Denial Management: CMS Confirms Ordering/Referring Edits Will Start May 1

Why This Topic Matters

Practices that submit claims tied to physician orders or referrals need to understand when CMS edits take effect and how that can affect claim acceptance. The article helps readers identify the administrative preparation needed to reduce denials and avoid delays in payment.

Article Sections

1. Ordering/Referring Edits Take Effect

   Introduces CMS’s planned activation of edits tied to Medicare claims and the expected impact on claims processing. It frames the denial-management issue for practices that depend on ordered or referred services.

2. Preparing for Denials Before the Deadline

   Discusses the need to confirm that ordering and referring physicians are properly enrolled and identifiable in the relevant systems. It also explains why practices should review provider information before the edits are turned on.

3. Phase 1 and Phase 2 Enforcement

   Summarizes the staged implementation approach described in the article and the transition from informational messages to claim denials. It also notes the role of specialty eligibility in the processing outcome.

4. Tracking NPIs and Using CMS Resources

   Covers operational steps for maintaining provider identifier records and references CMS tools for locating provider information. It emphasizes ongoing workflow readiness for practices that receive frequent referrals or orders.