Ordering and Referring

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: 9/18/2024

When you enrolled in Medicare, you indicated your Medicare specialty. Any physician specialty (chiropractors are excluded) and only the nonphysician practitioner specialties listed below are eligible to order or refer in the Medicare program.

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

• Physicians (doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery, doctor of podiatric medicine, doctor of optometry; 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
• Nurse practitioners
• Clinical psychologists
• Interns, residents and fellows
• Certified nurse midwives
• Clinical social workers

Last Reviewed: 9/18/2024

If you are a physician who has opted out of Medicare, you may order items or services for Medicare beneficiaries by submitting an opt-out affidavit to your local Medicare Administrative Contractor (MAC). Your opt-out information must be current (an affidavit must be completed every two years, and the National Provider Identifier (NPI) is required on the affidavit).

Last Reviewed: 9/18/2024

No. You are not required to have an enrollment record with Railroad Medicare to order or refer services for Railroad Medicare beneficiaries. You are required to have a current enrollment record with your local Medicare Administrative Contractor and to be of a specialty type authorized to order or refer services.

Last Reviewed: 9/18/2024

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 Order 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 CMS Medicare Order 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: 9/18/2024

The most common reasons for this denial are:

• The provider does not have a have a current PECOS enrollment record. Verify the provider's enrollment status with the provider and/or on the Medicare Order and Referring File. 

CMS maintains the Medicare Order and Referring file with information on all physicians and nonphysician practitioners, by their National Provider Identifier (NPI), who are of a type/specialty that is legally eligible to order and refer in the Medicare program and who have current enrollment records in Medicare.

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

Last Reviewed: 9/18/2024

• 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 Order and Referring File.
• The provider's name was spelled incorrectly. Confirm the correct spelling with the provider and/or on the CMS Medicare Order 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 Order 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: 9/18/2024

For electronic claims, Medicare uses remittance message N265 to indicate you did not complete the ordering or referring provider name and NPI fields for a service that requires an ordering or referring provider. The following fields should be completed to identify the ordering or referring provider.

ASC 837 v5010 Loop, Segment, Element:

• 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
• Ordering Provider National Provider Identifier (NPI): Loop 2420E, NM1/DK, 09
• Referring Provider NPI: Loop 2310A or 2420F, NM1/DN, 09

Last Reviewed: 9/18/2024

For paper claims, remittance message N265 indicates you did not submit the name and NPI of the ordering or referring provider and/or did not submit a valid provider qualifier in items 17 and 17b. Services that require an ordering or referring provider must be submitted with the ordering or referring provider’s name in item 17 and that provider’s NPI in item 17b. Also, claims submitted on the revised CMS-1500 (02/12) form must include one of the following qualifiers to identify the role of the provider.

• DK – Ordering provider
• DN – Referring provider
• DQ – Supervising provider

The qualifier should be printed to the left of the dotted vertical line, before the provider’s name, in item 17.

Important: Medicare accepts paper claims only on the revised CMS-1500 (02/12) claim form. Any claims received on a previous version of the CMS-1500 (08/05) form after March 31, 2014 will be returned to providers as unprocessable.

Last Reviewed: 9/18/2024