What are the ordering and referring edits?

Answer: 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)

Contact Palmetto GBA JM Part HHH Medicare

Email HHH

Contact a specific JM HHH department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

Other Palmetto GBA Sites

Palmetto GBA Home

DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

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