Effective May 1, 2013 the Centers for Medicare & Medicaid Services (CMS) will implement edits that will result in claims denial if the ordering or referring provider is not enrolled in Medicare. To prevent denials, claims submitted on or after May 1 must include the name and national provider identifier (NPI) of the practitioner who ordered or referred the service. This information must exactly match the information for that practitioner in the Medicare enrollment system. The rule applies to claims for services provided under Medicare Part B, DME and Part A Home Health Agency (HHA).
Under the rule, practitioners who order and refer items or services for Medicare beneficiaries must have an enrollment record with Medicare. Practitioners with a valid opt-out affidavit on file meet requirements of the rule. Practitioners can complete a shorter enrollment form known as the 855-O. The 855-O is intended only for practitioners that order and refer services but do not bill Medicare directly. For more information about the new edits and upcoming deadline, visit the CMS website. CMS has also developed an educational article, which includes FAQs.