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, please refer to 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)” below.
About the Ordering and Referring Files
The Ordering and Referring files, Pending Initial Physician and Non-Physician files and Power Mobility Device (PMD) O&R files can ONLY be accessed at https://Data.cms.gov (copy and paste into your web browser). The files are no longer available as downloads on this page. The Critical Access Hospital (CAH Method II) files are still available for download below in the Downloads box.
The O&R, Pending Initial Physician and Non-Physician and PMD files can be downloaded in different formats (i.e., CSV, PDF, XLS, XLSX or XML) from https://Data.cms.gov. To find each file, search on 'Order and Referring', 'Pending Initial L and Ts Physician', 'Pending Initial L and Ts Non Physicians or 'PMD'.
The Ordering and Referring files are displayed using 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).
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:
- Name suffixes (e.g., Jr.), if they exist, are not displayed.
- 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.
- Deceased physicians and non-physician practitioners are not included in the file.
Initial Physician and Non-Physician Applications Pending Contractor Review
The 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.
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 below.
Suppliers are required to ascertain that the provider is authorized to order a PMD. 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 below.
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.
- 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
- MLN Matters® article #MM8239 Denial for Power Mobility Device (PMD) Claim from a Supplier of Durable Medical, Orthotics, Prosthetics, and Supplies (DMEPOS) When Ordered By a Non-Authorized Provider
- MLN Matters® article #SE1505 Physicians and Non-Physician Practitioners Reported on Part A Critical Access Hospital (CAH) Claims
- Medicare Enrollment Guidelines for Ordering/Referring Providers
- The Basics of Medicare Enrollment for Physicians Who Infrequently Receive Medicare Reimbursement
- Page last Modified: 09/22/2015 3:52 PM
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