Last Modified: 5/14/2020
Location: FL, PR, USVI
Business: Part B
Q: What is the purpose of change request 6417 (CR)? How will it affect Part B claims that require an ordering/referring provider to be reported on the claim?
The Centers for Medicare & Medicaid Services’ (CMS) change request (CR) 6417
expanded the current scope of editing of electronic and paper claims to meet the requirements, established by the Social Security Act
, for providers who order or refer items or services for Medicare beneficiaries.
These requirements include:
• The ordering/referring providers must be uniquely identified in all Part B claims initiated by orders or referrals.
• The ordering/referring providers must have a National Provider Identifier (NPI).
• The ordering/referring provider must be enrolled in Medicare and have a current enrollment record in the Provider Enrollment, Chain and Ownerships System (PECOS).
• The ordering/referring provider must be classified as a provider who is eligible to order or refer:
• Doctor of medicine or osteopathy
• Dental medicine
• Dental surgery
• Podiatric medicine
• Physician’s assistant
• Certified clinical nurse specialist
• Nurse practitioner
• Clinical psychologist
• Certified nurse midwife
• Clinical social workers
The purpose of the claim editing expansion is to verify that the ordering/referring provider identified on the claim meets the aforementioned criteria. The claim editing expansion was implemented in two phases.
Phase 1 began on October 5, 2009. During phase 1, if the ordering/referring provider does not pass the required edits, the claim will still be processed and paid (assuming there are no other problems with the claim). However, during Phase 1, the billing provider -- the provider who furnished the item or service that was ordered or referred -- will receive an informational message from Medicare in the remittance advice.
The informational message notifies the billing provider that the either the ordering/referring provider is ineligible to order/refer (based on provider type requirements) or that the identification of the ordering/referring provider is missing, incomplete, or invalid.
Note: The informational message on an adjustment claim that does not pass the edits will indicate that the claim/service lacks information that is needed for adjudication.
With Phase 2, if the ordering/referring provider does not pass the required edits the billing provider will not be paid for the items or service that were furnished based upon order or referral.
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Source: SE1011, CR 6417
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