Last Modified: 8/10/2021
Location: FL, PR, USVI
Business: Part B
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?
According to the CMS change request (CR) 6417
, 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
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
on the CMS data website.
Source: CR 6417
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