decisionhealth Newsletters, Part B News - 2013 Issue 4 (April)
CMS to begin denials May 1 when ordering doc isn’t enrolled in Medicare
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Article Overview
This Medicare-focused article reviews pending claim-edit enforcement affecting ordering and referring provider information for Part B services, durable medical equipment, and home health claims. It is relevant to billing staff, coders, compliance teams, and providers who need to confirm enrollment status, provider eligibility, and claim data accuracy under Medicare rules. The article also points readers to CMS resources for checking provider status and enrollment.
Why This Topic Matters
Claims can be denied if the ordering or referring provider is not properly enrolled or eligible, so billing workflows must verify provider data before submission.
What You Will Learn
- What types of Medicare claims are affected by ordering and referring provider edits
- Which provider enrollment and eligibility issues can lead to claim denials
- What provider information must be present on claims
- What CMS resources are available to verify ordering and referring providers
Who Should Read This
- Medical coders
- Billing staff
- Revenue cycle teams
- Compliance teams
- Healthcare providers
Codes Discussed
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