Bulletin: September 30, 2009
New CMS Claim Edits for Ordering/Referring Providers
CMS is expanding claim editing to include new requirements for ordering and referring providers. Physician and non-physician practitioners who order or refer must be enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and must be of the type/specialty that is eligible to order/refer services for Medicare beneficiaries. Changes will impact Part B claims for ordered or referred services that are received and processed on or after October 5, 2009.
CMS clarified language in CR# 6421 to emphasize that "billed services requiring an ordering/referring provider on the claim must contain the ordering/referring provider under both phases of this change or the claim will not be paid." Phase 1 is October 5, 2009-January 3, 2010.
For details, see http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6421.pdf