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Last Modified: 9/30/2022 Location: FL, PR, USVI Business: Part B

Eligibility requirements for ordering/referring providers FAQ

Q: What are the requirements for a provider to be eligible to order or refer items or services for a Medicare beneficiary? How can I confirm eligibility as an ordering/referring provider?
A: According to the CMS change request (CR) 6417 external pdf file, a provider is eligible to order or refer items or services for a Medicare beneficiary only if he or she meets both of the following criteria:
The ordering/referring provider must be enrolled in Medicare and have a current enrollment record in the 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
Note: Only Medicare-enrolled physicians and non-physician practitioners that meet the above criteria are eligible to order/refer services for Medicare beneficiaries.
You can verify your eligibility to order or refer beneficiary services by checking the internet-based PECOS external link to ensure your enrollment record is current and includes your classification as a specialty or type of provider eligible to refer items or services for a Medicare beneficiary.
If you’re the billing provider, you can confirm the ordering/referring provider’s eligibility by accessing CMS’ Ordering and referring data file external link on the CMS data website.
Source: CR 6417
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.