Physicians must enroll, at minimum, as an ordering or referring physician to provide Medicare patients with services or prescriptions. Failing to enroll may lead to denials on claims and services.
An ordering physician can order non-physician services for patients, while referring physicians can request items or services that Medicare may provide payment for on behalf of Medicare patients. If a physician is not enrolled as either, their patients will not be able to obtain prescriptions or services.
To qualify as an ordering and certifying clinician, physicians must:
- Have an individual National Provider Identifier (NPI);
- Be enrolled in Medicare in either an “approved” or an “opt-out” status; and
- Be of an eligible specialty type, such as a physician, non-physician practitioner, nurse practitioner, intern, resident, or fellow, among other specialties.
If currently enrolled in Medicare Part B, physicians can already order and certify and don't need to re-enroll. If physicians decide not to bill Medicare for services, they can still order and certify by opting out of Medicare or enrolling solely to order and certify.
When a physician opts out or enrolls as an ordering and certifying physician, Medicare coverage will apply when they order or certify:
- Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)
- Clinical laboratory services
- Imaging services
- Home health services
The items and services a physician can order and certify will depend on their specialty type. For more information on which services are eligible, physicians should contact their Medicare administrative contractor; for Texas, contact Novitas Solutions.
The Centers for Medicare & Medicaid Services (CMS) provides information on all physicians and non-physician practitioners, by their NPI, who are of a type or specialty that are legally eligible to order and refer in the Medicare program and who have current enrollment records in Medicare.
For more billing help, visit the Texas Medical Association’s Billing, Coding, and Reimbursement page.
Last Updated On
December 15, 2023
Originally Published On
December 15, 2023
Alisa Pierce
Reporter, Division of Communications and Marketing
(512) 370-1469