Effective May 1, 2013, claims for Medicare Part B, Home Health Agencies, and Durable Medical Equipment, Orthotics, and Supplies (DMEPOS) must include a valid individual national provider identifier (NPI) for the certifying, ordering, or referring physician/non-physician provider or the claim will be denied.
- The name of the physician listed on the claim form must precisely match what is registered under the NPI, with no middle initials or titles (e.g., "Dr.").
- The physician must be enrolled in the PECOS system as either a participating or non-participating provider, including an updated opt-out affidavit if the physician has opted out of Medicare but refers for Medicare services.
- For audiology claims, the referring provider must be included for all services—even those that are not a benefit but a denial from Medicare—in order to bill other insurance coverage.
- For speech-language pathology claims, the certifying physician indicated in the referring provider box on the claim must also be appropriately enrolled in Medicare.
The Centers for Medicare and Medicaid Services (CMS) website posts the "Medicare Ordering and Referring File," which is updated weekly and includes the most current ordering/referring list in a PDF format; entries are sorted alphabetically by last name.
If you receive a denial with one of the codes below, it is likely that your referring physician is not in the provider system or the physician's name or NPI is incorrect on the claim:
- 254D, Referring/ordering provider not allowed to refer
- 255D, Referring/ordering provider mismatch
- 289D, Referring/ordering provider NPI required
- 37236, Attending physician NPI is not eligible/not in PECOS
- 37237, Attending physician NPI is not present/not in PECOS
Under the Affordable Care Act, physicians (and non-physician practitioners, such as physician assistants, clinical nurse specialists, and nurse practitioners) who order items or services for Medicare beneficiaries must be enrolled as Medicare providers.
The Patient Protection and Affordable Care Act (ACA) included requirements for referring providers—physicians, nurse practitioners, and physician's assistants—to be enrolled in Medicare. Until May 1, providers submitting claims without recognized referring providers are and have been receiving reminders with the Explanation of Benefits. This is one of many provisions required for Medicare payment.
For a checklist of important Medicare payment requirements, see the Medicare Part B Claims Checklist on ASHA's website.
For more information regarding the physician referral requirements, refer to the CMS MLN Matters publication 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) [PDF].
For questions, contact Lisa Satterfield, ASHA's director of health care regulatory advocacy, at [email protected] or a member of the health care economics and advocacy team at [email protected].