Ordering and Referring Edits

Several years ago, Centers for Medicare & Medicaid Services (“CMS”) mandated that payment for referral services would only be paid if the referring provider was properly enrolled in Medicare. Due to industry pressure, the effective date of this policy was continually delayed to allow providers sufficient time to meet the enrollment criteria. According to a recent CMS announcement, CMS intends to instruct its contractors to turn on the ordering and referring edits on January 6, 2014.

The ordering and referring 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).

Precision continues to monitor and review warnings on remits associated with the impending ordering and referring edit and notify providers, as necessary. We will continue to do so through the end of 2013 and into 2014 to minimize and attempt to eliminate the possibility of ordering and referring edit-related denials beginning in 2014.