National Provider Identifier (NPI)

The edits will determine if the ordering/referring provider are required on claims:

1. Has a current Medicare enrollment record in the Provider Enrollment Chain and Ownership System (PECOS) and contains a valid National Provider Identifier (NPI) (the name and NPI must match); and
2. Is of a provider type that is eligible to order or refer for Medicare beneficiaries

Only physicians and certain types of nonphysician practitioners are eligible to order or refer items or services for Medicare beneficiaries. They are as follows:

• Physicians: doctor of medicine or osteopathy, doctor of dental medicine (excludes home health services), doctor of dental surgery (excludes home health services), doctor of podiatric medicine, doctor of optometry (excludes home health services); optometrists may only order and refer DMEPOS products/services and laboratory and X-ray services payable under Medicare Part B
• Physician Assistants
• Clinical Nurse Specialists (excludes home health services)
• Nurse Practitioners (excludes home health services)
• Clinical Psychologists (excludes home health services)
• Interns, Residents and Fellows (excludes home health services)
• Certified Nurse Midwives (excludes home health services)
• Clinical Social Workers (excludes home health services)

Last Reviewed: 09/23/2024

You need to submit either an electronic application through the use of internet-based PECOS, or a paper enrollment application to Medicare.

• For paper applications: fill it out, sign and date it, and mail it along with any required supporting paper documentation to your designated Medicare enrollment contractor
• For electronic applications: complete the online submittal process and either e-sign or mail a printed, signed and dated Certification Statement and digitally submit any required supporting paper documentation to your designated Medicare enrollment contractor
• In either case, the designated enrollment contractor cannot begin working on your application until it has received the signed and dated Certification Statement
• If you will be using Internet-based PECOS, please go to Internet-based PECOS and on the left-hand side, read the information that has been posted there. Download and read the documents in the Downloads Section on that page that relate to physicians and nonphysician practitioners. A link to Internet-based PECOS is included on that web page.
• If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you need to submit an enrollment application to Medicare. You can do this using Internet-based PECOS or by completing the paper enrollment application (CMS-855O)

Last Reviewed: 09/23/2024