Jurisdiction 1 Part B Reminder for Providers & Suppliers
(12/2012)
December 2012
Jurisdiction 1 Part B
Important Reminder for Providers and Suppliers Who Provide Services and Items Ordered or Referred by Other Providers and Suppliers
MLN Matters® Number: SE1201
Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A
Provider Types Affected
This MLN Matters® Special Edition Article is intended for providers
and suppliers (including residents, fellows, and also those who are employed
by the Department of Veterans Affairs (DVA) or the Public Health Service
(PHS)) who order or refer items or services for Medicare beneficiaries.
Provider Action Needed: Impact to You
Medicare will only pay for items or services for Medicare beneficiaries
that have been ordered by a physician or eligible professional who is
enrolled in Medicare and their individual National Provider Identifier
(NPI) has been provided on the claim. The ordering provider or supplier
(physician or eligible professional) must also be enrolled with a specialty
type that is eligible (per Medicare statute and regulation) to order and
refer those particular items or services.
What You Need to Know
Make sure you follow Medicare directives when providing services ordered
for the services outlined below.
What You Need to Do
You should ensure that any items or services submitted on Medicare
claims are referred or ordered by Medicare-enrolled providers of a specialty
type authorized to order or refer the same. You must also place the ordering
or referring provider or supplier’s NPI on the claim you submit to Medicare
for the service or item you provide.
Background
CMS emphasizes that generally Medicare will only reimburse for specific
items or services when those items or services are ordered or referred
by providers or suppliers authorized by Medicare statute and regulation
to do so. Claims that a billing provider or supplier submits in which
the ordering/referring provider or supplier is not authorized by statute
and regulation will be denied as a non-covered service. The denial will
be based on the fact that neither statute nor regulation allows coverage
of certain services when ordered or referred by the identified supplier
or provider specialty.
CMS would like to highlight the following limitations:
• Chiropractors are not eligible to order or refer supplies or services for Medicare beneficiaries. All services ordered or referred by a chiropractor will be denied.
• Home Health Agency (HHA) services may only be ordered or referred by a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.) or Doctor of Podiatric Medicine (DPM). Claims for HHA services ordered by any other practitioner specialty will be denied.
• Portable X-Ray services may only be ordered by a Doctor of Medicine or Doctor of Osteopathy. Portable X-Ray services ordered by any other practitioners will be denied.
MLN Matters® Special Edition Article SE1011
provides further details about edits on the ordering/referring provider
information on claims. The article is available at http://www.cms.gov/MLNMattersArticles/downloads/SE1011.pdf
on the CMS website.
Additional Information
For more information about the Medicare enrollment process, visit http://www.cms.gov/MedicareProviderSupEnroll
or contact the designated Medicare contractor for your State. Medicare
provider enrollment contact information for each State can be found at
http://www.cms.gov/MedicareProviderSupEnroll/Downloads/Contact_list.pdf
on the CMS website.
The Medicare Learning Network® (MLN) fact sheet titled, “Medicare Enrollment
Guidelines for Ordering/Referring Provider,” is available at http://www.cms.gov/MLNProducts/downloads/MedEnroll_OrderReferProv_factSheet_ICN906223.pdf on
the CMS website.
MLN Matters® Article MM7097, “Eligible Physicians and Non-Physician Practitioners
Who Need to Enroll in the Medicare Program for the Sole Purpose of Ordering
and Referring Items and Services for Medicare Beneficiaries,“ is available
at https://www.cms.gov/MLNMattersArticles/downloads/MM7097.pdf
on the CMS website.
MLN Matters® Article MM6417, “Expansion of the Current Scope of Editing
for Ordering/Referring Providers for Claims Processed by Medicare Carriers
and Part B Medicare Administrative Contractors (MACs),” is available at
http://www.cms.gov/MLNMattersArticles/downloads/MM6417.pdf
on the CMS website.
MLN Matters® Article MM6421, “Expansion of the Current Scope of Editing
for Ordering/Referring Providers for Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) Suppliers' Claims Processed by Durable
Medical Equipment Medicare Administrative Contractors (DME MACs),” is
available at http://www.cms.gov/MLNMattersArticles/downloads/MM6421.pdf
on the CMS website; MLN Matters® Article MM6129, “New Requirement for
Ordering/Referring Information on Ambulatory Surgical Center (ASC) Claims
for Diagnostic Services,” is available at http://www.cms.gov/MLNMattersArticles/downloads/MM6129.pdf
on the CMS website.
Disclaimer
This article was prepared as a service to the public and is not intended
to grant rights or impose obligations. This article may contain references
or links to statutes, regulations, or other policy materials. The information
provided is only intended to be a general summary. It is not intended
to take the place of either the written law or regulations. We encourage
readers to review the specific statutes, regulations and other interpretive
materials for a full and accurate statement of their contents. CPT only
copyright 2011 American Medical Association.
last updated on 01/23/2012