Ordering and Referring Provider Responsibilities

CMS guidelines state that ordering providers can order items or services for Medicare patients and beneficiaries and referring providers can request items or refer a patient or beneficiary for services that Medicare may reimburse. These guidelines also state that to be eligible to order and certify Medicare covered services, supplies, and/or equipment, a provider must:

• Have an individual National Provider Identifier (NPI)
• Be enrolled in Medicare (in an “approved” or an “opt-out” status)
• Be of an eligible specialty type, including:

The CMS Ordering and Referring File lists all providers currently eligible to order and certify Medicare services, supplies, and/or equipment. This dataset includes provider information via National Provider Identifier (NPI) who are of a specific type/specialty (noted above), legally eligible, and currently enrolled to order and refer within the Medicare program.

If a provider is not listed within the CMS Ordering and Referring File, or if they are ordering and/or referring items or services for Medicare beneficiaries and do not have a Medicare enrollment record, submission of an enrollment application to Medicare is mandatory. Providers must access the CMS Provider Enrollment, Chain, and Ownership System (PECOS) or complete the paper enrollment application (CMS-855O [PDF]) in an effort to ensure appropriate submission of Medicare claims. 

Providers who see Medicare patients/beneficiaries but choose not to enroll in the Medicare program must Opt-Out of Medicare. This means that both the provider and the Medicare patient/beneficiary are unable to bill Medicare for services, and the patient/beneficiary must pay out of pocket.

If a provider does not see Medicare patients/beneficiaries at all, they do not have to enroll in or opt-out of the Medicare program. If the provider cares for Medicare patients/beneficiaries, they must choose to either enroll-in or opt-out of Medicare. The provider decision to opt-out is included within the CMS Opt-Out Dataset.

Section 10.6.12(B)(1) of the Medicare Program Integrity Manual, Chapter 10 (PDF) and Section 40.9 of the Medicare Benefit Policy Manual, Chapter 15 (PDF), has more information on the opt-out affidavit requirements.

Ordering, Referring, and Certifying Provider Documentation Requirements

Providers that are qualified (as outlined above) may order, refer, and/or certify the following Medicare equipment, supplies and/or services:

• Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
• Clinical Laboratory Services
• Imaging Services
• Home Health and Hospice Services
• Skilled Nursing Facility (Nursing Home) Admission

However, it is the responsibility of all providers involved in the care of Medicare patients and beneficiaries to:

• Maintain appropriate documentation of all orders, certifications and recertifications, referrals, prescriptions, requests for payment (claims), and any other medical records supporting any/all Medicare claims submitted for payment for seven years (or longer if required by individual state)
• Professionally collaborate and document interaction with any/all/other third-party suppliers and providers involved in each patients/beneficiary’s care
• Obtain medical record documentation from any/all/other third-party suppliers and providers to support claims submitted for Medicare reimbursement
• Document all collaboration and dialogue with and between interoffice providers, outside healthcare services and entities, family members and loved ones, clergy members, pharmacy, etc., regarding all patient/beneficiary care and services, including but not limited to:
  • One-on-one conversation, conference calls, and interdisciplinary group team (IDG/IDT) meetings to implement or revise a plan of care and/or patient/beneficiary services
  • Assessment or reassessment of patient/beneficiary status, services, supplies, or equipment
  • Certification or recertification of services, supplies, or equipment
  • Discharge procedures, protocols, and plans
• Ensure medical necessity for all equipment, supplies, and services referred, ordered, and/or certified/recertified
• Confirm face-to-face encounters are documented according to Medicare regulations for referred, ordered, and certified equipment, supplies, and services
• Make sure the patient/beneficiary meets any and all required eligibility criteria for referred, ordered, and/or certified equipment, supplies, and services
• Clarify that documentation of certified equipment, supplies, or services meets appropriate Medicare guidelines
• Monitor provider enrollment and revalidation in an effort to maintain an active status in PECOS

References and Resources

• Federal Register Medicare and Medicaid Programs: Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements
• MLN Matters® Article SE1305 (PDF)
• MLN Matters® Article MM8239 (PDF)
• MLN Matters® SE1505 (PDF)
• MLN 4840534 Fact Sheet (PDF)
• Medicare Benefit Policy Manual, Chapter 15 (PDF)
• Medicare Program Integrity Manual Chapter 10 (PDF)
• Medicare Provider Enrollment