Effective May 1, 2013, CMS will turn on the edits to deny Part B, Durable Medical Equipment (DME), and Part A Home Health Agency (HHA) claims that fail the ordering/referring provider edits. Physicians and others who are eligible to order and refer items or services need to establish their Medicare enrollment record with a valid NPI and must be of a specialty that is eligible to order and refer.
If the ordering/referring provider is listed on the claim, the edits will verify that the provider is enrolled in Medicare. The edits will compare the first letter of the first name and the first four letters of the last name. When submitting the CMS-1500, only include the first and last name as it appears on the ordering and referring file found on CMS.gov. Middle names (initials) and suffixes (such as MD, RPNA etc.) should not be listed in the ordering/referring fields. Including middle name/initial and/or suffix will cause the claim to be denied once the edits are turned on.