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CMS Will Turn On Ordering/Referring Provider Edits on May 1, 2013
From MLN Matters® Number SE1305
A physician or supplier that bills Medicare for a service or item must show the name and unique identifier of the attending physician on the claim if that service or item was the result of an order or referral. Effective May 23, 2008, the unique identifier was determined to be the National Provider Identifier (NPI). The Centers for Medicare & Medicaid Services (CMS) has implemented edits on ordering and referring providers when they are required to be identified in Part B, DME, and Part A HHA claims from Medicare providers or suppliers who furnished items or services as a result of orders or referrals.
May 1, 2013
Do Not Include Middle Names and Suffixes of Ordering/Referring Providers on Claims:
From the CMS e-News for Thursday, April 4, 2013
Effective May 1, 2013, CMS will turn on the edits to deny Part B, Durable Medical Equipment (DME), and Part A Home Health Agency (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 with a valid NPI and must be of a specialty that is eligible to order and refer. If the ordering/referring provider is listed on the claim, the edits will verify that the provider is enrolled in Medicare.
The edits will compare the first letter of the first name and the first four letters of the last name. When submitting the CMS-1500, please only include the first and last name as it appears on the ordering and referring file found on CMS.gov.
Middle names (initials), and suffixes (such as MD, RPNA etc.), should not be listed in the ordering/referring fields. Including middle name/initial and/or suffix will cause the claim to be denied once the edits are turned on.
Make sure that the electronic claim (ANSI X12 5010A1) 2310A loop is a person. Organizations cannot order and refer.
April 4, 2013