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Ordering & Referring Information

CMS instructed contractors to turn on Phase 2 denial edits on January 6, 2014. These edits check the following claims for a valid individual National Provider Identifier (NPI) and deny the claim when this information is invalid:


• Claims from clinical laboratories for ordered tests;
• Claims from imaging centers for ordered imaging procedures;
• Claims from suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for ordered DMEPOS; and
• Claims from Part A Home Health Agencies (HHAs).


For more information refer to MLN Matters article #SE1305 under the Educational Materials section


• MLN Matters® Article #SE1305, “Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696, and 6856)”


About the Ordering and Referring Files


The downloads below contain the National Provider Identifier (NPI) and legal name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is legally eligible to order and refer Part B (clinical laboratory and imaging), DME and HHA claims, in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS). A separate file is also available identifying those physicians and non-physician practitioners that are eligible to order and refer PMD and have a current enrollment record in Medicare.


To keep the available information up to date, CMS will replace the Report twice a week. At any given time, only one Report (the most current) will be available for downloading. The file can be downloaded by users with technical expertise and further sorted or manipulated. It can also be used to search for a particular physician or non-physician practitioner by NPI or by name. Please note the following: (1) Records are in alphabetical order based on the surname of the physician or non-physician practitioner. (2) Name suffixes (e.g., Jr.), if they exist, are not displayed. (3) There are no “duplicates” in the file. Many physicians or non-physician practitioners share the same first and last name; their corresponding NPIs are the assurance of uniqueness. (4) Deceased physicians and non-physician practitioners are not included in the file.


The Medicare Ordering and Referring files below are ZIP files available for download in a CSV format. The CSV file will allow users to open the Ordering and Referring data in Excel, Notepad and other software formats that could be easier for users to search/sort.


In order to use the CSV file, please left-click on the "Medicare Ordering and Referring File [ZIP, 64400KB]" and save the CSV document contained in the zipped download. Right-click on the saved CSV file, select "Open With" on the taskbar and select the program through which you would like open the Medicare Ordering and Referring File. Note that the CSV files are broken down into two files each within the ZIP file to aid in downloading. Users must have the most recent version of Excel in order to open the CSV file.
The new Initial Physician and Non-Physician Applications Pending Contractor Review files are lists of applications pending contractor review. These pending applications have NOT been processed by the CMS contractors. These lists have been compiled to allow individuals the ability to verify that an application has been submitted and is awaiting processing.


The O&R files can also be downloaded in different formats (i.e., CSV, PDF, XLS, XLSX or XML) by visiting https://Data.cms.gov and searching on ‘Order and Referring ‘.
The downloads below are the most recent versions of the O&R file. For a specific create date, please review each document individually.


Power Mobility Device (PMD) Denial Edits for Suppliers of DMEPOS


Effective April 7, 2014, CMS has instructed contractors to deny certain Power Mobility Devise (PMD) DMEPOS claims identifying an ordering/referring physician or non-physician practitioner who is not of an authorized specialty. For more information refer to MLN Matters article #MM8239 under the Educational Materials section.


Suppliers are required to ascertain that the provider is authorized to order a PMD. A list of providers authorized to order a PMD can be accessed under the downloads section.  A denial of the claim will be issued if the provider is not on the PECOS list.


Critical Access Hospital (CAH) Method II Claim Edits


Effective January 6, 2014, Critical Access Hospital (CAH) Method II claims submitted to Medicare must contain a physician or non-physician practitioner, in the attending and/or rendering fields, who has a valid National Provider Identifier (NPI), is of an eligible specialty, and is enrolled in Medicare in an approved status.   Failure to list a physician or non-physician practitioner in the attending and/or rending fields that meets the above requirements will result in the rejection of the CAH Method II claims.  For more information refer to MLN Matters article #SE1505 under the Educational Materials section.


To assist providers in determining if the physician or non-physician practitioner meets the requirements, CMS is providing an attending and rendering file that identifies those physicians and non-physician practitioners who are of a specialty type that is eligible to be listed as an attending or rendering provider on CAH Method II claims and is enrolled in Medicare in an approved status with a valid NPI.  The file can be found below under the downloads section. 

Educational Material