CREDENTIALING
By Machelle Giordon, Credentialing Specialist
ORDERING/REFERRING PROVIDER VERIFICATION
Centers of Medicare & Medicaid Services (CMS) under CR 6417 is expanding claim editing to verify that the ordering/referring provider on the claim is enrolled in Medicare and is eligible to order or refer Medicare services.
Beginning effective October 5, 2009, CMS is expanding claim editing to meet Social Security Act requirements.
According to CR 6417 only the following providers can order or refer beneficiary services:
Doctors of Medicine or Osteopathy, Dental Medicine, Dental Surgery, Podiatric Medicine, Optometrist, Chiropractic, Physician Assistant, Certified Clinical Nurse Specialist, Nurse Practitioner, Clinical Psychologist, Certified Nurse Midwife, and Clinical Social Worker.
Firstly,
If the claim does not pass the edits described above, Medicare will continue to process the claim and will include a remark message (M68- missing/ incomplete/invalid attending, ordering, rendering, supervising, or (referring identification) on the Medicare Remittance Advice.
Secondly,
If the billed service requires an ordering/referring provider and none is present, the claim will not be paid. If the ordering/referring provider is on the claim, Medicare will verify that ordering/referring provider’s NPI and name reported on the claim against Medicare’s provider enrollment records to ensure the ordering/referring provider is enrolled in Medicare and is a specialty eligible to order or refer.
O’Sullivan Consulting Group can assist providers in dealing with some of the additional demands of managed care plans and credentialing. For further assistance please contact Machelle at 330-723-2111 or machelle@osullivanconsult.com.
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