Medicare Part B 101 Manual

Ordering and Referring Claims Information

• • A referring physician is one who requests an item or service for the beneficiary for which payment may be made under the Medicare Program.
  • An ordering physician is one who orders services for the patient such as diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services or durable medical equipment services.

Services include:

• • Medicare-covered services and items that are the result of a physician’s order or referral
  • Parenteral and enteral nutrition
  • Immunosuppressive drug claims
  • Hepatitis B claims
  • Diagnostic laboratory services
  • Diagnostic radiology services
  • Consultative services
  • Portable x-ray services
  • Durable medical equipment
  • When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests)
  • When a service is incident to the service of a physician or NPP, the name of the physician or NPP who performs the initial service and orders the nonphysician service must appear in Item 17 on the CMS-1500 claim form or the electronic equivalent.
  • When a physician extender or other limited licensed practitioner refers a patient for consultative service, submit the name of the physician who is supervising the limited license practitioner
  • Effective for claims with dates of service on or after 10/1/2012, all claims for physical therapy, occupational therapy, or speech-language pathology services, including those furnished incident to a physician or nonphysician practitioner, require that the name and NPI of the certifying physician or nonphysician practitioner of the therapy plan of care be entered as the referring physician in Items 17 and 17b on the CMS-1500 claim form or the electronic equivalent.

Note: Under certain circumstances, Medicare permits a nonphysician practitioner to perform these roles. Refer to CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 for nonphysician practitioner rules. Enter nonphysician practitioner information according to the rules above for physicians.

How to Identify the Ordering or Referring Provider on a Claim

All claims for Medicare-covered services and items that are a result of a physician’s order or referral must include the ordering/referring physician’s name, applicable qualifier and NPI in Item 17 and 17b of the CMS-1500 claim form or electronic equivalent as indicated below:

Note: when a claim involves multiple ordering, referring or supervising physicians, use a separate CMS-1500 claim for each ordering, referring or supervising physician.

Ordering and Referring Eligible Provider Verification

In order to be eligible for payment of ordered or referred services, the ordering/referring provider must have a current Medicare enrollment record in an approved or opt out status. This can be verified using PECOS or on the CMS website search datasets ordering and referring. The download files contain the NPI and legal name (last name, first name) of all physicians and nonphysician practitioners who are of a type/specialty that is legally eligible to order and refer Part B (clinical laboratory and imaging), DME and HHA claims in the Medicare Program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS.) 

Providers who intend to enroll in Medicare for the sole purpose of ordering or referring services to Medicare beneficiaries should complete their enrollment application using the online PECOS or by completing the form CMS-855O. Providers who wish to enroll in Medicare for reimbursement of services provided as well as to order and refer services to Medicare beneficiaries or those who wish to opt out of the Medicare Program should refer to the Enrollment section of our website.

Note: Opt Out provider enrollment record with no Type I NPI are not permitted to order and refer. Regulations in 42 CFR, 405.425(j) and 42 CFR, 1001.1901(c) include exceptions that would permit Medicare to make payment for some services that are ordered or referred by excluded eligible practitioners. In order for the claims that meet one of the exceptions described at 42 CFR 1001.1901(c) to be paid, the provider or supplier shall file an appeal of the claim to the MACs. The appeal shall follow the guidelines found in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 29, Section 290 and should include documentation which proves that one of the exceptions described at 42 CFR, 1001.1901(c) has been met.

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