maintain an HHA workload) and Part A/B MACs
Optometrists may only order and refer DMEPOS products/services and laboratory and X-ray services payable under Medicare Part B

Provider Action Needed If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you need to submit an enrollment application to Medicare. You can do this using the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) or by completing the paper enrollment application (CMS-855O). Review the background and additional information below and make sure that your billing staff is aware of these updates.

What Providers Need to Know
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. Phase 2: Effective May 1, 2013, CMS will turn on the edits to deny Part B, DME and Part A HHA claims that fail the ordering/referring provider edits. Physicians and others who are eligible to order and refer items or services need to establish their Medicare enrollment record and must be of a specialty that is eligible to order and refer.

All enrollment applications, including those submitted over the Internet, require verification of the information reported. Sometimes, Medicare enrollment contractors may request additional information in order to process the enrollment application.

Waiting too long to begin this process could mean that your enrollment application may not be processed prior to the May 1, 2013 implementation date of the ordering/referring Phase 2 provider edits.