April 3, 2013
Ordered and Referred Services (Phase II): Immediate Action Needed to Prevent Claim Rejections
If you order or refer Medicare patients for services, or if you perform services based on these orders, please review the following information closely. There are changes in the way the Medicare claims system will handle claims for ordered and referred services. This includes, but is not limited to, claims for clinical laboratory tests and radiology and imaging services.
Effective for dates of service on or after May 1, 2013: if the referring provider's information (National Provider Identifier (NPI) and name) is missing, incomplete, or invalid, or the ordering/referring provider is not eligible to order or refer services under Medicare, claims for ordered/referred services will be returned as unprocessable. These claims must be corrected and filed as new claims; they cannot be appealed.
Who may order or refer items or services for Medicare beneficiaries?
- Physicians (MD, DO, DDS, DMD, DPM, OD (optometrists may only order and refer DMEPOS products/services and laboratory and x-ray services under Medicare Part B))
- Physician Assistants
- Clinical Nurse Specialists
- Nurse Practitioners
- Clinical Psychologists
- Interns, Residents, and Fellows
- Certified Nurse Midwives
- Clinical Social Workers
Other important notes:
- Chiropractors are not eligible to order or refer supplies or services for Medicare beneficiaries.
- Services of Home Health Agencies may only be ordered or referred by an MD, DO, or DPM.
What this means to ordering/referring providers:
- Testing entities and other health care providers that perform services based on orders or referrals rely on the information from the ordering/referring provider in order to file Medicare claims.
- Verify that your specialty is permitted to order or refer the services.
- You must be enrolled in in the CMS Provider Enrollment Chain and Ownership System (PECOS). If you are not sure you are enrolled in this system, you may:
- Download the Medicare Ordering and Referring File
from the CMS website and look for your name and NPI, or - Call the CGS Provider Contact Center at 866.276.9558 and ask if you have an enrollment record that contains your NPI, or
- Access Internet PECOS for your record (no record means you do not have an enrollment record in Medicare)
- Provide your individual NPI and the exact spelling of your name, as listed in PECOS, to the provider who is performing services based on your order or referral.
What this means to providers who perform services based on orders or referrals (including laboratory, radiology, and imaging services):
- Since October 2009 (Phase I), Medicare has included "warning messages" on remittance advices (RAs) for claims that have a missing, incomplete, or invalid ordering provider name or NPI or that include ordering/referring provider information for a provider specialty that is not eligible to order or refer:
- N264: missing/incomplete/invalid ordering provider name
- N265: missing/incomplete/invalid ordering provider primary identifier
- Effective for dates of service on or after May 1, 2013, these warning messages will result in claim rejections as "unprocessable."
- Act now: monitor your RAs to identify claims with remark codes N264 or N265.
- Contact the ordering/referring provider, as necessary, to obtain valid and complete information.
- Verify that the ordering/referring provider is listed in PECOS and is of a specialty permitted to order/refer by downloading the Medicare Ordering and Referring File
from the CMS website. Note: this report is updated weekly, so check often. - On your claim, enter the ordering/referring provider's name exactly as it appears in the provider's record in PECOS. Do not include titles like "Dr."
- Claims with missing, incomplete, or invalid ordering/referring provider information will be rejected as unprocessable with remark codes MA130, CO-16, and N264 or N265.
For more information:
- Read CMS MLN Matters article SE1305
to learn more about the edits for ordering/referring providers. - Internet-based PECOS


