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Last Modified: 9/15/2021 Location: FL, PR, USVI Business: Part A, Part B

Ordering/referring requirements for Medicare claims

CMS change request (CR) 6417 external pdf file expanded the 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.

Enrollment requirements

The ordering/referring providers must be uniquely identified in all Part B claims initiated by orders or referrals.
The ordering/referring providers must have an NPI.
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
Optometry
Physician’s assistant
Certified clinical nurse specialist
Nurse practitioner
Clinical psychologist
Certified nurse midwife
Clinical social workers

Claim editing

The purpose of the claim editing expansion is to verify that the ordering/referring provider identified on the claim meets the criteria. These requirements impact those Medicare claims that require an ordering/referring provider to be listed on the claim, which included some of the following types of claims:
Claims billed by laboratories (e.g., diagnostic tests)
Claims billed by imaging centers (e.g., Magnetic resonance imaging (MRI) tests, X-rays)
Claims billed by suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)
Claims billed by Part A home health agencies

Claim errors

If you receive the remittance advice remark code (RARC) N264: Missing/incomplete/invalid ordering provider name, the name submitted on the claim does not match the exact name included in the PECOS or in First Coast’s internal provider file.
To avoid this error -- N264: Missing/incomplete/invalid ordering provider name -- the billing provider should:
Make sure that the names in the claim are submitted in the appropriate fields on the claim form.
Do not include “MD,” “DO,” “Dr.,” or “PhD” in the name field.
If the name is a hyphenated last name, it must be submitted exactly as it is in PECOS or in First Coast’s internal provider file on the claims system.
Do not use middle names or initials.
When submitting paper claims, use the following format for names in “block 17”: “First name, last name.”
If you receive the RARC N265: Missing/incomplete/invalid ordering provider primary identifier, the ordering/referring provider‘s NPI is not found in PECOS or in First Coast’s internal crosswalk file.
To avoid this error -- N265: Missing/incomplete/invalid ordering provider primary identifier -- the billing provider should:
Make sure that the ordering/referring provider’s NPI included in the claim is the NPI of an individual and not of an organization
Ensure the ordering/referring provider has verified his or her enrollment in Internet-based PECOS
Ensure that the ordering/referring provider is classified as the type of specialty eligible to order/refer beneficiary services
Note: Billing providers can verify the eligibility of an ordering/referring provider by visiting the Ordering Referring Report external link page (located on the CMS website) and downloading the current Medicare Ordering and Referring File.
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.