Medicare ordering and referring: how to check a provider can order

The rule in plain words

Some Medicare services are paid to one provider but ordered by another. A DME supplier delivers the wheelchair, but a physician ordered it; a lab runs the test, but a nurse practitioner ordered it. For these services, CMS requires the ordering, referring or certifying provider to meet three conditions (CMS, Ordering & Certifying):

1. An individual NPI. A Type 1 NPI; organizations can’t order or refer.
2. Medicare enrollment in an approved or opt-out status. A provider who doesn’t bill Medicare can still enroll just to order and refer.
3. An eligible specialty. Only certain physician and practitioner types may order each kind of service.

CMS lists the affected services as DMEPOS, clinical laboratory services, imaging and home health. Since 2024 hospice claims are also edited for the physicians who certify a patient for hospice: CMS’s MLN article MM13531 gives an effective date of May 1, 2024 and an implementation date of October 7, 2024 (CMS MM13531). Medicare contractors started denying claims whose ordering or referring physician had no enrollment record on January 6, 2014 (CMA).

CMS’s Order and Referring file

CMS publishes the list of individuals eligible to order and refer on data.cms.gov, updated twice a week (CMS methodology). Each NPI appears once, with the last and first name and five Y/N columns:

A provider can be on the file with “Y” for some columns and “N” for others: for example, eligible for Part B and DME but not home health. A provider not on the file at all is not eligible for any category.

The fastest way to check: enter the NPI or name in our NPI lookup. Every individual’s result shows “Can order and refer” with the categories from the latest CMS file, alongside Medicare enrollment, opt-out and exclusion checks. For a list of referring providers, the bulk NPI lookup checks up to 100 at once and exports CSV.

Opted-out providers can still order

A physician who opted out of Medicare can’t be paid by Medicare for their own services, but CMS accepts an opt-out status for ordering and certifying (CMS). So a concierge physician who opted out can still order a wheelchair or lab tests, and the supplier or lab is paid, provided the physician’s specialty is eligible. CMS’s opt-out list gives the dates (CMS); our lookup shows it on every result.

Why ordering and referring claims get denied

Checking on data.cms.gov yourself

Our lookup reads the same CMS file, but it’s good to know how to check at the source, for example when a Medicare contractor asks how you verified a provider:

1. Open the Order and Referring dataset on data.cms.gov.
2. Use the dataset viewer’s filter to search by NPI (the most reliable) or by last name.
3. Read the five columns for the service you provide. “Y” means eligible for that category.
4. Note the dataset’s release date shown on the page, and save a screenshot or PDF with the date.

If the provider isn’t there, check whether you have the right NPI (an organization’s NPI won’t be on the file), then ask the provider about their enrollment.

Getting a provider on the file

A physician or practitioner who never bills Medicare (for example one who works only for the VA, a public health clinic or a practice that doesn’t take Medicare) can still enroll for the sole purpose of ordering, certifying and referring. They apply through PECOS online or on CMS’s paper application for eligible ordering, certifying and prescribing professionals (form CMS-855O). Once their enrollment is approved, they appear on the next updates of the file. Alternatively, a physician who has formally opted out of Medicare is also accepted as an orderer (CMS).

Enrollment has to be kept up: providers revalidate on CMS’s schedule, and an enrollment that lapses drops off the file. If you rely on a provider for many orders, it’s worth watching their status rather than checking once.

Which practitioners can order what

The eligible specialties are set by CMS and Medicare law, and they differ by service, which is why the file has separate columns. Two points cause frequent confusion:

• Home health certification. For years only physicians could certify a patient for Medicare home health. The CARES Act of 2020 allowed nurse practitioners, clinical nurse specialists and physician assistants to certify home health too. The HHA column reflects who is currently eligible.
• Hospice certification. The terminal-illness certification for hospice is made by physicians (the hospice physician and, for the first benefit period, the attending physician if the patient has one). CMS’s 2024 edits check those certifying physicians’ enrollment.

Because these rules change, rely on the current file’s Y/N flags and your Medicare Administrative Contractor’s guidance rather than on a fixed list.

Managing referral sources

Labs, imaging centers, suppliers and agencies often depend on a few dozen regular referrers. A short routine keeps their claims clean:

• Keep a list of each referring provider’s name, Type 1 NPI and the categories they order from you.
• Screen it monthly against the Order and Referring file, the opt-out list and the exclusion lists. Our bulk NPI lookup does all of that for up to 100 NPIs and exports a CSV you can keep.
• Tell referrers early when they drop off the file. Most don’t know until a supplier tells them.
• Screen for exclusions too. Medicare won’t pay for items or services ordered or prescribed by an excluded person, a separate problem from enrollment; see OIG vs SAM vs state lists.

Medicaid has a similar rule

Medicaid programs require ordering and referring providers to be enrolled too. Federal rules make state Medicaid agencies require all ordering or referring physicians and other professionals to be enrolled as participating providers (42 CFR 455.410(b)), so a provider who is fine for Medicare may still be missing from a state’s Medicaid enrollment, and the reverse. Each state publishes its own way to check, usually a provider search on its Medicaid portal. If you bill Medicaid for ordered services, add that search to your intake routine for each state you work in.

Medicaid also terminates providers for cause, and those terminations appear on state exclusion lists rather than on CMS’s Medicare files. Our exclusion check searches the state lists that publish downloadable data and tells you which states it did not search.

Who carries the risk

The rule falls on whoever bills for the ordered service. That is why suppliers, labs, imaging centers, home health agencies and hospices are the ones who need a check at intake. The ordering practice has an interest too: if its practitioners aren’t eligible, their patients’ equipment, tests and home care are delayed, and the practice’s phone rings with suppliers asking for new orders. Practices that keep every practitioner enrolled (or formally opted out) and their names consistent across NPPES and PECOS make life easier for everyone downstream.

Five examples

The providers and businesses below are invented. The rules come from the CMS sources cited.

1. A DME supplier and a new nurse practitioner

A supplier receives an order for a hospital bed from a nurse practitioner who joined a practice last month. Her NPI is active, but she isn’t on the Order and Referring file yet. The supplier holds the delivery date, tells the practice, and gets a co-signed order from an eligible physician in the meantime. Two weeks later her enrollment appears with DME = Y.

2. A lab and a retired physician’s old requisitions

An independent lab gets requisitions under a physician who retired. His NPI no longer appears in the registry and he has dropped off the CMS file. The lab contacts the clinic, which still had his name preprinted; claims are resubmitted under the physician now ordering.

3. Home health and a “Y, but not for HHA”

A home health agency checks a referring practitioner: on the file, PARTB = Y and DME = Y, HHA = N. The agency asks the patient’s physician, who is eligible for home health, to sign the certification instead.

4. An opted-out psychiatrist orders labs

A lab notices the ordering psychiatrist opted out of Medicare. Her NPI is on the Order and Referring file with PARTB = Y, so she may order. The lab bills Medicare for the tests as usual.

5. Hospice certification

A hospice admits a patient certified by a hospital physician. Before submitting the claim, the intake team checks both the hospice physician and the attending physician against the file, as CMS’s 2024 edits look at the certifying physicians on the claim.

An intake script that takes one minute

Most denials are prevented at intake, when an order arrives and before anything is delivered or performed. A simple script for intake staff:

1. Read the order. Is it signed by an individual practitioner, with their NPI? If only a clinic name or a group NPI is on it, call for the individual’s NPI.
2. Look up the NPI. Confirm the name matches the signature, and check “Can order and refer” for the right category.
3. If eligible, save the dated lookup with the order and proceed.
4. If not eligible or not found, call the office the same day: “Medicare shows Dr. X isn’t eligible to order this service. Can another eligible practitioner in your office co-sign or reissue the order, or is Dr. X enrolling?”
5. If the provider opted out, check the category flag: opted-out physicians of eligible specialties can still order.
6. Never change the ordering provider on your own. The order has to come from the practitioner named on the claim.

After a denial

If a claim is denied because of the ordering or referring provider, work through it in order:

• Read the denial reason on the remittance. It tells you whether the problem is enrollment, specialty, name or NPI.
• Check the file as it stood on the date of service. Save the current lookup, and ask the provider’s office about their enrollment dates.
• Fix clerical errors such as a group NPI or a misspelled name, then correct or resubmit the claim following your Medicare Administrative Contractor’s process.
• If the provider wasn’t eligible, ask whether their enrollment covers the date of service once approved; your contractor can tell you whether and how the claim can then be reprocessed.
• Fix the root cause: add the check to intake, and keep the referring provider on your monthly watch list.

Rules for reopening and resubmitting differ by contractor and claim type, so follow your contractor’s published process.

A routine that prevents most denials

Practice Pro watches the NPIs you save and emails you when one stops being eligible to order or refer, opts out, or leaves CMS’s enrollment list.

What our check can and can’t do

• It reads CMS’s latest public Order and Referring file, downloaded every Monday and Thursday; CMS updates it twice a week, so a very recent change may not show yet.
• It doesn’t check whether a particular service fits within a specialty’s scope, or state scope-of-practice rules.
• It isn’t PECOS. For a disputed denial, check PECOS or ask your Medicare Administrative Contractor.

Questions

Sources

1. CMS, Ordering & Certifying (who may order or certify; enrolled in approved or opt-out status, eligible specialty) — who may order or certify, approved or opt-out status, eligible specialty, the services affected
2. CMS, Order and Referring methodology (data.cms.gov) — what the Order and Referring file contains and how often it is updated
3. CMS, Order and Referring dataset — the Order and Referring dataset
4. CMS MLN MM13531, Hospice claims edits for certifying physicians (effective May 1, 2024; implemented October 7, 2024) — hospice certifying physician edits and their dates
5. California Medical Association, CMS to implement ordering and referring denial edits January 6, 2014 — the start of ordering and referring denial edits on January 6, 2014
6. CMS, Opt Out Affidavits dataset — Medicare opt-outs
7. 42 CFR 455.410, Enrollment and screening of providers (ordering and referring providers must be enrolled in Medicaid) — state Medicaid programs must require ordering and referring providers to be enrolled
8. CMS, NPI Fact Sheet (December 2024) — Type 1 and Type 2 NPIs

Checked October 27, 2026. General information, not legal or billing advice; Medicare rules and edits change, so follow your Medicare Administrative Contractor’s current guidance. Examples use invented people and businesses.