Ordering & Referring Information

Important Update on PECOS & Ordering/Referring

Effective May 1, 2013, CMS will instruct contractors to turn on Phase 2 denial edits on the following claims to check for a valid individual National Provider Identifier (NPI) and to deny the claim when this information is missing:

• Medicare Part B claims including Durable Medical Equipment, Orthotics, and Supplies (DMEPOS) that have an ordering or referring physician/non-physician provider; and
• Part A Home Health Agency (HHA) claims that require an attending physician provider.  

For more information:

• Attend the National Provider Call on March 20 from 3-4:30ET
• Refer to the MLN articles under the “Education Material” section below

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 in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS). 

A new file will be made available periodically that will replace the posted file; at any given time, only one file (the most recent) will be available. 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.

There are two file formats for the Medicare Ordering and Referring File below. The first is a PDF format. This file will allow a user to verify that an individual physician or eligible professional has an approved enrollment record in PECOS using Adobe Acrobat Reader. The second file is a ZIP file. The ZIP file contains the same information as the PDF, however, the file is 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 task bar and select the program through which you would like open the Medicare Ordering and Referring File. 

Users must have the most recent version of Adobe Acrobat Reader and/or Excel in order to open the PDF and/or 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 downloads below are the most recent versions of the O&R file. For a specific create date, please review each document individually. 

Educational Material

• 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
• Medicare Enrollment Guidelines for Ordering/Referring Providers
• The Basics of Medicare Enrollment for Physicians Who Infrequently Receive Medicare Reimbursement