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Last Modified: 8/10/2021 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
Optometry
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
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