Ordering & Referring Information
Important Update on PECOS & Ordering/Referring
CMS will instruct contractors to turn on Phase 2 denial edits on January 6, 2014. These edits will 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 in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS).
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.
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. Note that the both the CSV and PDF files are broken down into two files each within the ZIP file to aid in downloading.
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.
- 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
- Page last Modified: 11/22/2013 4:01 PM
- Help with File Formats and Plug-Ins