Services include:
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.
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:
Item Number | Description | ||||||||
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17 | Enter the name of the ordering or referring physician using only the first and last name as it appears in the ordering and referring file found on the CMS website. Middle names (initials) and suffixes (such as MD, RPNA, etc.) should not be listed. Enter the applicable qualifier to the left of the dotted vertical line in Item 17.
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17b | Enter the NPI of the ordering or referring physician |
Note: when a claim involves multiple ordering, referring or supervising physicians, use a separate CMS-1500 claim for each ordering, referring or supervising physician.
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.