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February 7, 2014 - Revised: 11.30.22

Claim Denials and Rejections: Ordering/Referring Edits

Phase 2 ordering/referring edits affect submitted claims as follows:

  • Claims without a valid ordering/referring NPI for the following services will be denied: claims from clinical laboratories for ordered tests and claims from imaging centers for ordered imaging procedures. These claims are identified on your Remittance Advice (RA) with remark codes CO-16 or CO-183, along with N264, N265, N575, and MA13.
  • Other claims that require valid ordering/referring NPI will be rejected. This includes: clinical lab tests billed by other than clinical laboratories; imaging and interpretation of imaging from other than imaging centers; and claims that include charges for drugs. These claims are identified on your Remittance Advice (RA) with remark codes CO-16 and/or N265, N276, and MA13.

Tips for Claim Submission

Please note that many of the claims subject to these edits were denied/rejected correctly. The following tips will assist you in preventing these denials and rejections:

  • Submit the ordering/referring practitioner's first and last name, as they appear on the CMS ordering/referring file.
  • DO NOT submit:
    • Professional designations (such as M.D.) or Jr., Sr., etc.
    • Nicknames which differ from the name listed in the CMS ordering/referring file (e.g., Stan instead of Stanley)
    • Middle initials

Reference:

  • Find the list of physicians and practitioners eligible to order and refer services and that have valid enrollment records in PECOS on this CMS Web pageExternal Website (under Downloads)

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