Medicare Will Deny Ordered/Referred Claims Without Enrollment

Starting Jan. 6, 2014, Medicare will deny claims for services ordered or referred by a physician who is not enrolled in Medicare.

Consider this: In June 2013, the month following the originally announced start date for these two claims edits, Novitas Solutions received more than 150,000 claims with an incomplete/missing/invalid ordering provider name or NPI. Once the edits become effective on Jan. 6, claims like these will be denied. Don’t let this happen to you

Verify enrollment. To avoid denied claims for you and for those to whom you refer, use TMA's free PECOS lookup tool to make sure you and physicians from whom you receive order/referrals have an enrollment record in the Centers for Medicare & Medicaid Services (CMS) Provider Enrollment, Chain and Ownership System (PECOS).

You can enter either first and last name or NPI number to locate yourself or another physician is in PECOS. You also can check the Medicare Ordering and Referring File. (TMA's PECOS lookup tool is based on the CMS data file.) Or, you also can contact Novitas at (877) 252-8782 (choose option 4) and ask if you have an enrollment record in PECOS. 

Enroll in PECOS, if necessary. If you order and refer, and you do not have a record in PECOS, you need to submit either an electronic application through PECOS, or a paper enrollment to Medicare. For instructions, see the FAQs in MLN Matters No.SE1305 Revised. (See pp. 7-8, "I order and refer. How will I know if I need to take any sort of action with respect to these two edits?")

Submit claims properly. When submitting your CMS-1500 claim, include only the ordering/referring physician's first and last name as they appear on the Medicare Ordering and Referring File. Do not list in the ordering/referring fields middle names or initials, or suffixes (such as MD, DO, RPNA).

Note messaging you are receiving now  don't wait until claims deny. Through Jan. 5, 2013, if you file a claim with an incomplete/missing/invalid ordering provider name or NPI, physicians and Part B suppliers will receive the following message:

N264  Missing/incomplete/invalid ordering provider name, or

N265  Missing/incomplete/invalid ordering provider primary identifier

For adjusted claims, the claims adjustment reason code is 16  Claim/service lacks information which is needed for adjudication.

DME suppliers who submit claims to carriers (applicable to 5010 edits) will receive message N544  Alert: Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless, corrected, this will not be paid in the future

Starting Jan. 6, 2013, the claim will deny and the messaging for physicians and suppliers, including DME suppliers, will be:

254D or 001L  Referring/ordering provider not allowed to refer/order, or

255D or 002L  Referring/ordering provider mismatch

 More information is available from CMS:

Revised Nov. 22, 2013 

  TMA Practice E-Tips main page  



Last Updated On

May 13, 2016

Originally Published On

April 09, 2013

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