Ordering and Referring

No. Psychologists do not meet the definition of a "physician" for the purposes of ordering tests for Medicare patients.

Reference: CMS Pub. 100-01, Chapter 5, Section 70 (PDF)

Last Reviewed: 12/02/2024

Paper Claims — Block 17 of the CMS-1500 Claim Form
Based on CMS IOM Publication 100-4, Chapter 1, Section 80.3.2.1.2, ordering/referring provider information is a conditional requirement. In accordance with the IOM, when ordering/referring provider information is required for a submitted service, Palmetto GBA is requiring providers to submit the ordering/referring provider’s name in Block 17 as follows:

• Submit the provider’s name in the order of first name then last name 
• Submit the provider’s complete name spelled as it appears on the CMS Medicare Ordering and Referring File
• Include a hyphen in the last name only if the last name is hyphenated on the CMS file
• Do not submit middle initials or suffixes such as M.D., D.O., Jr., etc.
• Do not submit Dr. before the name

Also include a valid provider qualifier in the space to the left of the dotted vertical line, before the provider’s name, in block 17. Choose the appropriate qualifier to identify the role of the provider.

• DK — Ordering Provider
• DN — Referring Provider
• DQ — Supervising Provider

Failure to submit the first and last name in this order and as the name appears on the CMS Medicare Ordering and Referring File could result in a denial for services that require this information.

Electronic Claims
On electronic claims, the provider’s name should continue to be submitted in the specified Loops for the ordering/referring provider name:

• Referring Provider Last Name: Loop 2310A or 2420F, NM1/DN, 03
• Referring Provider First Name: Loop 2310A or 2420F, NM1/DN, 04
• Ordering Provider Last Name: Loop 2420E, NM1/DK, 03
• Ordering Provider First Name: Loop 2420E, NM1/DK, 04

When submitting electronic claims, it is important to pay special attention to suffixes. Please only include the first and last name as it appears on the ordering and referring file. Middle names (initials) and suffixes (such as M.D., D.O., RPNA, etc.), should not be listed in the ordering/referring fields.

Last Reviewed: 12/02/2024

The most common reasons for this denial are:

The provider does not have a have a current PECOS enrollment record. CMS maintains the Medicare Ordering and Referring File as a list of providers who are enrolled in PECOS and who are eligible to order or refer for services. Verify the provider's enrollment status with the provider and/or on the Medicare Ordering and Referring File. 

The NPI entered is for a group practice or organization, rather than an individual physician or nonphysician practitioner.

Resources

• Ordering & Certifying
• CMS Ordering & Referring Information Page

Last Reviewed: 12/02/2024

The most common reasons for this denial are:

• The name and NPI combination submitted does not match our provider records. Confirm the correct name and NPI with the provider and/or on the CMS Medicare Ordering and Referring File.
• The provider's name was spelled incorrectly. Confirm the correct spelling with the provider and/or on the CMS Medicare Ordering and Referring File. Do enter "Dr." before the name or credentials after the name.
• The provider's name was entered in the wrong order. Confirm the correct name with the provider and/or on the CMS Medicare Ordering and Referring File. Confirm you are entering the name in the correct order. On electronic claims, the first and last name are entered in the following ASC 837 v5010 Loop, Segment, Element fields:
  • Referring Provider Last Name: Loop 2310A or 2420F, NM1/DN, 03
  • Referring Provider First Name: Loop 2310A or 2420F, NM1/DN, 04
  • Ordering Provider Last Name: Loop 2420E, NM1/DK, 03
  • Ordering Provider First Name: Loop 2420E, NM1/DK, 04
• The provider's last name is hyphenated and only one part of the last name was entered. The ordering/referring provider edits compare the first four letters of the last name. If, for example, the provider's last name is Allen-Jones, and a claim is submitted with the last name Jones, the claim will fail the edit and be denied.

Last Reviewed: 12/02/2024

The edits will determine if the ordering/referring provider are required on claims:

1. Has a current Medicare enrollment record in the Provider Enrollment Chain and Ownership System (PECOS) and contains a valid National Provider Identifier (NPI) (the name and NPI must match); and
2. Is of a provider type that is eligible to order or refer for Medicare beneficiaries

Only physicians and certain types of nonphysician practitioners are eligible to order or refer items or services for Medicare beneficiaries. They are as follows:

• Physicians: doctor of medicine or osteopathy, doctor of dental medicine (excludes home health services), doctor of dental surgery (excludes home health services), doctor of podiatric medicine, doctor of optometry (excludes home health services); optometrists may only order and refer DMEPOS products/services and laboratory and X-ray services payable under Medicare Part B
• Physician Assistants
• Clinical Nurse Specialists (excludes home health services)
• Nurse Practitioners (excludes home health services)
• Clinical Psychologists (excludes home health services)
• Interns, Residents and Fellows (excludes home health services)
• Certified Nurse Midwives (excludes home health services)
• Clinical Social Workers (excludes home health services)

Last Reviewed: 12/02/2024

You need to submit either an electronic application through the use of internet-based PECOS, or a paper enrollment application to Medicare.

• For paper applications: fill it out, sign and date it, and mail it along with any required supporting paper documentation to your designated Medicare enrollment contractor
• For electronic applications: complete the online submittal process and either e-sign or mail a printed, signed and dated Certification Statement and digitally submit any required supporting paper documentation to your designated Medicare enrollment contractor
• In either case, the designated enrollment contractor cannot begin working on your application until it has received the signed and dated Certification Statement
• If you will be using PECOS, please go to PECOS and on the left-hand side, read the information that has been posted there. Download and read the documents in the Downloads Section on that page that relate to physicians and nonphysician practitioners. A link to PECOS is included on that web page.
• If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you need to submit an enrollment application to Medicare. You can do this using PECOS or by completing the paper enrollment application (CMS-855O).

Last Reviewed: 12/02/2024