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Medicare to turn on ordering/referring physician edits May 1



April 03, 2013

Physicians who refer or order services for Medicare beneficiaries must be enrolled with Medicare by May 1. Enrollments can be completed via the online Provider Enrollment, Chain, and Ownership System (PECOS) or by completing a paper enrollment application (applicable CMS-855). Claims submitted on or after May 1 will be denied if the ordering/referring physician does not have an enrollment record.


Centers for Medicare and Medicaid Services (CMS) began notifying ordering/referring physicians of the need to enroll in Medicare in October 2009. Effective May 1, 2013, CMS will turn on claims edits that will automatically deny claims if the ordering/referring provider does not have an enrollment record.


In order to reduce the number of denied services, physicians are encouraged to enroll as soon as possible.


More information on the new edits can be found in the CMS MLN Matters article SE 1305 as well as on the CMS website, www.cms.gov (click on "Medicare," then on "Medicare Provider-Supplier Enrollment" and then on "Ordering & Referring Information").


For more information regarding enrollment options and opting out, see CMA On-Call document #0151, “Medicare Participation (and Non-Participation) Options,” available in the health law library at www.cmadocs.org/health-law-library. On-Call documents are free to members. Nonmembers can purchase documents for $2/page.

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