CEDI Ordering/Referring Provider Edits

The Centers for Medicare & Medicaid Services (CMS) has updated the "OrderingReferringReport" file containing the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and nonphysician practitioners who are of a type/specialty that is eligible to order and refer in the Medicare Program and who have current enrollment records in Medicare (i.e., they have enrollment records in Provider Enrollment Chain & Ownership System (PECOS) that contain an NPI). This file is downloadable from the Medicare provider/supplier enrollment Web site www.cms.hhs.gov/MedicareProviderSupEnroll, click on "OrderingReferringReport" on the left-hand side.

Note: The "Ordering Referring Report" is a large .pdf file (20000 KB). Due to the large size, CEDI suggests you right click and select "Save as" before attempting to open this file.

The Common Electronic Data Interchange (CEDI) receives PECOS updates Monday through Saturday and some holidays with physicians and nonphysician practitioners who are of a type/specialty that is eligible to order and refer in the Medicare program. These updates are incorporated by CEDI to be used to perform the PECOS edits.

In order to determine if the ordering and/or referring provider submitted on the claim to CEDI matches the records with PECOS, CEDI performs the following steps:

1. CEDI first checks if the Ordering/Referring Provider's NPI submitted on the claim is on the file CEDI has received from PECOS.
   • If not, the CEDI edit will set.
2. If the NPI matches the PECOS file, CEDI then verifies the Ordering/Referring Provider's name as submitted on the claim matches the name associated with the NPI.
• CEDI compares the first four characters of the last name to the Ordering/Referring Provider's name received from PECOS
• CEDI compares the first letter of the first name to the Ordering/Referring Provider's name received from PECOS
• If the first or last name does not match, the CEDI edit will set.

• Verify with the provider who ordered or referred services that they are enrolled in PECOS.
• Submit the Ordering/Referring Provider's name as enrolled with PECOS.
• Do include spaces in last names. For example, if the ordering/referring provider's last name is "A BCDE" do not submit the last name as "ABCDE"
• Do include special characters in last names. For example, if the ordering/referring provider's last name is "A-BCDE" or "A'BCDE" do not submit the last name as "ABCDE"
• Do not use nicknames ("BOB" for "ROBERT")
• Do not use credentials ("DR JOHN" for "JOHN")
• Submit the name in upper case letters. Lower case letters will not find a match on the PECOS file as the PECOS file only contains upper case.
• Submit the Type 1 (individual physician's) NPI and name of the Ordering/Referring Provider. If the Type II (physician's group) NPI and name is submitted, a match will not be found on the PECOS file.

Post Date 05/26/10

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