Palmetto GBA: Analysis of Phase 1 HHA Ordering/Referring Edits

Phase one of the ordering/referring edits began on October 5, 2009, with informational messaging (remark code N272) on the remittance advice (RA) to alert the billing provider that the identification of the ordering/referring provider is missing, incomplete or invalid, or that the ordering/referring provider is not eligible to order or refer. The informational message on an adjustment claim that did not pass the edits indicated the claim/service lacked information that was needed for adjudication.

Effective May 1, 2013, the Centers for Medicare & Medicaid Services will turn on the Phase two denial edits. This means that Medicare will deny claims for services or supplies that require an ordering/referring provider to be identified and that provider is not identified, is not in Medicare’s enrollment records, or is not of a specialty type that may order/refer the service/item being billed.

Palmetto GBA has completed an analysis of HHA claims which we processed from January 1, 2013, through February 28, 2013. The results indicate that 52,575 of the 2,304,971 (2.4 percent) claims would have denied if the ordering referring edits would have been active. Of the 9,939 HHAs which bill Palmetto GBA, 3,999 (40.21 percent) had received remark code N272 during the two month period.

Providers are encouraged to review the CMS’ ‘Ordering & Referring Report’ to ensure that the physicians and non-physician practitioners from whom you accept orders and/or referrals have current Medicare enrollment records, and are of a type/specialty that is eligible to order or refer in the Medicare program. The file lists, in alphabetical order based on last name, the NPI and the name (last name, first name) of the physician or non-physician practitioner. To keep the available information up to date, CMS will replace the Report on a weekly basis. At any given time, only one Report (the most current) will be available for downloading.

Helpful Ordering/Referring Tips:

  • The name and the National Provider Number (NPI) you enter for the Ordering/Referring Provider must belong to a physician or non-physician practitioner and not to an organization, such as a group practice that employs the physician or non-physician practitioner who generated the order or referral
  • Please ensure you are correctly spelling the Ordering/Referring Provider’s name. Do not use ‘nicknames’ on the claim, as their use could cause the claim to fail the edits
  • Do not enter a credential (e.g., ‘Dr.’) in a name field
  • If you have a claim denied due to the Ordering/Referring provider edits, you must file an appeal. An adjustment cannot be submitted.

More information may be found in Medicare Learning Matters ® Number SE1305 (PDF, 163 KB) located on the CMS website.

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